HomeMy WebLinkAbout032-2191-08-000 (2)Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and Bwlding Division
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT)
Personal information you provide may be used for secondary purposes (Privacy Law, s 15 04 (1)(mil
'ermit Holder's Name: illage Township
THOMAS JACKSON RVCBL TRUSTF��
TOWN OF SOMERSET
:ST SM Elev- Insp. BM Elev BM Description.
l;tF;l i li1 l i 11e] :i i'J_t I [�1 i
TYPE
MANUFACTURER
CAPACITY
Septic
WI I IiLf. . L . � " .�N : , 5 F+
12SD q�
Dosing
tf
Holding
TANK SETBACK INFORMATION
TANK TO
P/L
WELL
BLDG
vent to Air Intake
ROAD
Septic
5
Dosing
1
D
Holding
PUMPISIPHON INFORMATION
Manufacturer
Demand
GPM
Model Number
TDH
Lift
Friction Ln
a} M::=
m Length
r!��
Dia.
Dist. to Wed
SOIL ABSORPTION SYSTEM
ELEVATION DATA
County St. Croix
Sandary Permit No
645483
Stare Plan ID No
Parcel Tax No
032-2191-08-000
Sect on/Town/RangetMap No
26.31.19.1601
STATION
BS
HI
FS
ELEV.
Benthmark
1
Alt. BM
Bldg. Sewer
SIIHt Inlet
SuHt outlet
Dt Inlet
Dt Bottom
Header/Man.
Dist. Pipe
Bot System
Final Grade
St Coy
SEDrTRENCH
Width
Length
No Of Trenches
PIT DIMENSIONS
INo Of Pits
firs in.
Liquid Depth
DIMENSIONS
—IU
SETBACK
INFORMATION
SYSTEM TO
PIL
BLDG
WELL
LAKE/STREAM
LEACHING
Manufacture r 1 I /
"'4'
CHAMBER OR
ZhT `
Type Of System
Model Number.
'4 /nat
�17 W
�Qxck—
UNIT
Ulb 1 KIlSILI I IUIY ,Yb I tM
HeaderiMandold
Distritlution x Hob Size
x Hob p
vent to Air Intake
LLength
p n
IL
/
Ora
Dla Spacing
P%JIL- x Pressure Systems Only xx Mound Or At -Grade Systems Only
)apth Over Depth Over xx Depth of xx Seeded,Sodded xx Mulch"
lec"renchCenter Bo&fr4neKEdo&
COMMENTS: (Include code discrepancies, persons present. etc) Inspection #1.
Location: 1946 64TH ST 3 ys+tty, c l f,,/4lim vex i �TeA w 11"I'l S01(
1.) Alt BM Description = ;Ibx r
2.) Bldg sewer length = 7 rf
amount of cover = in +
Plan revision Required? ® Yes _. No
Use other side for additional information. �(f
SBD-6710 (R 3197) Dom
Inspection #2:
Car. No.
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P.O. Boot 7162
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Madisoe4 W133707-7162
pplication
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M OWNER: 3� `tom- O 5 �. ''` ° v` ►�u�� (�- P °"� ,` �,
1. Septic tank, effluent filter and dispersal cell Ate- ^+S ��-;"'-� U °I Q+ � /�
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must be serviced / maintained as per vC-� d-
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management plan provided by plumber. �� or1S a we-••-QaQ
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POWTS OWNER'S MANUAL & MANAGEMENT PLAN page I of -I-
FILE INF F4"TION
Owner S O S NO Shc
Permit re
DESIGN PARAMETERS
Number of Bedrooms
❑ NA
Number of Public Facility Units
J$ NA
Estimated flow leverage)
��
al/der
Design flew (peak), (Estimated x 1.5)
( gal/day
Soil Application Rate
�-7 alld /W
Standard Influent/Effluent Quality
Monthly average*
Fate, Oil & Grease
IFOG)
530 mg/L
Biochemical Oxygen Demand
(BOD6)
5220 mg/L
❑ NA
Total Suspended Solids
(TSS)
51 b0 mg/L
Pretreated Effluent Quality
Monthly average
Biochemical Oxygen Demand
(BOD6)
530 mg/L
Total Suspended Solids
(TSSI
530 mg/L
❑ NA
Fecal Coliform (geometric
mean)
510' cfullOOml
Maximum Effluent Particle Size
Ye in dia.
❑ NA
Other:
❑ NA
'Values typical for dornestie wastewater and septic tank effluent.
MAINTENANCE SCHEDULE
SYSTEM SPECIFICATIONS
Septic Tank Capacity
7-56 al
❑ NA
Septic Tank Manufacturer
A 1e5r= R,
❑ NA
Effluent Filter Manufacturer Lr ) reTj )-+b E
❑ NA
Effluent Filter Model
I
❑ NA
Pump Tank Capacity
al
NA
Pump Tank Manufacturer
fi�NA
Pump Manufacturer
9YA
Pump Model
i&A
Pretreatment Unit
XNA
❑ Sand/Gravel Fitter
❑ Peat Filter
❑ Mechanical Aeration
❑ Wetland
❑ Disinfection
❑ Other.
Dispersal Call(s)
❑ NA
;9,ln-Ground Igravityl
❑ In -Ground (pressurized)
❑ At -Grade
❑ Mound
❑ Drip -Line
❑ Other:
Other:
❑ NA
Other.
❑ NA
Other:
❑ NA
Service Event
Servka Fnw*wncy
Inspect condition of tank(s)
At least once every:
month(Madmum 3 s) ) ❑ NA
3 serfs) Y�
Pump out contents of tank(s)
When combined sludge and scum equals one-third (Y.) of tank volume ❑ NA
Inspect dispersal cellfs)
At least once every:
3 ❑ rnonth(s) (Maximum 3 years) ❑ NA
mCyear(g)
Clean effluent fitter
At least once every:
? Clmonthle) ❑ NA
Jjkyearw
Inspect pump, pump controls & alarm
At least once every:
❑ mortth(s)
❑ year(s)
NA
Rush laterals and pressure test
At least once every:
' ❑ month(s)
❑ earls)
NA
Other
At least once every:
❑ month(s)
❑ year(s)
A
other:
NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual carving 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 tankis) to identfty 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 eelt(el 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 (Yx) 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 Coda.
All other services, including but not limited to the servicing of effluent fitters, 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. CRI NTY SANITARY SYSTEM File �f
,,, OfficeUse Only
OWNERSHIP/ADDRESS FORM aaftdw02r
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 Property 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, WI 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 �—s'/4 , SW '/4 , Sec. Z6 , T 31 N R 19 W, Town of Somerset
Subdivision Plat: Pine Cliff Fourth Addition Lot # 60
Certified Survey Map # Volume . Page #
Warranty Deed # z u (before 2006)Volume , Page #
Number of bedrooms 4 Spec house C3 yes ■ no Lot lines identifiable ■ yes C] no
New Property Address
44--
(54ff Initials)
OFt}SE ONLY
(v � OFFICE
(Verification of new address required from Community
[I /210 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 mop if reference is made in the warranty deed.
Community Development Department — Land Use Division
715-386-4680 St. Croix County Government Center 715-245-4250 Fax
cddL@sccwi.gov 1101 Carmichael Road, Hudson, Wl 54016 www•sccw.- Z
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�hTYPLATOF: PINE CLIFF FOURTH ADDITION \ I ' = l
TED IN PART OF THE SE1/4 OF THE SWI/4, SWI/4 OF THE SWI/4, NW 4 OF THE I i iOr a6 \ Lol 471 LOr a§ v
Y ptHF C11I1 - - -
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TOWNSHIP 31 NORTH, RANGE 19 WEST, TOWN OF SOMERSET, ST. CROIX COUNTY, 3 LOT ro
WISCONSIN; INCLUDING OUTLOT 1 OF CERTIFIED SURVEY MAP VOLUME 16, PAGE 4309. i- J i -
LOCATION SKETCH Leap i 6?ND y'e�r'r W t
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Wisconsin Department of Safety and Professional Services NOV O 4 2019 Page / of J
Division of Industry Services
SOIL EVALUATION R ORT .1 ._.oix Cour1lYnent lgyl4 (aq
Cori
In accordance with SPS 385. Wis. Adm. T y
Attach complete site plan on paper not less than 8 1/2 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. �32 Y Z,� �' �$ ��
scale or dimensions, north arrow, and location and distance to nearest road.
Please print all Information. Re ' by ,/ Date
Personal information you provide may be used for secondary purposes Priva Law, s. 15.04(l)(
Prppe y Qwner Property Location ❑ 45
L >< / 7 NGovl. Lot /y. S T3/ N R E (or) W
Property Owner's M g @s� 7� I� L Lot # /D O Block # S .Name or CS r �/7j� f
Z7 if
City State Zip Code Phone Number ❑ city ❑ Village Town Nea st R 1
nJ I wX I Syol b I f I 1Sorrz;,Pz e f t IV ST
alNewConstruction Use: M Residential I Numberof bedrooms
❑ Replacement ❑ Public or commercial — Describe:
Parent material
General comments and recommendations: .S
MBoring #
❑ Boring
,1 Pit
Code derived design flow rate—7--C-dPD
Flood Plan elevatio�pppli abble ft.
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CST Number q9
Address
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' Effluent #1 = BOD, > 30 5 220 mg/L and TSS > 30 5 150 mg/L ' Effluent #2 = BOD, > 305 220 mg/L and TSS > 30 5 150 mg/L
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