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Home My WebLink About038-1190-20-000 (4)PRIVATE SEWAGE SYSTEM INSPECTION REPORT (ATTACH TO PERMIT) Wisconsin Department of Commerce Safety and Building Division GENERAL INFORMATION TANK INFORMATION TANK SETBACK INFORMATION PUMP/SIPHON INFORMATION SOIL ABSORPTION SYSTEM DISTRIBUTION SYSTEM SOIL COVER COMMENTS: ELEVATION DATA Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: CST BM Elev:Insp. BM Elev:BM Description: County: Sanitary Permit No: State Plan ID No: Parcel Tax No: TYPE MANUFACTURER CAPACITY Septic Dosing Aeration Holding TANK TO P/L WELL BLDG.Vent to Air Intake ROAD Septic Dosing Aeration Holding Manufacturer Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia.Dist. to Well Demand GPM STATION BS HI FS ELEV. Benchmark Alt. BM Bldg. Sewer St/Ht Inlet St/Ht Outlet Dt Inlet Dt Bottom Header/Man. Dist. Pipe Bot. System Final Grade St Cover BED/TRENCH DIMENSIONS Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia.Liquid Depth SETBACK INFORMATION SYSTEM TO P/L BLDG WELL Type Of System: LAKE/STREAM LEACHING CHAMBER OR UNIT Manufacturer: Model Number: Header/Manifold Length________ Dia________ Distribution Pipe(s) Length_________ Dia_________ Spacing_________ x Hole Size x Hole Spacing Vent to Air Intake x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Bed/Trench Center Depth Over Bed/Trench Edges xx Depth of Topsoil xx Seeded/Sodded xx Mulched Yes No NoYes (Include code discrepencies, persons present, etc.) Location: 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Inspection #1: Inspection #2: City Village Township Section/Town/Range/Map No: Plan revision Required?Yes No Use other side for additional information. Date Insepctor's Signature Cert. No.SBD-6710 (R.3/97) SBD-6398 (R. 11/11) Safety and Buildings Division 201 W. Washington Ave., P.O. Box 7162 Madison, WI 53707 7162 County St. Croix Sanitary Permit Number (to be filled in by Co.) Sanitary Permit Application In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to the Department of Safety and Professional Services. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats. State Transaction Number Na Project Address (if different than mailing address) SameI. Application Information Please Print All Information Ronald Haaland Parcel # 038-1190-20-000` 1360 214th Ave. Property Location Govt. Lot ________ NW ¼, SE ¼, Section 13. (circle one) T __31___ N; R __18____ W City, State New Richmond, WI 54017 Phone Number (651) 278-3358 II. Type of Building (check all that apply) 1 or 2 Family Dwelling Number of Bedrooms ______3 _______ Public/Commercial Describe Use . State Owned Describe Use _________________________________ Lot # 24 Subdivision Name NorthgateBlock # Na City of __________________________________ Village of __ ______ Town of __ Star Prairie________________ CSM Number Na III. Type of Permit: (Check only 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) B.Permit Renewal Before Expiration Permit Revision Change of Plumber Permit Transfer to New Owner List Previous Permit Number and Date Issued 374906 issued 10/12/2000 IV. Type of POWTS System/Component/Device: (Check all that apply) Non-Pressurized In-Ground Pressurized In-Ground At-Grade Mound > 24 in. of suitable soil Mound < 24 in. of suitable soil Holding Tank Other Dispersal Component (explain)___________________________Pretreatment Device (explain)_ _ V. Dispersal/Treatment Area Information:Diversion valve, 32 - Design Flow (gpd) 450.0 Gpd Design Soil Application Rate(gpdsf) 0.7 Gpd/Sq. Ft. Dispersal Area Required (sf) 642.85 sq. ft. Dispersal Area Proposed (sf) 654.40 sq. ft. System Elevation VI. Tank Info Capacity in Gallons Total Gallons # of Units Manufacturer New Tanks Existing Tanks Septic or Holding Tank 1,000 1,000 1 Huffcutt Concrete X Dosing Chamber VII. Responsibility Statement-I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. James K. Thompson MP/MPRS Number MPRS 30021 Business Phone Number (715) 248-7767 340 Paulson Lake Lane, Osceola, WI 54020 VIII. County/Department Use Only Approved Disapproved Owner Given Reason for Denial Permit Fee $ Date Issued Issuing Agent Signature IX. Conditions of Approval/Reasons for Disapproval Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size Project Name: Haaland 3 Bedroom Replacement Conventional POWTS Owners Name: Ron Haaland Owner's address: PO Box 2152, Stillwater, MN 55082 Site address: 1360 214th Ave., New Richmond, WI, 54017 Project Location: Subdivision: lot 24, Plat of Northgate Legal Description: NW1/4 SE1/4, Sec. 13, T.31N., R. 18W., Tn. of Star Prairie, St. Croix Co., WI. Parcel ID #: 038-1190-20-000 Page 1 Index and Title Sheet Page 2 Site Plan Page 3 Dispersal Cell Sizing Calculations Page 4 Dispersal Cell Cross Section Page 5 Infiltrator "Q-4" Chamber Specifications Page 6 Conventional POWTS Management Plan Page 7 Existing Septic Tank Certification Page 8 Sanitary System Ownership & Address Form Page 9 Parcel Map page 10 Warranty Deed Attached: Soil Evaluation Report Mater Plumber Restricted Service: Jim Thompson, DSPS Credential #30021 Signature: Date: Conventional POWTS Index & Title Sheet Page 1 0f 10 Design pursuant to In-Ground Soil Absorption Component Manual for POWTS, version 2.1 SBD-10705-P (N.01/01) Andrews 3 Bedroom Dispersal Cell Sizing Calculations 1. (3 bedrooms)(100 gallons estimated flow)(1.5 design factor) = 450.00 Gpd design flow 2. Infiltrative capacity of native soil = 0.7gpd/sq. ft. 3. Absorption area required: 642.86 sq. ft. 4. Absorption area as proposed: 654.40 sq. ft. (32 chambers + 2 pair end caps) s = 7.20 sq.ft, EISA/pair 642.86 sq. ft.- (7.2 x 2)/20.00 = 31.72 chambers required Number of trenches: 2 @ 16 chambers per trench (32 chambers total) Trench width: Trench length: 67 Trench spacing: 9 Total system area w/ 6 : 12 67 Pg. 3 of 10 Pg. 4 of 10RESET 1 Pg. 5 of 10 Conventional Septic System Management Plan Pursuant to SPS 383.54, Wis. Adm. Code General The conventional septic system shall be operated in accordance with SPS 382-384 Wis. Adm. Code, and shall be maintained in accordance with component manual SBD-10705-P (N.01/01). All local and/or state rules pertaining to system maintenance and maintenance reporting shall be complied with. Questions on the operation or maintenance of the system should be directed to the installing plumber, Jim Thompson at (715) 248-7767 or the Polk County Zoning Department at (715) 485-9279. Septic Tank Septic tank servicing mechanics comply with SPS 3 bottom of tank to be e operating condition of the septic tank and outlet filter shall be assessed at least once every two years by inspection. The septic tank contents shall be removed when the sludge and scum in the tank exceed 1/3 the liquid volume of the tank. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code, by an individual certified to service septic tanks under s. 281.48, Stats. If the contents of the tank are not removed at the time of a biannual assessment, maintenance personnel shall advise the owner of when service will be needed to maintain less than 1/3 scum and sludge accumulation in the tank. 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. Septic tank manholes 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 individual should ever enter the septic tank as dangerous gases may be present that could cause death. Septic tank abandonment shall be in accordance with Comm83.33, Wis. Adm. Code when the tank is no longer used as a POWTS component. The addition of biological or chemical additives to enhance septic tank performance is generally not required. If such products are used they shall be approved for septic tank use by the Department of Commerce, Safety and Buildings Division. Soil Absorption Cell Trees or shrubs should not be planted directly on the soil absorption system. The area above and around the system should be seeded and mulched as necessary to prevent erosion and provide some degree of frost protection. Traffic (other than for vegetative maintenance) over the system is to be avoided. Soil compaction may hinder aeration of the infiltrative surface within and above the system and will promote frost penetration during cold weather months. Cold weather installations (October-March) dictate that the system be heavily mulched for frost protection. Influent quality into the system may not exceed 220mg/L BOD5, 150 MG/L TSS, and 30 mg/L FOG. Influent flow may not exceed maximum design flow specified in the permit for the installation. Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels shall be reported to the owner. Levels above 8 inches indicate an impending hydraulic failure requiring additional, more frequent monitoring. Effluent flow shall be alternated between dispersal cells on a two-year schedule by use of diversion valve. Effluent to be diverted from new cell to old dispersal cell at 3 year anniversary of new system installation. Old dispersal cell to be utilized for a 1 year period. Effluent dispersal to be alternated between systems on a two year rotating basis thereafter. Contingency Plan If any POWTS component becomes defective, the component shall be repaired or replaced to keep the system in proper operating condition. Excessive ponding within the dispersal cell will be eliminated by alternating the diversion valve between dispersal cells to bring the system into proper operating condition. If alternating cells does not result in a properly operating system, a new dispersal cell will be installed. Pg. 6 of 10 ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) This is to certify that I have inspected the existing septic and/or dose tank presently serving the following residence: (Street address)_________________________________________ located at: _____ ¼, ____ ¼, Section ______, Town______N, Range_______W, Town of ____________________________, St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of SPS. 384.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service _________________________. Did flow back occur from absorption system? Yes____ No____ (if no, skip next line.) Approximate volume or length of time: ________ gallons _______ minutes Tank Capacity: __________ Construction: Prefab Concrete ______ Steel ______ Other _____________ Manufacturer (if known): ________________________________________ Age of Tank (if known): _________________________________________ Permit number (if known) ___________________ ______________________________ _____________________________ (Licensed Plumber Signature) (Print Name) ______________________________ _____________________________ (Title) (License Number) MP/MPRS ______________________________ (Date) Form to be completed by licensed plumber (Dept of Safety and Professional Services Chapter 305 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 2/2012 Pg. 7 of 10 Community Development Department – Land Use Division 715-386-4680 St. Croix County Government Center 715-245-4250 Fax cdd@sccwi.gov 1101 Carmichael Road, Hudson, WI 54016 www.sccwi.gov SANITARY SYSTEM OWNERSHIP/ADDRESS FORM 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. Owner/Buyer Mailing Address City/State/Zip Phone Number (required) Email Address (required) Parcel Identification Number (found on the property tax bill) Property Location _____ ¼ , _____ ¼ , Sec. _____, T _____N R_____W, Town of . Subdivision Plat: , Lot # _____. Certified Survey Map # , Volume , Page # . Warranty Deed # (before 2006)Volume , Page # . Number of bedrooms Spec house yes no Lot lines identifiable yes no New Property Address (Verification of new address required from Community Development Department for new construction.) / / (Staff Initials) (Date) 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. NEW SYSTEM: LEGAL DESCRIPTION File #: ______________ Office Use Only Created 2/2021 OFFICE USE ONLY OWNER/BUYER INFORMATION Pg. 8 of 101 Pg. 10 of 10 Pg. 9 of 10