HomeMy WebLinkAbout040-1318-00-035PRIVATE 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)
Wisconsin Department of Safety and Professional Services Phone: 608-266-2112
Division of Industry Services Web: http://dsps.wi.gov
4822 Madison Yards Way Email: dsps@wisconsin.gov
PO Box 7302
Madison, WI 53707 Tony Evers, Governor
Dan Hereth, Secretary
July 24, 2023
CONDITIONAL APPROVAL
PLAN PROVAL EXPIRES: 2025-7-24
Plan Review: PWTS-
Shaun Bird
1432 120th St
New Richmond, WI
SITE:
Creative Homes
719 Mount Curve Court, Lot 35
St Croix County
Town of Troy
NW ¼ NW ¼ S11 T28N R19W
FOR:
Description:4 Bedroom-600 GPD mound 24
to restrictive feature- Effluent Filter -
Maintenance required.
Mound Component Manual Ver. 2.1, SBD-
10691-P (5/22-5/27)
Pressure Distribution Component Manual Ver.
2.1 (May 2022-2027)
Verify proper dose is achieved and system is not being over dosed.
The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative
Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. This system is to be
constructed and located in accordance with the enclosed approved plans and with any component manual(s)
referenced above. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance
with all code requirements.
No person may engage in or work at plumbing in the state unless licensed to do so by the Department per
s.145.06, stats.
The following conditions shall be met during construction or installation and prior to occupancy or use:
Reminders
removed. To avoid matting, any leaves or loose organic matter shall be raked up and removed. Cut trees
and shrubs flush to the ground and leave stumps. Avoid operating equipment on the
Mound site. If necessary, use only tracked equipment, during dry conditions, with minimal passes, to avoid
compaction.
Components and soil removed from an existing drain field shall be properly disposed of so that there is no
risk to public or environmental health.
Conditionally
APPROVED
DEPT. OF SAFETY AND PROFESSIONAL
SERVICES
DIVISION OF INDUSTRY SERVICES
Joshua Rowley
SEE CORRESPONDENCE
072301485-C
A sanitary permit must be obtained from the county where this project is located in accordance with the
requirements of Sec. 145.19, Wis. Stats.
Inspection of the private sewage system installation is required. Arrangements for inspection shall be made
with the designated county official in accordance with the provisions of Sec. 145.20(2)(d), Wis.
Stats.
A state approved effluent filter is required. Maintenance information must be given to the owner of the tank
explaining that periodic cleaning of the filter is required.
A copy of the approved plans, specifications and this letter shall be on-site during construction and open to
inspection by authorized representatives of the Department, which may include local inspectors.
Owner Responsibilities
The current owner, and each subsequent owner, shall receive a copy of this letter. Owners shall also receive a
copy of the appropriate operation and maintenance manual(s) and be responsible for ensuring that POWTS is
operated and maintained in accordance with this chapter and the approved management plan under s. SPS
383.54(1).
In the event this soil absorption system or any of its component parts malfunctions so as to create a health
hazard, the property owner must follow the contingency plan as described in the approved plans.
The owner is responsible for submitting a maintenance verification report acceptable to the county for
maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s)
utilized in the POWTS.
In granting this approval the Division of Industry Services reserves the right to require changes or additions should
conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review
shall relieve the designer of the responsibility for designing a safe building, structure, or component.
Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the
address on this letterhead.
The above left addressee shall provide a copy of this letter and the POWTS management plan to the owner and
any others who are responsible for the installation, operation or maintenance of the POWTS.
Sincerely,
Joshua Rowley
POWTS Plan Reviewer, Division of Industry Services
(715) 634-5124
Joshua.rowley@wisconsin.gov
Conditionally
APPROVED
DEPT. OF SAFETY AND PROFESSIONAL
SERVICES
DIVISION OF INDUSTRY SERVICES
Joshua Rowley
SEE CORRESPONDENCE