HomeMy WebLinkAbout030-2149-04-000
PRIVATE SEWAGE SYSTEM County: St. Croix
Wisconsin Department of Commerce
Safety and Building Division Sanitary Permit No:
INSPECTION REPORT 552355 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:
Leaf, Jane St. Joseph, Town of 030-2149-04-000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
6 fh ~ (~6r 36.30.20.3029
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
.rut.
Septic Benchmark T
7 •1
` 59 d~0
Alt. BM qd 3
Aeration Bldg. Sewer AS
Holding St/Ht Inlet 3 g~
~5 9Z. a~
TANK SETBACK INFORMATION St/Ht Outlet
O
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet `
Bt Bottom
Septic 1 A)p
Dosing Header/Man. .5 c.7//, 32;
Aeration Dist. Pipe t~,$Z 0 7/' n
Holding Bot. System S 5*Z, 16 J ~Q x,.
Final Grade ~ /1 ~ ~CJ7` ~-'pU d~
PUMP/SIPHON INFORMATION "r U
Manufacturer Demand St Cover Y~/L , cso ` 2
GPM 1 / v J
Model Number ) " c{ !Jd VA 3 U ~ - /
TDH ift Friction Loss System TDH Ft
Forcemain Length Dia. Dist. to Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS Z IC~LK.S+~
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM CHLEACHING AMBER OR Manufacturer:
INFORMATION Type Of System.
UNIT Model Number: QU
L- , <j
46'1 Awl
DISTRIBUTION SYSTEM ~j VL/(0 = jil ot
HDistributio x Hole Size x Hole Spacing Ven to Y Intake
Pipe(engh__ Dia Length Dia Spacing`
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth of xx Seeded/Sodded F Mulched
Bed/Trench Center Bed/Trench Edges \ Topsoil \ Yes No Yes Q No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / J Inspection #2:
Location: 246 124th Ave Hu on, WI 5 16 (NE 1/4 W 1/4 36 T30N R20W) Seven Oaks Lot 4 i Parcel No: 36.30.20.3029
1.) Alt BM Description = Tti~ P,
2.) Bldg sewer length
b
-amount of cover = T
1/2
Plan revision Required? ❑ Yes No
Use other side for additional information. U1
Date Insepctor's nature Cert. No.
SBD-6710 (R.3/97)
County e2 G ;
. Safety and Buildings Division
t 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.)
:DSp d=
Madison, WI 53707-71132
Sanitary Permit Application State Transaction Number
In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this to the appropriate governmentid unit "
is required prior to obtaining a sanitary permit- Note: Application fo state-owned POWTS are submitted to P%ject Address (if different than mailing address)
the Department of Safety and Professional Servies. Personal on provide may be used for secondary
purposes in accordance with the Privacy Law, s- 15.04(( Ste 2 '16 J!2
7 Gam-
L Application -!km Print oe l 104 4.. W , it, Property Owner's Name , 11. Parcel #
-1? L ~A G 310X14 t2, ay_ 6d
Property Owner's Mailing Address 00, y` t.,A p Property Location
2?elf 2vr~ i~V~_? C C•
(11041W Govt. Lot
City, State / Zip /Code /her h (V 47- YS S 4/ K. Section to
7"TGY%2_ ~~S=Go~~"/,~ef~ '1UIE
84l~~✓I~h k)
T ~J~/ N; R
IL Type of Bni~ing (check all that apply) Lot
1 or 2 Family Dwelling-Number of Bedrooms J? Subdivision Name
Block # ~ ~ ~ ,f
❑ Public/Commercial - Describe Use d ❑ City of
❑ State Owned-Describe Use CSM Number ❑ Village of
gTown of !~f . tG r e_ ,,p Az
tJ
III. Type of Permit: (Check only one boa on line A. Complete Hue B if applicable)
,ytem ❑ Replacement System ❑ TreatrnentlHokling Tank Replaceatent Only ❑ Other Modification to Existing System (e ►lain)
A- [New &
B. ❑ Permit _Renewal ❑ Permit Revision ❑ Charge of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued
Before Expiration Owner
I.V. Type of POWTS S m/Com nt/Device: Check all that apply)
NorPressurized InGkound ❑ Pressurized Im-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in a
❑ Holding Tank ❑ Other Dispersal Component ❑ Pretreatment Device (explain) ^ 5
V. Dis rsaUT nt Area Informationt ,e L = 4/ h o
Design Flow (gpd Design Soil Applicat gpd DispersfA Area Required Dispersal Area Syste Elev
L~~Z L q2 G( c
VI. Tank Info Capacity in Total # of
Gallons Gallons Units
New Tanks Existing Tanks
~ U inn ~ a~ W b P,
Septic or Hokhng Tads
. ESc.
Dosing Chamber
VII. Res ' " ity Statement- 1y tie andervigaed, amaime respoasibtiity for imWiatiot of the POWTS shown as tic attaicied plea
Plumber's Name (Print) Plumber' Signature jt0RoB'RS Number Business Phone Number
o e 514 2d2-3"0>- ~5 =~~~/-SSG`
Plumber's Address (Street, City, Zip Code)
VII]MBUICOUR eat use only
KApproved Per fmit Fee Date Issued I Issuing Si
Besot for Denial sit 175
I%. Coaditm~i3IQ11Nhlj~teasons for Di4approval f _
1. Septic tank, effluent filter and 3 r ~1JJ tf~~ G d r~
dispersal cell must all be services / maintained b y
a
as per management plan provided by plumber.
2. AMa ck•Pegt*emettte must be maintained j
Attsei to complete plans for fte system said submit to the Comity only as papa not less than 8 tn: Y)nches do size
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CONVENTIONAL COMPONENT DESIGN
Residential Application
INDEX AND ` RLE PAGE
Project Name: G 7- ( 0 ri Ct L
Owners Name: t V a-
Owners Address: o{ L~ 7 d h AV
a lc~ w~ ~v S~~ 0 2
Legal Description: 's UJ N Poo (A
Township: T - o S f~ h
County:
Subdivision Name:
Lot Number 41
Parcel lD Number. d /4~y - C3 ^ Ca
Page 1 index and We
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 Crobc Cty Septic Tank Maintenance Form
Page 8 Warranty Deed
Page 9 CSM or Plat
Attac : Soil Test & House Plans
r
Designer/Plumber License Number.~x _
Date: Phone Numbed!
Signature
Duned p nt to ft in-Grauna Solt Absorption Component Manua! for PdWra vwWpn 2D s8D-io7o5-p (nl.o1/01
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Mound System Management Pion
Pursuant to Comm 83.54, Wis. Adm. Code
general This system shall be operated in accordance with Comm 82-54 Wis. Adm. Code, and shall maintained in acCOroance with its!
component manuals (SBD-10691-P (N.01/01) and SSWAAP Publication 9.8 (01181)] and local or state rules pertaining to system
maintenance and maintenance reporting. No one should ever enter a septic or pump tank since dangerous, gases may be present that could cause death.
Septic and pump tank abandonment shall be In accordance with Comm 83.33, Wis. Adm. Code when the tanks are no longer used
as POYYTS components. Septic or pump tank manhole risers, access risen; and covers should be Inspected for water tightness and soundness. Moose
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 "ches in diameter shall be secured by an
effective locking device to prevent accidental or unauthodaed entry into a tank or component.
Tank
The septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, Stats. The contents of the
aseptic tank shall be di3pwed of in accoriclence with NR 113, Wis. Adm. Code. The operating condition of Jim x,;rar7. Wink hnd 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 fitter alarms may indicate surge flows or an impending continuous alarm.
The septic tank shall have its contents removed when the volume of sludge and scum 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 a triennial assessment, maintenance personnel shall advise the owner of when the next service needs to be
performed to maintain less than maximum scum and sludge accumulation in the tank.
The addition of biological or chemical additives to enhance septic tank performance is generally not required. rif such
products are used they shall be approved for septic tank use by the Department of Commerce. }
i
The pump ( ing) tank shall be inspected at least once every 3 years. All switches, alarms, an4lmps shall be tested to verify
proper operation. an effluent filter is installed within the tank It shall be inspected and servioa4198 necessary.
JYI
No trees or shrubs sho be planted on the mound. Plantings may ma eroun mound's' perimeter, and the mound shall be
seeded and mulched as ry to prevent erosion and to provide some p~Pteetion from frost penetration. Traffic (other than for vegetative maintenance) an them d is not recommended
since soil co Won may hinder aeration of the infiltrative surface within
the mound and snow compaction in th nter will promote frost penet ion. Cold weather installations (October-February) dictate that
the mound be heavily mulched as protect from freezing. Influent quardy into the mound system of exceed 220 BOD5, 150 mglL TSS, and 30 mg/L FOG for septic tank effluent
or
30 mg& BOD,, 30 mg/L TSS, 10 mg/L FOG, and 4 du/1 mt_ for highly treated effluent. Influent flow may not exceed maximum
design flow specified in the permit for this installation.
The pressure distribution system is provided with flu ing point at the end of each lateral, and it is recommended that each lateral be flushed of accumulated solids at least once
18 mo s. When a pressure test is performed it should be compared to the initial
test when the system was installed to determl if orifice cioggi has o=urred and if orifice cleaning is required to maintain equal
dlatribution within the dispersal cell.
Observation pipes within the diapers II shall be checked for effluent ponding. Ponding levels shall be reported to the owner, and any levels above 6 inches conside s an impending
hydraulic failuni'xaquiring additional, more frequent monitoring.
ConHnaencv.Phm If the septic tank or any its components become defective the tank or coriiponent shall be repaired or replaced to keep the system
in proper operating cond' ' ,
If the dosing tank, p, pump controls, alarm or related wiring becomes defer we the defective component(s) shall be immediately
repaired or ra a component of the same or equal performance. If the mound mponent fails to accept wastewater or begins to discharge wastewater to the ground surface, it
will be repaired or
replaced in Its' resent location by increasing basal area if toe leakage occurs or by removing- biologically clogged absorption and
dispersal ~ media, and related piping, and replacing said components as deemed neoessary to tiring the system into proper operating condition. "
See Page 5 of this plan for the name and telephone number of your local POWTS regulator and service provider.
Project: Heath Mound Page 6 of 8
1170d =QI SZ:9T ZT-9T-S0
ST. CROIR COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer Al e
Mailing Address 941 a e, 14-G
rtYAddress R4 /d L'U" S-e- OG 'Z. AVU
(Verification required from Planning & Zoning Dgnrtmieot for new coustruction.)
G
City/State 9" Pmel Identification Number 0 3 ~2 - 2 -G - 6G G
LEGAL DESCRFnON
Property Location tJ t/. , S k~ %a , Sec. 3 G , T N R W, Town of 56-
Subdivision- lot -
CertMed Survey Map # , Volume , Page #
Warranty Deed # , Volume , Page #
Spec house yes no Lot lines identifiable yes no
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
In roper use and maintenance of your septa system could result in its p me failure to handle wastes. Proper
,O,m, consists of pumping out the septic tank every three years or soo=, if needed, by a licensed pumper. What you put into
the system can affect the function of the septic took as a treatment stage in the waste disposal system owner ace
responszbfiities are specified in §Comm. 8352(1) and in Chapter 12 - St. Croix County Sanitary Ordinance.
The property owner agrees to submit to St: Croix County Planning & Zoning Department a certification form, signed by the
owner and by a nmster phnnber, journeyman plumber, rested plumer or a licensed pumper verifyiug'dw (1) the on-site
wastewatrr disposal system is in proper operating condition. and/or (2) afar inspection. and pumping (if necessary), the wpttc tank is
less than 113 fill of shulge.
Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the
standards 30t forth, herein, as set by the Department of Coerce and the Department of Natural Resources, State of Wisconsin.
Cartificafian stating that your septic system has been maiNained must be completed and returned to the St. Croix County Planning &
Zoning Department within 30 days of the throe year eapn stion. date.
Uwe certify that all slatetnents on this form are true to the best of my/our knowledge. Uwe amlare the own(s) of the
pope rty desenbed above, by virtue of 76anty deed recorded in Regis of ]Doeds Office.
Numb e of bedrooms 3
SIGNATURE O PLICANT(S) DATE
***Any information that is misrepresented may result in the sanitary permit being revoked by the Plaummg & Zoning Departmezit.
Include with fire application a recorded warranty deed from the Register of Dodds Office and a copy of the certified survey map if
refea+enee is made in the warranty deed.
(REV. OM S)
953308
BETH PABST
STATE BAR OF WISCONSIN FORM 2 - 2000 REGISTER OF DEEDS
Document Number WARRANTY DEED ST. CROIX CO., WI
RECEIVED FOR RECORD
THIS DEED, made between Pirius Development Company, 03/28/2012 08:57 AM
LLC, Grantor, and Jane R. Leaf, a married person EXEMPT # NA
REC FEE: 30.00
Grantee. TRANS FEE: 288.00
Grantor for a valuable consideration, conveys and warrants to PAGES: 2
Grantee the following described real estate in St. Croix County, **The above recording information
Wisconsin: verifies that this document has
been electronically recorded
& returned to the submitter
Lot 4 6 and 7, Plat of Seven Oaks in the Town of St. Joseph,
St. Croix County, Wisconsin.
Recording Area
Name and Return Address:
Edina Realty Title, Inc.
400 South Second Street, Suite 115
Hudson, WI 54016
917886
Exceptions to warranties: 030-2149-07-000
Easements, restrictions and rights-of-way of record, if any. 030-2149-06-000
030-2149-04-000
Dated this Parcel Identification Number (PIN)
This is not homestead property.
Pirius Develo ent Compan
BY: t
Terry E. Piri Member
WARRANTY DEED STATE BAR OF WISCONSIN FORM No. 2-2000
1 of 2
Wisconsin Department of Commer~ SOIL EVALUATION POIR►Page 1 of
Division of Safety and Building
Y in rdancewith Comm 85, Wis. Adm. Code
C y'
Attach complete site p not less than 8 1/2 x 11 inches in size. Plan must S Croix
include, but not limited t : vertical and horizontal reference point (BM), direction andr~(CO 03 2149-04-000
percent slope, scale or dimensions, north arrow, and location and distance to nearest r JKA PUN s ~ Y
Please print all information. DLig Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). ! 21
Property Owner Property Location
Jane Leaf r(S o- Govt. Lot NE 1/4 SW 1/4 S 36 T 30 N R 20 E❑(or)❑W
Property Owner's Mailing Address Lot # Block # Subd. Name r C$K# / g
2487 20th Ave. 4 ~ vt4-,-0 r t c
b (1-
City State Zip Code Phone Number []City Village E]Town Nearest Road
Baldwin Wisc. 54002 ( 715-698-2168 71-1 (P 124th Ave
El New Construction UseE] Residential / Number of bedrooms 3/4 Code derived design flow rate 450/600 GPD
0 Replacement Public or commercial - Describe:
Parent material Outwash Flood Plain elevation if applicable Ivy ft.
General comments Conventional System System Elevation @ 91ft.
and recommendations:
A
Boring # 0 Boring
a Pit Ground surface elev. 98.3 ft. Depth to limiting factor >140 in
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0-6 10YR2/2 sil 2mbk mfr as if .6 .8
2 6-13 10YR3/3 sil 2mbk mr cs if .6 .8
3 13-20 10YR3/6 sicl 2mbk mfr cs .4 •6
4 20-140 7.5YR4/4 cos os ml 7
1 ' s P-1-
OIL
r
~o S s
2 Boring # Boring 93.6 >140 El Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0-7 10YR2/2 sil 2mbk mfr as if
2 7-19 10YR3/3 sil 2mbk mfr cs if
3 19-25 10YR3/6 sicl 2mbk mfr cs 19
4 25-140 7.5YR4/4 cos osg ml , 7 f . 4,
* Effluent #1 = BOD > 30:5 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L
CST Name (Please Print) Signature / ~ /CST Number
Thomas W. Gedatus ib-htcm 6, 962178
Address Date Evaluation Conducted Telephone Number
Stang Plumbing & Electric P.O. Box 263 Woodville, Wisc. 54028 4/11/2012 715-684-5166
Property Owner Jane Leaf Parcel ID # 032-2149-04-000 page 2 of
F 3 Boring # 11 Boring
E] pit Ground surface elev. 98'5 ft. Depth to liming factor >140 in
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0-6 10YR2/2 sit 2mbk mfr as if , 63
2 6-22 10YR3/3 sil 2mbk mfr cs if , (o , Q
3 22-140 7.5YR4/4 cos osg ml NA
,1 t, ro
F-1 Boring # Boring
Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
H Boring
❑ Boring #
Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
* Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mgA. * Effluent #2 = BOD', 5 30 mg& and TSS 5 30 mg&
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-2648777.
SBD-8330rest (8.07/00)
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