HomeMy WebLinkAbout020-1001-40-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT S nitary Permit No:
569559 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:
Collins, John E. &Anne I Hudson, Town of 020-1001-40-000
CST BM Elev: Insp.BM Elev: BM Description/: Section/Town/Range/Map No:
/ (�(�a.�2. c.,�" 07.29.19.2D
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER ;,�e� CAPACITY STATION BS HI FS ELEV.
Septic � • � Benchmark
Dosing Alt. BM
"r ✓V�, /D to D
Ae
< Bldg.Sewer
Holding (" V St/Ht Inlet T7 a
TANK SETBACK INFORMATION St/Ht Outlet 4.to
TANK TO �P/� WELL 5tL`G Vent Air Intake ROAD Dt Inlet
Septic Dt Bottom-7166 166
Dosing Header/Man.
Aeratio Dist. Pipe
Holding Bot.System
Final Grade
PUMP/SIPHON INFORMATION
Manufacturer Demand St Cover
GPM I ��•
Z
Model Numb
TDH Lift Friction Loss System Head TDH Ft
Forcemain Length Dist.to Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No.Of Trenches PIT DIMENSIONS No.Of Pits Inside Dia. Liquid Depth
DIMENSIONS
SETBACK SYSTEM TO P/L JBLDG IWELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION Type Of System: CHAMBER OR
-6 UNIT Model Number:
DISTRIBUTION SYSTEM
Header/Manifold IDistribution x Hole Size x Hole Spacing Vent to Air Intake
Pipe(s)
Length Dia I 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 Mulched
Bedlrrench Center Bed/trench Edges Topsoil
Yes 0 r No 0 Yes ❑ No
COMMENTS: (Include code discrepencies,persons present,etc.) Inspection#1: / / Inspection#2:
Location: 1042 GOLDEN OAKS DR Hudson,WI 54016(SE 1/4 NE 1/4 7CT229N 1319W) metes&boundsL4ot 5, /I Parcel Nq�07.29.19.2D
1.)Alt BM Description= �• �K. GaJ -- �xl) I-ZX ^'k r1, f
2.)Bldg sewer length= �jr1S Gd 1 5o
-amount of cover=
PPP
Plan revision Required? ❑ Yes No
Use other side for additional informati n. V
SBD-6710(R.3/97) Date Insepctor's Sig r ure Cert.No.
IM-1060 General Specifications and Illustrations
LIFTING STRAP LIFTING LUG RISER CONNECTION
(TYPICAL) R L) (TYPICAL)
The IM-1060 is an injection molded two piece mid-seam
plastic tank.The IM-1060 injection molded plastic design A A'
allows for a mid-seam joint that has precise dimensions 0
for accepting an engineered EPDM gasket. Infiltrator's t 0%0 a 0 b 62.2
gasket design utilizes technology,from the water industry 0 %0 115801
TERIOR
to deliver proven means of maintaining a watertight seal. EXWIDTH
The two-piece design is permanently fastened using a
series of non-corrosive plastic alignment dowels and
locking seam clips. The IM-1060 is assembled and sold
through a network of certified Infiltrator distributors. 117.0[3226]EXTERIOR LENGTH
TOP VIEW
oum.Er
Working Capacity 1094 gal(4141 L)
or
Total Capacity 1287 gal(4872 L)
7 54.7
Airspace 16.5% [13891
EXTERIOR
Length 127"(3226 mm) SEAM CUP HEIGHT
Width 62.2"(1580 mm) (TYPICAL)
LIFTING STRAP
Length-to-Width Ratio 2.3 to 1 (TYPK�4AL)
Height 54.7"(1389 mm) END VIEW
Liquid Level 44"(1118 mm)
Invert Drop 3"(76 mm) 04[1021 0 24[6101 ACCESS OPENINGS WITH LOCIONG LIDS(2)
PVC OR ABS 0 4(1021 PVC OR
Fiberglass Supports 2 INLETTEE -10-2[2601 FREEBOARD UTLET TEE
Compartments 1 or INLET 165%
10 t2[2601 FREEBOARD ABS AWORS
5%
6
AIR
AIRISPACE OUTLET
W
Maximum Burial Depth 48"(1219 mm) PER 3.0
[761 PER
C-f H CODE
Minimum Burial Depth 6"(152 mm) 44.0 1
FIBERGLASS (11181 FIBERGLASS
Maximum Pipe Diameter 6"(152 mm) SUPPORT LIQUID SUPPORT
(TYPICAL) DEPTH (TYPICAL)
WITH BAFFLE
Weight 320 lbs(145 kg) WALLWHERE
REQUIRED
SIDE VIEW
TANKTOP CONTINUOUS
HALF GASKET
TANK
INTERIOR SEAM CLIP
ALIGNMENT
DOWEL TANK BOTTOM
4
HALF
4 Business Park Road
P.O.Box 768
Old Saybrook,CT 06475
660-5777000-Fax a60-577-7001 MID-HEIGHT SEAM SECTION
INFILTRATOR" 1.800-221-4436
systems Inc. wwwrifiltratorsyswmiscom
U.S.Patents:4,759,661;5,017,041;5,156,488;5,336,017;5,401,116;5,401,459;5,511,903;5,716,163;5,588,778;5,839,844 Canadian Patents:1,329,959;2,004,564 Other patents pending.Infiltrator,
Equalizer,Quick4,and SideWinder are registered trademarks of Infiltrator Systems Inc.Infiltrator is a registered trademark in France.Infiltrator Systems Inc.is a registered trademark in Mexico.
Contour,Microl-eaching,PolyTuff,ChamberSpacer,MuttiPort,PosLock,OuickCut,QuickPlay,SnapLock and StraightLock are trademarks of Infiltrator Systems Inc.
Polyl-ok is a trademark of PolyLok,Inc.TUF-TITE is a registered trademark of TUF-TITS,INC.Ultra-Rib is a trademark of IPEX Inc.
0 2013 Infiltrator Systems Inc.AN rights reserved.Printed in U.S.A. IM02 1213
Contact Infiltrator Systems' Technical Services Department for assistance at 1-800-221-4436
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atr+ rT County 1 Safety and Buildings Division St.Croix
$ 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.)
P$ Madison,Wl 53707-7162 6-6 q 57��7
Sanitary Permit Application State Transaction Number
In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit N4
is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Pro �i different iffeerrent than mailing address)
the Department of Safety and Professional Services. Personal information you provide may be used for secondary a V/ D
purposes in accordance with the Privacy Law,s.15.04 1 m,Stats.
I. Application Information-Please Print All Information S y "0 Z (jai
Property Owner's Name 6 7P
/ 1# L�0 ,
'IOU % I iG7
John&Anne Collins
Property Owner's Mailing Address Property Loc 4'1ENT 6 Z /\
1042 Golden Oaks Dr Govt,Lot 1�
City,State Zip Code Phone Number `'/.,NE '/., Section 7
(circ
Hu on,WI 54016 715 386-0636 T 29 N; R 19 E C—wl)
II. ype of Building(check all that apply) Lot#
1 or 2 Family Dwelling-Number of Bedrooms Na Subdivision Name
�+ Block#
❑Public/Commercial-Describe Use Na ❑City of
❑State Owned-Describe Use �� CSM Number ❑ Village of
ivia Na g}ownof Hudson
III.Type of Permit: (Check only one box on liqb A. Complete line B if applicable)
A' ❑New System ❑Replacement System Tmatrumt/Holding Tank Replacement Only ❑Other Modification to Existing System(explain)
Addition of septic tank&Filter
B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued
Before Expiration Owner
IV.Jde of POWTS System/Component/Device: Check all that apply)
Non-Pressurized In-Gro ❑Pressurized In-Ground ❑At-Grade -❑ and> 4 in.of suitable soil El Mound<24 in.of suitable soil
❑Holding Tank Other Dispersal Component(explain "`��— ❑Pretreatment Device(explain)
V.Dis ersalff'reatment Area Information: Pol Lok PL-525 effluent filter to be installed at septic tank outlet.
Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation
450 Gpd Na Na Na 15
VI.Tank Info Capacity in Total #of Manufacturer ,
Gallons Gallons Units o v
New Tanks Existing Tanks � ny tbk-
Septic or Holding Tank 1,000 To be abandoned 1,000 1 1 Wies Concrete X
Dosing Chamber
VIL Responsibility Statement- I,the un ersigned, some responsibility for i lion of the POWTS shown on the attached plans.
Plumber's Name(Print) lumber's Signatu re MPlMPRS Number Business Phone Number
James K.Thompson _ �-- MFRS 30021 715 248-7767
Plumber's Address(Street,City,State,Zip CWel
340 Paulson Lake Lane,Osceola,W1 54020
VIII. oun /De artment Use Only
Permit Fee D Iss Issuin ant Sign
Approved 4
even Reason fo-,-Mnial
0L Cond�,�easons for Disapproval n i,-
T�'lE''10 tank affluent filter ohd J) UPi
tlispersal cell.rnust all be services I maintained n � 1
as per management plan provided by plumber. C.iadC�
7. zM sell at k fequitemertts>rtnust be maintained
as per applicable Code/ordinances.
Attach to complete plans for the system and submit to the County only on paper not less than 8 In x I l inches in size
SBD-6398(R. 11/11)
Index & Title Sheet - Septic Tank Replacement
Project Name: Collins Septic Tank Replacement
Owners Name: John&Anne Collins
Owner's address: 1042 Golden Oaks Dr.,Hudson,WI 54016
Site address: Same
Project Location
Subdivision:
Legal Description: SEli4 NEv4,Sec. 7,T.29N.,R. 19W.,Town of Hudson,St.Croix Co.,WI.
Parcel ID#: 020-100140-000
Page I Index and Title Sheet
Page 2 Site Plan
Page 3 Replacement Treatment Tank Crossection
Page 4 Filter Specifications
Page 5 Septic Tank Maintenance Agreement
Page 6 Conventional Dispersal Cell Management Plan
Page 7 Parcel map
Page 8 Deed
Mater P her JRes *cteWd Service: James K.Thom son,De 't.of Comm.Credential#30021
Signature: Date: CSC 7 4/fl
—f-
Page 1 Of 8
Design pursuant to In-Ground Soil Absorption Component Manual for POWTS,version 2.0 SBD-10705-P(N.01101)
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0— SEPTIC MANUAL DATE: 00/00/00 DATE: POST-POUR:
W3716 US HWY 10 MAIDEN ROCK, N 54750
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30142-525 1
HOUSING-POLYPROPYLENE
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ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer John & Anne Collins
Mailing Address 1042 Golden Oaks Dr.
Property Address Same
(Verification required from Planning&Zoning Department for new construction.)
City/State Hudson, W1 Parcel Identification Number 020-1001 -40-000
LEGAL DESCRIPTION
Property Location SE '/4, NE '/4 , Sec. 07 J 29 N R 19 W, Town of H u d so n
Subdivision Plat: Na , Lot#
Certified Survey Map# N a , Volume Na , Page# Na
Warranty Deed# (before 2007)Volume , Page#
Spec house DyesC no Lot lines identifiable dyesono
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper
maintenance consists of pumping out the septic 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 system. Owner maintenance
responsibilities are specified in§SPS.383.52(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 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.
I/we,the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the
standards set forth,herein,as set by the Department of Safety And Professional Services and the Department of Natural Resources,
State 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 oFain form are true to the best of my/our knowledge. I/we am/are the owner(s)of the
property described above,by virtue of a ty deed recorded in Register of Deeds Office.
Number of be ms 3
K4 !S / /&1(
TURE OF APPLICANT(S) DATE
***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning&Zoning Department. ***
Include with this application 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.
(REV.04/12)
SoF�'
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 St.Croix County Zoning Department at
(715)386-4680.
Septic Tank
Septic tank servicing mechanics comply with SPS 383.54(1)(e). Septic tank to be located within 150'of service pad,with
bottom of tank to be 515'below service pad elevation. The 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 BODS, 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 4 inches indicate an impending hydraulic failure requiring additional,more frequent monitoring.
Continaenev Plan
If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the
system in proper operating condition. Excessive ponding within the dispersal cell will be eliminated by installing a new soil
absorption cell to bring the system into proper operating condition.
Pg.6 of 8
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DOCUMENT NO. STATE-BAR OF WISCM1114-FO1t*Z
Box 492 PasE464 '" "' KC
313767 THIS SPACE RESERVED fql IIECdIDING DATA
BY THIS DEED, Kendall B. Priester I
rtEG1STER5 OFFICE
ST,CROIX CO.,WIS.
Rec'd for Record this-?th_
Grantor conveys and warrants to John E. Collins and Anne C. day of Degembe_r___A,D.19 12
Collinsx husband and wife as ioint tenants, ___At M.
Grantee S •
for a valuable consideration - RETURN TO
r ,
the following described real estate In St. Croix.County,State of Wisconsin:
A parcel of land known as Parcel #5 located in the
Southeast Quarter of the Northeast Quarter of Section Tar-Key q
7, Township-29 North, Range,19 West, Town of Hudson, This is not homestead.Property.
described as follows: Beginning at the East quarter corner of said Section
7; thence South 89°26' West (true bearing) 482•.70 feet along the South line
of said Northeast Quarter; thence North• 0 046' East 634.33 feet; thence North
78036!.East 460.00 feet; thence Southerly along the Westerly right of way
line of an existing Town Road to a point North-0°24f40" East 313 feet, more.
or -less,'of said East quarter corner; thence South 0°24'40" West 313 feet,
more or less, along the East line of said Northeast Quarter to the POINT OF
BEGINNING.
Also arl,• easement for an adcess road as described in the Affidavit of the
Grahtdr-dated November 2, 1972, recorded in the office of the Register of
Deeds for St. Croix County, Wisconsin, in Volume 491, page 207, document
313208. TRANSFER
FEE f
Exception to waapntiest Easements and restrictive covenants of record.
Hudson i'.
Executed et r Wisconsin 72 thi �,�Pda�y oP 19
SIGNED AND SEALED IN PRESENCE OF
Kendall B. Priester
,SEAT.)
(SEAL)
(SEAT.) i
t
• i
Signatures of
i
authenticated this 11th day of Decemhe;
Title: Member State Bar of Wisconsin or Other Party
Authorized under Sec.. 706.06 viz.
STATE OF WISCONSIN
St. Croix as' -
County.
Personally came before me,this day of 119 72
the above named Kendall B. Priester
to me known to be the person_ who executed the foµ+go19 46 w�iaeat end ac edged the same. _
This instrument was drafted by �+ t.' Y I? ` - Darrell R. YWU ber
John D. Heywood, Attorney—.at,-Law -
Hudson• W13COriSri P 7 k_R v Notary Public ,St. Cr0 County,Wis.
The use of witnesses is optional. f -, My Commission(Expires)(rs) 8-18-74
Names of persons signing in any capacity should be typed or printed below their signatures.
�II M�I��rCpryrq�
I
l WARRANTY DEED-STATE BAR OF WISCONSIN, FORM 240.2- 1971 m�
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