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HomeMy WebLinkAbout042-1090-20-650 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 572839 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: Berg, Donavin Warren, Town of 042-1090-20-650 CST BM Elev: Insp. BM Elev: BM Description: Sectionrrown/Range/Map No: • > . ; D t L 32.29.18.497A91 TANK INFORMATION Ott T , 3 ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark G'v C S L / 2 C C j 1 t IGI, p- ' jU+ c~ Dosing Alt. BM 1. ~f Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic (5c) k Dt Bottom Dosing vv 'v VlJ !v / Header/Man. C Aeration Dist. Pipe .5~ ~Ll. (v2 Holding Bot. System O) Z i G) 1-12,57 Final Grade 2,310 CIE, 7H PUMP/SIPHON INFORMATION ~,Ip 9q, e, Manufacturer mand St Cover jr ) GPM 1 1 I 99. y~ Model N ber TDH 1111ift Friction Loss ystem TDH Ft j~~~ (r' .5fc> 'down 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 3 `t - - - SETBACK SYSTEM TO P/ BLDG WELL LA REAM LEACHING Manufacturer: INFORMATION Type Of System: r1 ' ` CHAMBER OR 1 a l fYL1;~~✓ V'l! Model Number: u / us DISTRIBUTION SYSTEM Header/Manifold ID istribution x Hole Size X Hole Spacing Vent to Air Intake L Pipe(s) Length Dia Length Dia pacing _ SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Ov Depth Over _ xx De th of xx Seeded/Sodded xx Mulched Bed/T enter 32 , Bed/Trench Edges Topsoil E Yes ® No ~ Yes ~ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: 12 b " Inspection #2: Location: 1035 70th Ave Roberts, WI 54023 (NW 1/4 NW 1/4 32 T29N R18W) NA Lot 8 Parcel No: 32.29.18.497A91 1.) Alt BM Description = , c CUV~^~~ 2.) Bldg sewer length = -amount of cover= J \V(\~ Y\UA ~t~ Plan revision Required? Yes No LSW~ Use other s ide for addition'on. SBD-6710 (R.3/97) Date nature Cert. No. 76 7 ~ o? &r r? Z- ® f- ~ a i IWUDTSON PLUMBING & CONTRACTING, LLC 927150TH SL 648447MPRS ROBERTS, WI 54023-8526 CELL 651-470-1737 j Zej 7~ 1 County r Safety and Buildings Division 4~f 0/ 201 W. Washington Ave., P .O. Box 7162 Sanitary Permit Number (to be filled in by Co.) r 1rLo\N ~ Madiso7s J f'+S 572 C7 00'` of nitary Permit Application State Transactio Number G~ In accordanc ~ko 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit is requir obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to Project Address (if different than mailing address) the Depaftment of Safety and Professional Servies. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law, s. 15. I m Stats. I. Application Information - Please Print All Informs Property Owner's Name / Parcel # lee Property Owner's Mailing r+uuress Property Location / 86 Govt. Lot Z. _ City, State Zip Code Phone Number 1 hll j ~ I.tJ Section e CA f r /-7 00, ircle one r '9~ H. Type of Building (check all that apply) Lot # , N; R E ❑ 1 or 2 Family Dwelling -Number of Bedroo s g Subdivision Name Ak aD tl t, ,o J'yC_ Block # ❑ Public/Commercial - Describe Use ❑ City of ❑ State owned - Describe Use CSM Number a' 2 ❑ Village of 3 ~ ; 5j- <<s L.) 12o e, P &615 lown of WQ III. Type of Permit: (Check on one box on line A. Complete line B if a licable) p X A'w System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber [101 Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration wner C~a IV. Type ofPOWTS System/Component/Device: Check all that app ) LPL) (Ov 1 ; 0- a Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound ? 24 in. of suitable soil ❑ Mound < 24 in. of suitable soilpt.".,.~ ❑ Holding Tank ❑ r Dispersal Component (explain) ❑ Pretreatment Deg ice (explain) /the V. Dis ersal/Trea ent Area Information: Design Flow (gpd) Design Soil A lication Rate( sf) Dispersal Area Required (sf) Dispersal A Proposed ( System Elevation n VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units U v ti New Tanks Existing Tanks' ~d o p U v~ v~ w C7 a Septic or Holding Tank Dosing Chamber VII. Responsibility Statement- 1, the undersigned, assu responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plum s ignatur MP/MPRS Number Business Phone Number Y t~57 72) umbers Address (Street, City~Syite, Zip Code) /v1 ` 57, V Couny/Dtpartment Use Only Approved ❑ Di Permit F Dat71;ed Issuing gent Signature Owner eason for Denial IX. Condi9 IVO easons for Disapproval ? _ r I . ` Septic; tank, i;fflulent ffterartd A, ' . ✓ / v fzz,14- dispersal cell must all be services / maintained as per management plan provided by plumber. 2. >:Allse#I2ack requirementa.must ba ir►alntai4ei as par appgcableC0&/ ordintinces: Attach to complete plans for the system and submit to the County only on paper not less than 81/2 111 inches in size I SBD-6398 (R. 11/11) CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Berg Sewer Owner's Name: Donavin Berg Owner's Address: 1416 130th Ave Legal Description: NW 1/4 NW 1/4 S32 T 29 R 18 W Township: Warren County: St. Croix Subdivision Name: Lot Number: 7 Parcel ID Number: 042-1090-20-630 Page 1 Index and title 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. Croix Cty Septic Tank Maintenance Form Page 8 Warranty Deed Page 9 CSM or Plat Attachments: Soil Test & House Plans Designer/Plumber. Keith Knudtson License Number: 648443 Date: 10/22/2014 Phone Number (651) 470-1737 Signature Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01/01). Page 1 76 7 ~ ?,,7 P/, f 0. KNUOTSON PLUMBING & CONTRACTING, LLC 927150TH ST. 648447MPRS ROBERTS, WI 54023-8526 CELL 651-570-1737 A le3 J e~- iaso ak ~ gad I Soli Absoratlon Svstem Ginn $60410 96.00 ft f-- 95.00 ft C Sc hedWe 40 Final Grade ~ VV~ ~ 91.50 ft 90.50 ft 4 System Elevation V 3.00 ft 5.00 ft ft $oli Absor Aon &atem Plan View ft 3.00 ft 5.00 ft Leaching Trench 1 Chambers own 4°Dia. Trench 2 Header Vent Or Observation Pipe IIIIIIIIIIIIIIIIIIIIIIIII 1111191111 Trench 3 Leaching Chamber Soecilindot Manufacturer And Model EISA Rating 20.00 sq ft per chamber Soil Application Rate 0.50 gpd/sq ft 600-PA gpd Design Flow + 0.50 Soil Application Rate + 20.00 EISA = 60.00 Chambers 3 rows of 20.00 chambers each. Page of L Wisconsin Department of Commerce SOIL EVALUATION REPORT Division of Safely and E i ' gs P age of ccordance with Comm 85, Wis. AdRkQej Attach complete site pl r northarrow, t than 8 112 x 11 inches in size. Pla ust ' J indtxie, but not lim cal izontal reference point (BM), directi d percent sbpe, scat ime s, and location and distance to nearerr,r~Q Parcel I.D. 2 020-2 o- -70 Please print all information. ST CROfX R e Date Personal Information you provide may be used for secondary Purposes (Privacy Low, s. 15.04 (y wWoll n Property Owner IF _ Property Location /Fi Govt. Lot 1 4 4 SL2T ~n N R E (a w Property Owners Mailing,Address Lot # Block it b d. Name CSM# city State zip Code Phone Number ❑ city 1:1 ,,,Town Nearest Road New Construction Use. Residential / Number of bedrooms; L Code derives design flow rate GPD ❑ Replacement ❑ Public or mmerdal - Describe: Parent material G' 9 - - - - - _ of Flood Plain/elevati.)n if applicable _/_~ft. commen }col GQ >,7'f2i#jv/h 0~ 4f/ a-- and recun rMations: ~ / U System System Type_ t • G9'a~~~~ d. System Elevation__ Boxing # ❑ Boring p f Pit Ground surface elev. / J t t ft. Depth to limiting k ctor in. Soil Application Rate Horizon Depth Dominant Cola Redox Description Texture Structure consistence Boundary Roots GPD/fP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 n - l (A /V' ! EL l/Y1 Gtr f y- L°/ r / Z Boring # ❑ Bori r,g Pit Ground surface elev. S 1 / ft. Depth to limiting fa:xor in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft° in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 "Eff#2 Z- 47"y o e' _ c ► rn r . y , is D• ' Effluent #1 = BOD > 30 < 220 mg1L and TSS >30 < 150 mglL ' Effluent #2 = BOD < 30 mg1L and TSS < 30 rngfL CST Name (Please Pmt) Sign CST Number Bird Plumbing, Inc. Shaun Bird 226900 Address Date Evaluation Conducted Telephone Number 1008 192nd Ave, New Richmond, WI 540177 , r z 715-246-4516 Property Owner Parcel ID # Page of Boring # Borinlt C4 0 [31 Pit Ground surface elev. Depth to limiting fact it in. Soil Application Rate Horizon Depth Dornina -it Coto Redox Description Texture Structure Cotisistence Boundary Roots GPD/ff ' in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2` D• Lo r 3l2 S t rtFr c-1 - Am 6 /.a 3 Yo S M t n ,1 V a Boring # ❑ Boring - ❑ Pit Ground surface elev. It. Depth to limiting factor in. Soil lic;ation Rate Horizon Depth Dominant Color Redox Description _ Texture Structure Corsistence Boundary Roots GPD/ff _ in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Boring Boring # Ground surface elev. ft. Depth to limiting factor in. ❑ Pit Soil Application Rate Horizon 'Depth Dominant Color Redox Description. Texture Structure Cor sistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 `Eff#2 I Effluent #1 = BOOS > 30 < 220 mg/L and TSS >30 < 150 mg/L ` Effluent Q = BODS ~ 30 mg/L and TSS < 30 mg/L The Department of Conxmerce 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 608-264-8777. SB0.8330 (RAW) Soil Test Plot Plan Project Name Richard Stout Shau ird Address 1353 Awatukee Trail Y' Hudson Wi 54016 WM #226900 Lot 7 Subdivision Date 6/24/13 N W 1/4 N W 1/4S 32 T 29 N/R18 W Township Warren ❑ Boring Q Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft. Top of survey iron System Elevation TBD Q.51 *HRPSa easBenchmark r w'' 269' roperty Line i B.M.* 726' Property Line C~, it 22 15' )$-1 45' 0' B-3 Scale is 1" = 40' 10% Slope 15' unless otherwise noted 100' B-2 97' 99' 95' 70th Ave POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page FILE WFOW'1710N SYSTEM SPECiRCA noNS Ov. ner v e~ Septic Tank Capacity al ❑ NA . PetitI J Septic Tank Manufacturer 0 NA z DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA (o. Number of Bedrooms ❑ NA Effluent Fitter Model 5Z ❑ NA Number of Public Facility Units j+lA Pump Tank Capacity al *14A Estimated flow (average) Rai/day Pump Tank Manufacturer A Design flow (peak), (Estimated x 1.5) al/day Pump Manufacturer R'rA Pump Model A Soil Application Rate i aUday/ft2 Standard Influent/Effluent Quality Monthly average* Pretreatment Unit A Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Fitter ❑ Peat Filter Biochemical Oxygen Demand (BOD5) 5220 mg/L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg/L ❑ Disinfection ❑ Other. Pretreated Effluent O.uality Monthly average Di Cell(s) y+~h'(~-fctr QJ:t~ ❑ NA Biochemical Oxygen Demand (BODS) 230 mg/L in-Ground (gravity) ❑ In-Ground (pressurized) Total Suspended Solids (TSS) 230 mg/L ❑ NA ❑ At-Grade ❑ Mound Fecal Conform (geometric mean) 510° cfu/100m1 ❑ Drip-Line ❑ Other. Maximum Effluent Particle Size $ in dia. ❑ NA Other. ❑ NA Other: ❑ NA Other. ❑ NA *Values typical for domestic wastewater and septic tank effluent. Other. ❑ NA MAINNTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: 3 ❑ nth(s) (Maximum 3 years) ❑ NA year(s) Pump out contents of tank(s) When combined sludge and scum equals one-third (Y3) of tank volume ❑ NA ❑ rrth(s) Inspect dispersal cell(s) At least once every: 3 year(s) (Maximum 3 years) ❑ NA Clean effluent filter At least once every: yearly) ❑ NA Inspect pump, pump controls & alas At least once every: ❑ month (s) ❑ year(s) ❑ month(s) Rush laterals and pressure test At least once every: ❑ year(s) NA Other: At least once every: O~(s) ❑ NA year(s) Other. ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying 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 tank(s) to identify 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 cell(s) 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 (Y3) 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 Code. All other services, including but not lin ited to the servicing of effluent filters, 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. Filters t . a . -525 EFFLUENT FILTER PL-525 Filter is rated for 0,000 GPD (gallons per day) 1116' Filtration Slots AWM making it one of the largest filters class. It has 525 linear feet of 6" filtration slots. Like the aawMPK V Wok PL-122, the Polylok e,525 has an automatic shut zF, ball installed with every filter. When the filter is removed for 6eaning, the ball will float up and Wmporarily shut off the system so e effluent won't leave the tank- No ether filter on the market can mesas make that claim. \e 1°adforo loaoocro 0 kv Am" PL-525 Maintenance: SCHM 400109 ~ € , e PL-525 Effluent Filter should operate efficiently for several years r E under normal conditions before requiring cleaning. It is recom- mended that the filter be cleaned every time the tank is pumped or at least every three years. If the installed filter contains an optional alarm, the owner will be notified f ~ by an alarm when the filter needs i servicing. Servicing should be done by a certified septic tank U ft DAMw pumper or installer. 1. Locate the outlet of the U.S. Patent Not 6,015,488 --o 5,871,M septic tank. 2. Remove tank cover and pump tank if necessary. 0_55 installation: 3. Glue the filter housing to 3. ?o not use plumbing when the 4" or 6" outlet pipe. If filter is removed. Ideal for residential and com- the filter is not centered 4. Pull PL-525 out of the housing. mercial waste flows up to under the access opening 10,000 Gallons Per Day (GPD). use a Polylok Extend & . Hose off filter over the septic Lok or piece of pipe to tank. Make sure all solids fall 1. Locate the outlet of the center filter. See page back into septic tank. septic tank. 19-21 for Extend & Lok 6. Insert the filter cartridge back 2. Remove the tank cover and information. into the housing making sure pump tank if necessary. 4. Insert the PL-525 filter the filter is properly aligned into its housing. and completely inserted. 5. Replace and secure the septic tank cover. 7: Replace septic tank cover. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Donavin Berg Mailing Address 1416 130th Ave New Richmond Wi. Property Address 1035 70th Ave (Verification required from Plannin Zoning Department for new construction.) City/State Roberts Wi. 54023 parcel Identification Number ' Ada ` (y---d LEGAL DESCRIPTION Property Location NW `/4 , NW '/4 , Sec. 32-, T 29 N R 18 W, Town of Warren Subdivision Plat: , Lot Certified Survey Map # clot ~ 47 _7z_ Volume , Page # b ~J Warranty Deed # /00 3 &//:r,, (before 2007)Volume , Page # Spec houseDyesEho Lot lines identifiable El yesono 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. Uwe certify that all statements on th' orm are true to the best of my/our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of ;/"'my deed recorded in Register of Deeds Office. Number of bedrooms 4 114 S URE OF AP LTCANT(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. 04112) SI09 aved 9Z TOA Z10 L abed ZLS966 AlunoO x1oj0 -iS S199HS Z 30 L 133HS (p Op o c p p N M pp N (D Z (N1 I O S (''S 7 w O^ ~ O~ - A 29 (W31SAS 31VNIOd000 O p N $ w ~ Iv 1 11Nf100 XIO>1J '1S) v n ~I z I~ pz rn u a r ^ zoo o S 3.9VZ5.68S E)NIHV39 b/LMN w o. O ¢ ° ' S? cr, 31-11 30 3Ni1 H1tlON 3Hl Ol z m m o z °z z P. m m cn 0- 030N3ii333ki 3FJV SJNI~IV38 I = x z V\ w p ~4\ o W C\j z = o i I L56S 'J_d `9z '~O/1 - 7N'S•O 0 - w w o 9107 5107 vUi OZ N o a w~ C/~I I Lo'E£ ,Sl'9ZL 3.,Ll.L0e408 v v b U. 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Vendor sells and agrees to convey to Purchaser, upon the prompt and full performance of this Contract by Purchaser, the following real estate, together with the rents, profits, fixtures and other appurtenant interests ("Property"), in St. Croix County, State of Wisconsin: Recording Area Name and Return Address A parcel of land (14 acres exclusive of road right-of-way) located in part of Roscon Properties, LLC the NW 1/4 of the NW 1/4 and part of the NE 1/4 of the NW 1/4 of Section c/o Dick Stout 1353 Awatukee Trail 32, T29N, R18W, Town of Warren, Hudson, WI WI 540 16 St. Croix County, Wisconsin; being Lot 8 of Certified Survey Map recorded in the office of the Register of Deeds of St. Croix County on MA y 30, 2-0 t Lt , in Vol. .Z6- Page eL'(S" asDoc ntNo. 4%965^72- - 0~2-~09O-2D-~eo Parcel Identification Number (PIN) 1~a4. This is not homestead property. (is) (is not) This is not a purchase money mortgage. (is) (is not) Purchaser agrees to purchase the Property and to pay to Vendor at 1353 Awatukee Trail, Hudson, WI 54016 the sum Of $ 120,400.00 in the following manner: (a) $ 12,040.00 at the execution of this Contract; and (b) the balance of $ 108,360.00 , together with interest from the date hereof on the balance outstanding from time to time at the rate of 5.0 % per annum until paid in full as follows: Monthly payments of principal and interest in the amount of $581.70, plus a monthly escrow of 1/12 of the estimated taxes in the amount of $90.46, making the total monthly payment $672.16, commencing on June 29, 2014, and continuing on the 29th day of each and everv month thereafter, provided the entire outstanding balance shall be paid in full on or before May 29th, 2017. - provided the entire outstanding balance shall be paid in full on or before see above. ("Maturity Date"). Payments shall be applied first to interest on the unpaid balance at the rate specified and then to principal. CHOOSE ONE OF THE FOLLOWING OPTIONS; IF NO OPTION IS CHOSEN OPTION A SHALL APPLY: 9 A. Any amount may be prepaid without premium or fee upon principal at any time. ❑ B. Any amount may be prepaid without premium or fee upon principal at any time after ❑ C. There may be no prepayment of principal without written permission of Vendor. State Bar Form 11-Page 1 © 2003 STATE BAR OF WISCONSIN St. Croix County 1003616 Page 1 of 4