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HomeMy WebLinkAbout261-1285-02-400 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 210 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes[Privacy Law,a.15.04(1)(m)). Permit Holder's Name: X City Village Township Parcel Tax No: BHJN LLC, Arthur Rose Residential Facility City of New Richmond 261-1285-02-400 CST BM Elev: Insp.BM lev: IBM Description: .�- 1 Section/Town/Range/Map No: V. �� �' 04.30.18. ,-- -caw TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt.BM Aeration ,� Bldg.Sewer 7.6,/ 97, 11 M Holding St/Ht Inlet „/% �T QQ�Y /O. e /4/'Ts8 St/Ht Outlet TANK SETBACK INFORMATION sPA.7 TANK TO P/L WELL BL 1 G. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing Header/Man. Aeration Dist.Pipe Holding Bot.System Final Grade PUMP/SIPHON INFORMATION I Manufacturer Demand St Cover GPM Model Number TDH 'Lift Friction Loss System ead TDH Ft Forcemain Length Dia. Dist. o 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/1 BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR _ Type Of System: \\ /UNIT Model Number: DISTRIBUTION SYSTEM Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length 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 xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil Yes 0 No Ea Yes d, No COMMENTS: (Include code discrepencies,persons present,etc.) Inspection#1: / / Inspection#2: / / Location: 1164 State Hwy 64 New Richmond,WI 54017(NW 1/4 NE 1/4 4 T3ON R18W) A Lot 1 Parcel No: 04.30.18. 1.)Alt BM Description= / N S li& ) f d�/� 2.)Bldg sewer length= (07 II -amount of cover= / / Plan revision Required? El Yes No J 3 I • 4037 75 Use other side for additional information. 3 Date Insepctorj ignat e Cert.No. SBD-6710(R.3/97) '' I :1°4 County SanitartY Per�11 iLAppIication ST.CROIX COUNTY WISCONSIN ea tonal with Chapert 12 St.Croix County Sanitary Ordinance PLANNING&ZONING DEPARTMENT Personal information you provide may be used for secondary purposes ST.CROIX COUNTY GOVERNMENT CENTER [Privacy Law.S. 15.04(1)(m)] 1101 Carmichael Road .4 r)IV) Hudson,WI 54016-7710 F�8 A r (715)386-4680 Fax(715)386-4686 CpV4+�)a�f�0s4[plete plans for the system on paper not less than 8-1/2 x 11 inches in size. s-(,GR �1►(+?t�ary Permit# ❑ Check if revision to previous application I. Application Information-Please Print all Info mation ,Location: Property Owner Nam NE 1/4 NW 1/4,Sec y 6 ii T-/� i./..c_. 402 Zft T 3.0' N, R i$14/ E(or)6p) Property Owner's Mailing Address Lot OA Block Number //tW A/11LO 44 6V ....--... City,State Zip Code Phone Numer Subdivision Name or CSM Number At, ,&%hkei '4 s)0i9 GS„M 21 .. 5z58 II Type of Building: (check one) —7 ity ❑Village ❑Town of i` ❑ 1 or 2 Family Dwelling-No.of Bedrooms: // ,,, ---�Public/Commercial(describe use): A.k c_L4 Ase13 ❑ State-owned ,7 Nearest Road,i G U II.Type of Permit: (Check only one box on line A. Check box on line B if applicable) U4 e41 // 7 Parcel Tax Number(s) aL ^ t,[h( A) 1 Repair Reconnection I3.❑Non-plumbing 4.❑Rejuvenation I 2‘1-/Z-45-19 _d.d,d-�.a+ Sanitation B) Permit Number ?7 /14Z-- Date r) Co 0 State Sanitary Permit was previously issued Z O IV.Type of POWT System: (Check all that apply) ❑ Non-pressurized In-ground Mound? 24 in.suitable soil ❑ Mounds 24 in.suitable soil ❑ Mound A+0 ❑ Sand Filter ❑ Constructed Wetland ❑ Peat Filter ❑ Drip Line ❑ Pressurized In-ground ❑ Holding Tank ❑ Single Pass ❑ Other ❑ At-grade ❑ Aerobic Treatment Unit ❑ Recirculating V.Dispersal/Treatment Area Information: 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application Rate 5.Percolation Rate 6.System Elevation 7.Final Grade Required Proposed (Gals./day/sq.ft.) (Min./inch) Elevation $S7 VI. Tank Information Capaicty in Gallons Total #of Manufacturer Prefab Site Con- Steel Fiber- Plastic New Existing Gallons Tanks Concrete structed glass Tanks Tanks ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ VII.Responsibility Statement I,the undersigned,assume responsibility for repair/reconnenction/rejuvenation/installation of non-plumbing for the POWTS shown on the attached plans. A license is not required for terralift repair or the installation of non-plumbing sanitation system. Plumber's Name print) Plumber's Signature(no stamps): MP/MPRS No. Business Phone Number T /�-lavers '!�/G� C4 viii >, 251.26" Plumber's Address(Street,City,State,Zip Code) 72/ t tilseoh,,,A i,;,e_ Nees. Ado./✓/ ivr slid/7 VIII.County Use Only cap ved Sanitary Permit Fee D to Issued lssuin gent Sign ur o s'tam∎: Approved (\Owner Give dverse ZZ 5 . to 2 Za f 5— Determination IX.Conditions of Approval/Reasons for Disapproval: / �• r oSTEMOWNER: 3� v -1 �j)flC$ Gam. Gl O.�V� t'' Septic tank,effluent filter and Q .dispersal cell must all be services/maintained . as per management plan provided by plumber. kj, B/i 5a�u.. rYt�. (a/ _ _ 2. : •seFhack requirements must be;iPahntailted, 'i") p TtC+ _ecto rn- as per ecede/ordinances. / Rev:8/05 4. _._... ...._........e i I dt\ . Atz, 84, , /O'er W1 j '4 41111r1414111A-ro , v 2 Q 1- 1 : 1 ----7."-, - .-••,,,..,„,,,...„,,,..,,„._ Vt t t 5t1t,1:),LAL\ ....._, _ 4:711-ttiv OWLou10 & HEATING. INC. 321 WISCONSIN DRIVE NEW RICHMOND. WISCONSIN 54017 715-246-2660 TOLL FREE 1-800 542-4243 February 19, 2015 To Whom it May Concern, This system at 1164 Hwy 64 in New Richmond, WI was checked in December of 2014. I have checked the mound system to the best of my ability for the time of year checked. System shows no sign of back up or leakage out of mound and appears to be in working order. Respectfully Submitted, Paul Koehler MP#225410 • PLUMBING • HEATING • AIR CONDITIONING • SHEET METAL • WISCONSIN REGISTERED DESIGNER (MP CREDENTIAL#664713) SP ... 1164 Business Hwy 64/P.O.Box 474 New Richmond,WI 54017 Phone:(715)246-0800 Fax:(715)246-9568 E-Mail:arthurroseassistedliving @gmail.com Web:www.arthur-rose.net February 19, 2015 To: Ryan Yarrington, Saint Croix County Timothy DeYoung, Country Side Plumbing Mike Stevens, Derrick Construction Chris Stevens, Derrick Construction Re: Arthur-Rose, LLC Mound System Design Greetings All, The existing mound system at Arthur-Rose, LLC, is currently servicing five (5) bedrooms. The addition will require the mound system services seven (7) bedrooms total. The balance of bedrooms is serviced by our existing traditional system. The system has had no issues and is working well. Please advise if you should have questions or concerns about this statement. Sincerely, Jessa A. Nelson, Owner Arthur-Rose, LLC & BHJN, LLC ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERI'JYICATION FORM OwnerBuyer .-Hei-LJIJ1 L 1.-.c.__. Mailing Address ?•o , B e X N V/ I Al ew 7r; ll rk,...d, (N 1 S 9 )f 7 Property Address //!o q ,b'trJS i A) Flu, !o Y f "'AA) 7(;C I b1 O1 ), 'W r S f O( Z (Verification required from Plsnning&Zoning Department for new construction.) City/State & e-t u r S&L, "at A 1 0/ Parcel Identification Number 2 6 i - 12rS- &2 - 20 C LEGAL DESCRIPTION Property Location V4, 1A, Sec. `-` , T 30 NR 1g W, of N es-J 76-c-t weit.D• . Subdivision Plat: 7, h L 0 c-rA .k.\. • ,Lot# 2 . Certified Survey Map# ,Volume 2 O , Page# Soo I Warranty Deed#Mti (before 2007)Volunae ,Page# . Spec house 0 yes io Lot lines identifiable%yes 0 no SYSTEM MAINTENANCE AND OWNER CERI'll+'ICATION 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. . Uwe,the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth,here' as set the Department of Safety And Professional Services and the Department of Natural Resources, stern � � by P 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 '' form are true to the best of my/our knowledge. Uwe am/are the owner(s)of the property described above,by virtue of a ty deed recorded in Register of Deeds Office. Number of bedroo dr littAIP . 1---1/q11-S- g •PLICANT(S) DATE . ***Any info 11 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) ' WARRANTY DEED Document Number 02/16/2007 in:worn Pitchford, WARRANTY DEED THIS DEED,made between Thomas R.Pitchford and Kristin M. WARRANTY # husband and wife, Grantor, and BHJN, LLC, a Minnesota limited liability REC FEE: 13.00 company,Grantee. TRANS FEE: 1659. Grantor, for a valuable consideration, conveys to Grantee the following COPY FEE: described real estate in St. Croix County, State of Wisconsin (the CCCGFE ` 2 "Property"): SEE ATTACHED EXHIBIT A Recording Area Name and Return Address: Land Title,Inc. 1900 Silver Lake Road Suite 200 New Brighton,MN 55112 #283590 261-1285-02-200 Together with all appurtenant rights,title and interests. Parcel Identification Number(PIN) This is not homestead property. Grantor warrants that the title to the Property is good,indefeasible in fee simple and free and clear of encumbrances except • Dated this 02/09/2007 -1--:— -------rs.-4 1AAc;AP--- 94C11/14 Pitchford �4..1 ��' *Thomas R.Pitchford *Kristin M..Pitchford * * ACKNOWLEDGMENT AUTHENTICATION ) STATE OF MINNESOTA Signature(s) COUNTY. 14e-A^t4-e-3?ty )ss. Personally came before me this q day of authenticated this 'FebvURV , '200�- the above named Thomas R. • Pitchford aui Kristin M. Pitchford, husband d and.wife, foregoing * known to be the person(s) TITLE:MEMBER STATE BAR OF WISCONSIN instrument and aclmowledlil the .me. (If not, i • * Bradle authorized by§706.06,Wis.Stats.) ! Swanson 7 THIS INSTRUMENT WAS DRAFTED BY Notary Public,State of Minnesota My commission is permanent. (If not,stat�e;xpiration date: ) Larry Mountain,Attorney, 1900 Silver Lake Rd#200,New Tavvvav aa BRA Bri: ton,MN 55112 ; EY D.SWANSON Notary Public ■ (Signatures may be authenticated or acknowledged. Both are not necessary.) ' Minnesota "Names of persons signing in any capacity must be typed or printed below their signature Y commission Expires January 31,2010 WARRANTY DEED STATE BAR OF WISCONSIN FORM No.1-2000 AGENT FOR CHICAGO TITLE INSURANCE COMPANY • FIRST AMERICAN TITLE INSURANCE ART TITLE NYA LAWYE COMPANY ANY INSURANCE CORPORATION E r — ----1Safety and Buildings Division County • 201 W.Washington Ave.,P.O.Box 7162 St.Croix iseonsin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) Department of Commerce (608)266-3151 q 9 9/72_ Sanitary Permit Application State Plan I.D.Number In accon l with Conrm 83.21,Wis.Adm.Code,personal information you prove• 473,7r% =-V�s. ,a.. . may be used for secondary purposes Privacy Law,s15.04(I)(m) ject Address(if different than mailing 1 �0 1164 State H 64 I. Application Information—Please Print All Information v Pp GG, aG Property Owner's Name Parcel C Lot�/ark Block C•4 2pp6 run U1lCrIne�, I I Na New Richmond Golf Club itAIS ti Property Owner's Mailing Address GROIX GOV•'- Properly Location ' 1 1226 180th Ave. $ Gov't lot. NE 'A, NW 'A, Section 4,, City,State Zip Code , • . •umber , 30 N; R_j$-W New Richmond WI 1 54017 (715)246-6724 II.Type of Building(check all that apply) / L/ - Subtliieiwti?Iwn6✓. rte' ❑ 1 or 2 Family Dwelling-Number of Bedrooms " 4 230 X Public/Commercial-Describe Use Community based residential facility-7 beds -.111 '' =mar ❑State Owned-Describe Use X City❑Village❑To'ship of New Richmond III.Type of Permit: (Check only one box on line A. Complete line B if applicable) A. ❑New System X Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System B. ❑Permit Renewal ❑Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner I i if IV.T , of POWTS S stem: Cheek all that a, ,I il�� dalwt 1 onirarMillliffielearillifffxamr ❑Non-Pressurized In-Ground OX Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil ❑At-Grade ❑Single Pass Sand Filter ❑ Constructed Wetland ❑Pressurized In-Ground ❑Holding Tank ❑Peat Filter ❑Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) V.Dispersal/Treatment Area Information t,/ Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(s0 Dispersal Area Proposed(st) System Elevation 897.0 gpd 1.0 gpd sq.R.-ASTM C-33 fill 897.0 sq ft 897.0 sq R EISA 97.75'@ 12"above 96.75'contour VI.Tank Info Capacity in Total Number Manufactuur-err Prefab Si---- Steel Fiber Plastic Gallons Gallons of Units� hr ) Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank 1,800 - 1,800 1 Wieser Concrete Combination X Aerobic Treatment Unit ' Dosing Chamber 1,111 1,100 1 Wieser Concrete Combination X VII.Responsibility Stat.1,ent-I,the ma ersigned,assume t lity for installation of the POWTS shown on the attached plans. Plumber's Name(Print) Plumber' Sign y'a'�� MP/MPRS Number Business Phone Number James K.Thompson �, _ —tom - MPRS#30021 (715)248-7767 Plumber's Address(Street,City,S ,,Zip Code) 340 Paulson Lake Lan-,Osceola,WI 54020 VIII.Coup /De,artment Use Only___ Approved ❑Zpapinved Sanitary Permit Fee(includes Date Issued Issuin:Agent Signature /'Stamps) Grown' - urcharge Fee) 1 `..n Reason for Denial ;• 55D '&Oa _.■n.'' at ; IX.Conditions of .pro ''easompfos4lipappevaL I �y, SYSTEM OWNER: 3 �t► � �a ZS S Zq l' - a-� 1. Septic tank,effluent filter and S�G`$M S%S ^A-10 64...6/0 Ceti",01:7 dispersal cell must all be serviced/maintained S S � -�-r as per management plan provided by plumber. f 2. All setback requirements must be maintained i l,) U �;(u..4L_, P01,41 A ea-u-37% Io C� as per applicable code/ordinances. "T ` (PS l r (A Attach complete plca(to the County only)for the system oa paper mot 8/1 z l hrches is site 4... tJ.1,,a1 �C t7K SBD-6398(R.01/03) "' (T' l - • Design Flow Calculations JOB DESCRIPTION; Existing three-bedroom residence located within the municipal limits of the city of New Richmond service by conventional POWTS(see pgs. 11). Municipal sewer and water proposed to be extended to property within 5 years. New owner proposes to add 4 bedrooms to existing residence,creating an 8 bed Community Based Residential Facility with two employees per shift, 3 shifts per 24hr. period. New mound to be connected to proposed addition. Mound designed and constructed to accommodate entire daily flow of proposed facility. Existing conventional POWTS to remain in service until hydraulic failure occurs. Interior plumbing will be rerouted to mound at time of failure. ARSORPTION AREA S!ZINC;; 1. Total Daily Design flow (59R Gpd daily flnw)(LIcnnversinn factnr)= R97 f Gpd (8 bed spaces)(65 gal.bed space)= 520.0 Gpd daily wastewater flow (6 employees all shifts)(13 gal./employee)= 7R 0 Gpd Daily wastewater flow= 598.0 Gpd 2. Depth to limiting factor: 24_' 3. Land slope: 2°Ln 4. Infiltrative capacity of soil at system elev.: 1 0 gpd/sq ft ASTM C33 med.Sand 5. Infiltrative capacity of native soil: 0 6gpd/sq ft 6. Proposed Dispersal Cell area: 600 sq ft area required R97 sq ft bed width(A) .&5 bed length(B) 105 00' SEPTIC TANK CAPACITY CALCIJIATIONSj 1. Design wastewater flow=897.0 gpd 897.0 gpd/75 gpd= 11.96 gpd person equivalency 2. Minimum required capacity: I)116 55 Gallons (897.0)+(11.61 x2*x 11.96)+(46.77 x 11.96)= 1,734.08 *(Requires a two year maintenance cycle) 3. Existing septic tank Capacity&Manufacturer: 15)00 gjil Weeks Concrete S T. 4. Proposed S.T.capacity&Manufacturer: Wieser Concrete WI.P1$00/1 110-MR gal septic yank/pump chamber PolyLok PL-625 effluent filter to be installed at septic tank outlet. Pg. 10ofII u,mw a.9n .wwoLae ir..ua LL04S IM'ONOWHOW M3N o eaurt v,..9•stcmaro'e 49AVMHJIHY9LL : w Olanis NJISaU NOWOOVA190 q —] A Xc -g.i loos sad wL 011 3s02:M11H1 V ; °LL .1,41,311 IIVO ON 11 11 lii 11 ! 18 nag RA !II � � tL ! ` � .+c({ �� yF3 � t 6 �F s gaq`3 .9 .a.c -.tl .o-�G '.o.t f C yYy hi I !$ Ii i ili !I 2Y2Y2Yiill id Oi •; gj: I ans9a.c-,a o 00 000 00 O 1 n 9 r i. 30-:I 'A-L FL .0-.9i -.—_I_ 0 ED _ I �T ,e,f ^`E4rI1 0 �J 82 'a lc v.z,„,,,,,, 0 r k■I W . to 11 X70-(0 '', it . O gg ti i a.r J rli I ----r- "9,0 _ _ a. :a W L / - I k — ©� I 4 j U gg 8 0 0 0 �, nun [ 3 a '\ /\ a LJ __ ..t iDA P' k • g 3. 1FAa E O .,, . I o ® I L_ ��� Ii Ill U_c,_ 8 H L------- I , , r 1. ii L OI 1 L 1 1 _ 1 I 1 1 1 I 1 1 I 1 L___ '�, 1 _____________ 1 _____