HomeMy WebLinkAbout040-1133-40-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
572885 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:
Lynch, Mark I Troy, Town of 040-1133-40-000
CST BM Elev: Insp.BM Elev: BM Description: Section/Town/Range/Map No:
6-DT- 35.28.19.5568
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER S CAPACITY STATION BS HI FS ELEV.
g•
Septic ^y Z �6ba Benchmark > 6 75 6a •7J
Alt.BM /15 L /fy7,•
Ft P,� ! k- 5zs 60jtA 41
Aeration Bldg.Sew
w�— e,n c.t_ (OW 163.
Holding St/Ht Inlet 5.43 163. 17
TANK SETBACK INFORMATION St/Ht Outlet (�,$ /p3 •Z
TANK TO P/L WELL BLDG. en Air Intake ROAD Dt Inlet
So J�' 6J+ear
Septic 2-3 , g 37 Zba Dt Bottom
Dosing Header/Man. �� / • 31 9y� 4/1
y
Aeration _ Dist. Pipe �•Z 7y.y
"re a a
Holding Bot.S tem
.
PUMP/SIPHON INFORMATION Final Grade ^7 5 5 S
Manufacturer Demand St Cover
GPM F( Jt.�. I. 3 /D7• $S
Model Number
TDH Lift Friction Loss System Head J`rbh-__� Ft
Forcemain Length Dia. Dist.to Well
SOIL ABSORPTION SYSTEM
BEDITRENCH Width Length No.Of Trend PIT DIMENSIONS No.Of Pits Inside Dia. Liquid Depth
DIMENSIONS 3
SETBACK SYSTEM TO JPIL JBLDG WELL LAKE/STREAM LEACHING Manufactyt��: r
INFORMATION Type System: 7 27 � CHA uNET OR
3 M A . `f-
Go,nlJe�o� b � L {v� �• �S
DISTRIBUTION SYSTEM aC 19 k3 =- 5-7 mod-%
Header/Manifold / a Distribution \ \ x Hole Size x Hole Spacing Vent to Air ntake
(04-5 `1" Pipe(s) � \ �w 5
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 2. 6O Bedrrrench Edges Topsoil '_� Yes H No Yes Z No
COMMENTS: (Include code discrepencies,persons present,etc.) Inspection#1: / / Inspection#2: / /
Location: 48 Pineridge Terrace River Falls,WI 54022(NE 1/4 SE 1/4 35 T28N R19 ) metes►&bounds Lot Parcel o: 35.2 9.556B
1. Alt BM Description= % A
p � �ctit�t� 'S �u�
2. Bldg ewer length= �a
9 9 2� o Cr- I`ea..J $cJweDJ�,-Q. 4b Go,n,n�e�-�- � �°.x• a'�'•"'
-amount of cover=
II
Plan revision Required? Yes No c�
31
Use other side for additional information. __ -
Date Insepctor' Signatur Cert.No.
SBD-6710(R.3/97)
I ....,,,...,......,
Safety and BUildings Division 5).
rill 2 ' -rc% RECEIVED 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number tto be filled in by Co i '
. " P N, S : - ; Madison,WI 53707-7162
't b' 5, ,7 2. 1 3 g5
,........:_- .oP MAR 232 01':, (-- _ / ,, /
State Transaction umber
SSI.74 1. 1 • Application --
gi A/./i
In accordance with SlitAtM.,Ti•II. . . '-. isi:0,4 1. sion of this form to the appropriate governmental unit —
is required prior to obtaining a sanitary permit Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address)
the Department of Safety and Professional Smits. Personal information you provide may be used for secondary 0-
purposes in accordance with the Privacy Law.s.I5.04(1)(m),Slats.
`0
I. Application Information—Please Print All Information v-AL (2, 46 (trca c.&...
propry/pvimer's Na
( Parcel#
Property Owner's Mailin4 Address Property Location
/9S' riamiqua AAA 1 Govt.Lot
Zip Code Phone Number At '-. ih, &"E1/4, Section
Ar 6 116,de A.
... 502 1 11/d - 7-d 8'07g circle one) 4-/_
T 4?. N; It /1'4 E or W 1..) ,)(.0 e) 1
II.Type of Building(check all that apply)
/ Lot it
•
gh-or 2 Family Dwelling-Number of Bedrooms , Subdivision Name
WV I / Block N ----- M 4 6
0 Public/Commercial-Describe Use
,0 I - n I D City of
0 State Ownetl-Describe Use
I
' r g,ty r,i_ pool'.Number
7i 06 0 village of
1 0 Town of Tre.,_
III.Type of Permit: (Check only one box on line A. Complete line B if applicable)
A' 0 New System Re11a..-c-_.-me tt S'stem 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System trcplaito
S P I Slifib07Li0 A Cei/S 1^3/ i q uni-iy eack_
B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued
Before Expiration Owner ',, J3 15 i
IV.Type of POWTS System/Component/Device: (Check all that apply)
ls. lon-Pund 0 Pressurized In-Ground 0 At-Grade 0 Mound 224 in.of suitable snit 0 Mound<24 in.of suitable soil
0 Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain)
V.Dispersal/Treatment Area Information: - 0 1 L °. _191 V S )g1.0,431 h e42__ *
Design Flow(god) Design Soil Application R;) (gpdsi) Dispersal Area Require7 Dispersal Area Pro d System Elevation
<1. 0 I . ei /495 , - Y.?0
VI.Tank Info Capacity in Total It of Manufacturer s, I
Gallons Gallons Units "5
New Tanks Existing Tanks
ie\j/ Poll/lOCk -125 I! ii
Septic ot Holding Tank
X %,t6 / 1A/I ES E• k _ -
x
Dosing Chamber
VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name(Print) -1 , PI 's Signature z It 1,1•1F9MPRS>umbqk Business Phone Number
-7-Abyme, a 1,-. . . r :;c9767 .9102 -9956P
Plumber's Ad dres. (Street City,State/Zip Code)
17
0 t
7D 4o Jeio&tc/A., ik)„ -iosG9 .
VIII.County/Department Use Only
1 Permit Fee Date Issued I Issui A gnat '
/Pr-Approved 0 Disapproved _____.o 0 3 ,, i /z I 0 Owner Given Reason for Denial 1 $L/75 i - Z.'t /) t er/i4 /
IL ceitufftemowpv at/Reasons for Disapproval v
, ,
1.Septic tank,effluent filter and G.5)6)(IS-t)(1 sup/on lb i' ' i i
dispersal cell must be_s_cryibed/maintained .4. a Lo,44, eV/A.91).o/ A
0 be a-i- 0. cc,2_pf---A, o-f-
as per management plan provided by plumber. e/t-Pi'
/
2.All setback requirements must be maintained 0,, or LESS.
. •- .IIII . .11 :- Oil— a di.a., -s
Attach to complete plans for the system and submit to the County only on paper not less than 5112 a ii inches in size
SBD-6398(R. 11/11)
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n.oy Tu...,,,o - Sr C�,'x Cy - Parcci.r. o4 /l 3310 oco p 3°r3
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i 1—or 2—Family Dwelling In-ground Soil Absorption System (2-cell Conventional)
1 Oath/Wastewater Flow(DWF) = _.i 4 of bedrooms x 150 gal/day/bedroom = r�D gal/day
7_ t r#uad n&nate(Wit)or Dail Apniicatinn lime.= ,y and/ft2 roar SPS Table 383A4--1.2.or 31
squired Distribution cell area a DWF ]' t gal/day : DIP t g gpdift2 = ild ft
1,. ... !"-- °r zR: D isti buton e�,area d f2 f/d ft , unit EIS A �6•°
l Chambers
'y
�v Chamber Manufacturer and Model: () yS Z. [Iva ter 'r ?I r'eu S J9/1# !I\
/ _= 376.7 .'
�, xccuai Distribution cell area m rtecjuueu Geis n.rn .311.b tt` 4 . --'r^�f 1 �tt"i unit iwK ��o c.a�,ray. iz
.1y ?
■ �S krl Cross-Section In-ground Soil Absorption System i2-yei(i:
��`���� �� �, � -�-�"Schedule 40 PVC cap� n ,q f F U�n C��
l i.4 vent pipe with vent cap. --y 1. )q 1 1'Y4 Nna V�
\,S 12 inches minimum iI }[ r .1..z inches minimum �1� �` Qr .
_... t
I I I 1?S inches Soil Cover
Trench 7"cys_ °f+x", y "` 4
1 4)3.e) /. t fr Trench 2 System - . i
l -1 Eic,v3tior,
ft ft
Trench Separation irarhina Chamber Width ‘f1
to li ' ng factor
Alan View In-ground Soil Absorption System(2 cell :
Trench 1
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flinch Header
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3 _c t Sch. 3031
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., . ► i,1� 400 I' % ft with end camps
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Draw 0 for;a Vent and i for Observation Pipe above. They will be located ) ft from the end of the cell.
Vent pipes shall be Schedule 40 PVC and extend at least 12 inches above finished grade.
Observation pipes that extend above finished grade must also be 4 Inch Schedule 40 PVC.
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'ST.CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
'AND
OWNERS
HIP CERTIFICATION FORM Guyer 1214r 2
Mailing Address 19.. 6 j /2l ix 114 f 6 �, Ni 1)
c
Property Address A.14 C -4 . a rra c,'
(Verification required fr., Planning&Zoning Department for new construction.) '
City/State eutvf-4 /h /,LJ( . Parcel Identification Number O97//? 5b 'a
LEGAL DESCRIPTION
Property Location ' , Y4 , Sec. 3 S , T aP N R /7 W,Town of 71:4
Subdivision rh/I l° lC[ e 7-apiiive , Lot# .
Certified Survey Map# , Volume ,Page# .
Warranty Deed# , Volume , Page# .
Spec house yes no I.ot lines identifiable yes no
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 Comm.§ 83.52(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 COii'serce and the Department of Naturi1 Resourees,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 stag ., . on this form are true to the best of my/our knowledge. I/we am/are the owner(s)of the
property desenbed above,by , , of a ,r, • , deed recorded in Register of Deeds Office.
Num
per
of hedroo 1.:4
/441. ►►
Si i' A 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.08/05)
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner Pit 1. it il Arc k Septic Tank Capacity /p(ej gal ❑ NA
Permit# Septic Tank Manufacturer j;e3er ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer Sac/el /4 I D NA
F
Number of Bedrooms 3 ❑ NA Effluent Filter Model �DG to e e 0 NA
Number of Public Facility Units NA Pump Tank Capacity / gal ❑ NA
Estimated flow (average) j'/) gal/day Pump Tank Manufacturer ❑ NA
Design flow(peak), (Estimated x 1.5) 6 ?9- gal/day Pump Manufacturer ❑ NA
Soil Application Rate , gal/day/ft2 Pump Model ❑NA
Standard Influent/Effluent Quality Monthly average* Pretreatment Unit ❑ NA
Fats, Oil &Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (B0D8) 5220 mg/L ❑ NA ❑ Mechanical Aeration ❑Wetland
Total Suspended Solids (TSS) 5150 mg/L ❑ Disinfection ❑ Other:
Pretreated Effluent Quality Monthly average Dispersal Celi(s) ❑ NA
Biochemical Oxygen Demand (B0D5) 530 mg/L In-Ground (gravity) ❑In-Ground (pressurized)
Total Suspended Solids (TSS) 530 mg/l ❑ NA ❑At-Grade ❑ Mound
Fecal Coliform (geometric mean) 5104 cfu/100m1 ❑ Drip-line ❑ Other:
Maximum Effluent Particle Size Y8 in dia. ❑NA Other: ❑ NA
Other: ❑ NA Other: ❑ NA
*Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Inspect condition of tank(s) At least once every: ❑month(s r (M mum 3 sans) ❑ NA
0 year(s) y
Pump out contents of tank(s) When combined sludge and scum equals one-third (19 of tank volume 0 NA
❑month(s) ax m 3 years) ❑ NA
Inspect dispersal cell(s) At least once every: ❑year(s) �M _
Clean effluent filter At least once every: ❑month(sl� //
years! f, ' ❑ NA
❑month(s) ❑ NA
Inspect pump, pump controls& alarm At least once every: ❑year(s)
Flush laterals and pressure test At least once every: ❑ month(s) ❑ NA
- _ ❑year(s)
Other: At least once every: ❑ month(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 (Y9) 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 limited 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.
r
MAR i 4J 2015 i,.. _ __
Wisconsin Department of Comm rce SOIL EVALUATION REPORT Page j of
Division t
:OMIviUN TY DE`v`EL PMENT in accordance with Comm 85,Wis. Adm. Code
County Attach complete site plan on paper not less than 81/2 x 11 inches in size.Plan must Sr- CN D f X
include,but not limited to:vertical and horizontal reference point(BM),direction and Parcel I.D.
percent slope,scale or dimensions,north arrow,and location and distance to nearest road. C,4-0 11334o 00 U
Please print all information. Reviewed by 5,5, 2.$,19,55 ie Date
Personal information you provide may be used for secondary purposes(Privacy Law,s.15.04(1)(m)). zds 1 3/z ///.5
Property Owner 1 Property Location
Al cc tit- t e r,,1, J a i/& 1-.y/F CA Gwt J.et ,V 1/4 s.L 1/4 Sag-T 02 8 N R 17 &(ey W
` ?roperty Owner's Mailing Address Lot# Block# Subd.Name or CSM#
' 19S63' f/Qn7,i fps, Sr- J�1 W — --�
City State Code Phone Nurhber ❑City ❑Village ,,TTown Nearest Road
Ogrc1„ave I/44/ ISS-01/ 1 (di�)38A6-8 j"�or (€�$7 ) I Finc i/f;ry:,a.ce
❑ New Construction Use; Residential/Number of bedrooms 6.--i Code derived design flow rate 6-0 Ci GPD
,Replacement ❑ Public or commercial-Describe: N, •
Parent material ,4--0 e.55 t�Flood Plain elevation if applicable ,4141 ft.
General comments -�Qec6/ /7 /cll,e J ,s 4.C7 P`he�,'dq 7-.(✓ic j R,"ve. icct//s� c4r
and recommendations: o`
1- vA9 -i 7 ,t.4' /ei" vc.p/3e«,..r' to bed, tie.. ektraTes•/.1or✓ct/ &yr,'t Q a-e�c.r� tde
//,_��-^ % / •:
•
Property Owner C114/./C d" rict eijcirpe y c1 Parcel ID# c/tC'/' ,13+c' 000 Page of 3
3 Boring# ❑ Boring ?
❑ Pit Ground surface elev. 7C-3 ft. Depth to limiting factor --in— ' cal Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPM'
in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. *Eff#1 *Eff(lt2
l o-1 /o 7/f.11,z , t■ $L fcchk m h ct s . 1 v- 0-c 1.0
/OFR 3/. (N)&1 , �9 C " 44k , 4- c�,s )p 0 D.4 ' -tS
3
c- 16' �op',0/4 U9sj $c1. ,2i,Q4k th Qs /yi 5-4
4 36= 6 S _ m 2 c a., - r,7 /-
S
-0
C6-7o/o. ,e84 Y'/' 7rP't /r 1' �' osc7.- , w O.S /-(�
7 70415 7Jfigs/4- ail? C2 14'7 101 ei ( O U.v
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/W
in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. *EfI1 *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 Consistence Boundary Roots GPD/tf<
in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. 'Ett#1 *Eff#2
*Effluent#1 =BODS>30<220 mg/L and TSS>30<150 mg/L. *Effluent#2=BOD5<30 mg/..and TSS<30 mg/_
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