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HomeMy WebLinkAbout020-1447-26-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 463071 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 Noo Bast, Kernon Hudson Townshi CST BM Elev: Insp. BM Elev: BM Description: Sectionlrown /Range /Map No: "41 15.29.19. TANK INFORMATION V ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic / �� p BencJlmar f /� / 1G / A > Dosing Alt. BM ably. u�a!! � �• a / 3 • � Aeration 1 Bldg. Sewer Holding S HtL nl�et� . /0 TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. Ve t to Air Intake ROAD Dt Inlet _ Septic , Dt Bottom an. Dosing .� (� an ? Aeration Dist. Pipe - 7o , o A lLYrt Holding Bot. System !r 3 ` • V6 Final Grade f 0 PUMP /SIPHON INFORMATION (u�ey w —. D • 3Z D' /••L(i Matt)lfacturer Demand St Cover i GPM 3 illlse f Model Number > 2`'0'; -kt 144 L- TDH Lift Friction Loss stem Head TDH Ft G• 1 Forcemain Length Dia. Dist. to SOIL ABSORPTION SYSTEM ,2 -f �?.-� S GB — ra a" l BEDITRENCH Width Len No. Of Trenclhgs PIT DIMENSIO S No. Of P s Inside Dia. Liquid h 4 DIMENSIONS (( ddJJ -2-1 SETBACK SYSTEM TO P/L BLDG WEL LAKE /STREAM LEACHING Manufactur INFORMATION CHAMBER O Type Of System: -1 7 / r /- Model Number. J Y DISTRIBUTION SYST M is o .3V. h 2^� HeaderfManifgld Distribution /,y/� L x Hole Size x Hole Spacing Vent to Air Intake CP N I Pipe(s) 1 �ength Dia Length '6 Dia Spacing l" SOIL COVER A^ 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 E� Yes [j_ No ( Y COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / Inspection #2: / ! Location: 935 Coyote �Lane '' Hudson, W � ' 1 54016 (NW 1/4 SW 1/4 1 T29N R19W) Coyote Ridge Lot 26 � Parcel No: 15.29.19. 1.) Alt BM Description = tl/Yt (�-l� �� !�. –�C/N� Qlk `% -4� 2.) Bldg sewer length = I � A� amount of cover = ,3 t�� Plan revision Required? Yes I �T c bse other sideafor additional information. � ( i0 v Date Insep tors Signs u Cert. 6gt710 (R3/97) 4 C� _ 30 1 ` - q L T a- /aso � 1 J i \- / h� Sakty and Buildings Division County 201 W. Washington Ave., P.O. B 162 �5 1* isconsin M,ai 6-315 — Saniuuy P4/6 2u / be filled in by Co.) (ti08 2G6 -3151 '.•�`� s 7 ? Department of Commerce State PWn I.D. Number Sanitary Permit Ap lication In accord with Comm 8321, Wis. Adm. Code, I inf Project Address (if different than mailing address) may be used for secondary purposes PH Law, n C 0Y6 - tom 1. Application Information — Please Print All Informati J t t > Q3 Parcel_M Lo Block N Property Owner's Name c7 / Pro tion propert Mailing Address --- 'r � / / 8 A-1 /J y. S' /. Section City, State �^ Zip Code Phone Number sue-- q JC�u Af [L Type of Building (check all that apply) ai► S ` S W ACS N Describe umber 1 or 2 Family Dwelling — Number of Bedrooms O PublWCommercial —ibe Use ownship of ❑State Owned — Describe Use EgLAI III. Type of Permit: (Check only one box on line A. Complete line B if ap ble) A- New System ❑ Replacement System ❑ Tratment/Holding Tank Replaoanatt Only ❑ other Modification to Existing System B. ❑ Permit Renews!! ❑ Permit Revision ❑Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. Type of POWTS System: Check all that a pply) /Non - .Pressurized in -Ground ❑ Mound > ❑ _ 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑Single Pass Sand tiller ❑ Constructed Wetland ❑ Pressurized h mund ❑ Holding Twk ❑ Peat Filter ❑ Auobic Treatment Unit ❑ Recirculating Sand Filter C Recirculating Synthetic Media Filter Leaching Chamber Dri Line ❑ Gra -less ipe ❑ Other (explain) V. Dis rsalffreatment Area Information: (sfj Dispersal Area Proposed (sf) S El n / Des © (gpd) Design Soil lication ltate(gpdst) ispersaI Area Required / f 7 V[. Tank info Capacity in Total Number anuCacturer fab Site Steel Fiber Plastic Pre Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank S !� Aerobic Treatntnn Unit Dosing Chamber VII. Responsibility Statement - L the undersigned, assume responsibility for Nation of the POWTS shown on the attached es plans. Number PI u (Print) P tuber's 'gnature P RS Number 11 95? -0 7 Plumber's Address (Street City , State, Zip VIII. Count y /De artment Use Onl Sanitary Permit Fee includes Groundwater Date sued 1 sum gent Signature (No Stamps Approved ❑ sapprov Surcharge Fee) 4t 2 ❑ Owner Given R for Denial 250 I3;. Conditions of Approval/Reasons for isapproval SYSTEM OWNER: 1 Septic tank, effluent filter and dispersal cell must all be serviced I maintained as per management plan provided by plumber. 2. All setback requirements must be maintained as per applicable code /ordinances. Attach eompkte plans (to the county only) for the syste n on paper Rot less tluR g1/2 x" aches in size SBD -6398 (R. 01/03) _ - - / v 0- a� T- 9- laso VvI Ta �01 r -� l �v � 6 3S 7 ' RECEIVED Wisconsin Depa*mt of lL � ALUATION REPORT 3 Division of Saf�yard Brame DEC 2 9 20 � �/ in M. Adm. Cate ST. CROIX COUN County Attach complete site plan on not � AtBtc# M:919 inches L size. Pla ri must andud% but not limited to. drection and percent t D. ` C. �O LU percent slope. scde ordsmmensions. north mow. arid locabon and d to neamd road Phase print aft Ink madam Reviewed by Data P*nMXW Mannakm you provide mmr to wea rorsecandwy purposes (hfV41CY Low * 1s of (m) ") Al tJ o s£ I SEX-r- [ k'�iP�t/O,tl f3f�$ T covr Lot ��a ua s r Z 9 N R 19 A40r) w Property Owners Address trot # Block # Stbd Name or CSMN 6 N Fqg CKY State 4p Code Prone Number ❑ 0 O village ® Town Nearest Road #UDS A) 40 1. s yoj(P 1 ( '71 5 ) 3,?1,-7n7 H UP 50,j 8,4rl--E Now Consiruck" Use less Rasiden" / Number of bednoonw node derived deem kw rate yS0 —• O GPD O Replacernert O Pubic or aonmma dd - Dew. bw. parent SANDY o y i w,� FWd Plain eltrvafm ff applkmble iv 11L General carrmrrmerrts and KKNINUMwedom. 'r�l?Eh T�S is sv�T��3� -e.. ��e rtv ia��,eovwp �oc� v�7at�•4 � s ysrc"� C 'P. o.w . r.s .> F 71 Pit Ground efev. _ tt' Depth to factor i,m. Soil A&&Mm Rafe Hoitax Depth Oon*iant Color Redort Description Te *n Strickae Camidence Boundary Roots GPOW h iMicxmeell f]u. SL Cont Color Gf Si. Sh. 'M 'W2 f 0 /0 Y1 J/3 L /fsbK dSA T . Cr z • /G a Y,4 G 51& she d - it - 3 • L 16 s 5/1, f sh d S - 3 S YA5 V F2-1 # 0e«� p 3 . 3 p I > p s K Pit Gromxd surface elev ! ft. Depth to ter ` Z ' in Rele Wor(mon t)epth Dondn"CAft Red= Description T swum" Cam Bounder► Roots WON In. Murmsedi am Sz Cora. color Gr. SL Sh. 'mot 'EW#z O va toy AS w 3 F Z 4-17 1,6 t 5/6 a S GGJ • S • 0 14 Sl iL / f,5hx — -5 Or S /• Z so 9 . 160 off' SZ . o� ' ' E D #1= BO a 30:5 nd 220 mWL a TSS X <_ 30 150 nvL E1nm t #2 = BUD < 30 nvt and TSS :5 30 mpiL. CST Name (Fmlease Prim , Sigrmatcrre =14umber Rot ewr �t�b�(c�+ c.3 Address oft Evaltradiorm Conducted Tempdmone Number A100- /F 7l5• Private Sewage Consultants 2812 1 Qth Ave. P/N • S / k TOT.+-L- d/- 0 Spring Valley, WI 54767 2 0. to 17 - 2-0 • O'a'r 2-0 • /0.17 • 30 - aaa 1 11 iJ . Ct) yo T, Propert �RND � 131+5 T' Parcel to # L 0 f' 2 CP 2 of 3 E fl 0 Pit Ground surface elev. D ' ft. Depth to +fl factor ` � in Sot Rate Hori m Depth Dominant Redox Description Texture Strcucturi Cons Boundary goofs F In. Munsell Qu. Sz. Cont. Color Gr. Sr- Sh. TI L zfshK 3�F . S • � R .1 RS Si /-�S 7 (0a L i i 2• F—I Bork # rs ❑ Soft ❑ Pit Ground surface elev. fk Depth fo &nft factor ' in. Sot Application Rate Horizon Depth Dominant Cokm Redox Desa"m Texture Structure Consistence Boundary Roots GPD/[F in. Munsell Qu. Sz. Conk Color Gr. Sz. Sh. 'EWI 'Ef02 I F-I # ❑ �9 ❑ p Ground surface Slay. fk Depth too tirrWQ factor in. aorr Soti Ram Hari Dominant Redoxosscroft_ TOO" Stucture Corrsistenoe Bourg Roots GPM In. Muisell Qu. Sz. Cont. Color Gr. Sz Sh. *MI 'Eff#2 Eftfuant #1 = BOD :,- 30 < mgiL and TSS >30 <_ 150 mq L Mart #2 = BOD < 30 melt. and TSS < 30 nV L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an aftcrnate format, please contact the department at 608 - 266 -315 i or TTY 608- 2644rM. For issuance of permits and designing Contact: Ulbricht & Associates Registered private wastewater consultant and plumbem 2812 10th Ave. Spring Valley, WI 54767 715- 772 -3442 3 D W T C /000 7L a Y y S� /09 0 0 y -7-1 i nje ..�. . POWTS OWNER'S MANUAL &MANAGEMENT PLAN Page I of 2 FILE INFORMATION SYSTEM SPECIFICATIONS 1 Owner Septic Tank Capacity Z Q a l ❑ NA 4 1� � 0 Ll Permit # Septic Tank Manufacturer 13 NA DESIGN PARAMETERS Effluent Filter Manufacturer _ ❑ NA Number of Bedrooms y ❑ NA Effluent Filter Model ❑ NA Number of Public Facility Units ❑ NA Pump Tank Capacity a l ❑ NA Estimated flow (average) gal/day Pump Tank Manufacturer ❑ NA Design flow (peak), (Estimated x 1.5) fQ gal /da Pump Manufacturer A Soil Application Rate . 7 gal/day/ft' Pump Model A Standard Influent /Effluent Quality Monthly average` Pretreatment Unit E A Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD 5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BOD 530 mg /L Vn- Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) :530 mg /L ❑ NA At -Grade ❑ Mound Fecal Coliform (geometric mean) :510 cfu /100ml ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size Y 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: ❑ earl 1(s) (Maximum 3 years) 13 NA Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA Inspect dispersal cell(s) At least once every: ❑ y a lsj(s) (Maximum 3 years) ❑ NA C2 X Clean effluent filter At least once every: ❑ month(s) ❑ NA year(s) ❑ month(s) ❑ NA Inspect pump, pump controls & alarm At least once every: ❑ year(s) ' ❑ month(s) ❑ NA Flush laterals and pressure test At least once every: ❑ year(s) Other: At least once every: 13 month(s) 13 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 cells) 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 (Y 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. Page Z of, START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tankls) for the presence of painting products or other chemicals that may impede the treatment process and /or damage the dispersal cellls). If high concentrations are detected have the contents of the tankls) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal g d spe sal cells) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or. must be taken, to provide a code compliant replacement system: X A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. !Y� T alua ' a o ing tank ❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name u Name Phone �S` _ Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name S G b Phone Phone This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP C;2,RTIFICATION FORM Owner/Buyer y Mailing Address Property Address S coq� (Verification required from Planning 4artment for new construction) City/State l/.!�r l � " tY — Parcel Identification Number _ V; �f LEGAL DESCRIPTION I/ Property Location M %, y,, Sec. �S, T & -RZ�W, Town of, Subdivision _,at � Lot # Certified Survey Map # % olume �- , Page # Warranty Deed # 2 ,!5 6 �/ �L� Volume Page # -22n Spec house ❑ yes�no Lot lines identifiably yes ❑ no SYSTEM MAINTENANCE Improper use and maintenanceof 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. c Th ProPeziY -owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a masterplumber, journeymanplumber, restrictedplwmber or a licensedpumperverifying that (1) the on -site wastewaterdisposal 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, herein, as set by the Department of Commerce 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 Zoning Office within 30 days of the three year expiration te. I AT JRE F ICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the property described above, y virtue of a warranty deed recorded in Register of Deeds Office. SIGNATURE OF APPLICANT DATE * * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * "" Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed KATHLEEN H. WALSH REGISTER OF DEEDS ST. CROIX CO., MI STATE BAR OF WISCONSIN FORM 2- 2000 RECEIVED FOR RECORD Document Number WARRANTY DEED 01/07/2004 12:35PH WARRANTY DEED THIS DEED, made between Kemon J. Bast, a married person, EXEMPT # 8M Grantor, and Kernon J. Bast and Donalda J. Speer -Bast, husband and wife, REC FEE: 13.00 as Survivorship Marital Property, Grantee. TRANS FEE: Grantor, for a valuable consideration, conveys and warrants to Grantee COPY FEE: the following described real estate in St. Croix County, State of Wisconsin: CC FEE: PAGES: 2 SEE ATTACHED EXHIBIT A Recording Area Name and Return Address: Edina Realty Title, Inc. 400 S. 2n' St. — Suite 115 Exceptions to warranties: Hudson, WI 54016 Easements, restrictions and rights -of -way of record, if any. 412540 20- 1027 - 40-000 & 30 -000 &20 -00 Parcel Identification Number (PIN) This is not homestead property. Dated this 6th day of January, 2004. * ernon J. Bast * * AUTHENTICATIQN l ACKNOWLEDGMENT heC' c Signature(s) G , pU6 S TATE OF WISCONSIN ) 0 I1 , M ST. CROIX COUNTY. ) ss. authenticated this 6th day of J g a� Personally came before me this January 6, 2004 the above named Kernon J. Bast, a married person to me known to be the person(s) who executed the foregoing instrument and TITLE: MEMBER STATE BAR OF WISCONSIN acknowled the same. (If not, 51A- authorized by § 706.06, Wis. Slats.) THIS INSTRUMENT WAS DRAFTED BY *Chen Brown Notary Public, State of Wisconsin Edina Realty Title — Doug Berg My commission is permanent. (If not, state expiration date: 400 South Second Street #115, Hudson, WI 54016 3/11/2007 ) (Signatures may be authenticated or acknowledged. Both are not necessary.) 'Names of persons signing in any capacity must be typed or printed below their signature WARRANTY DEED STATE BAR OF WISCONSIN FORM \0.2 -2000 U 2y87P 12 EXHIBIT A The NE '/4 of the SE %. and the NW %. of the SE %,, all in Section 15, Township 29 North, Range 13 West, St. Croix County, Wisconsin, EXCEPT a parcel described as: Beginning at the E'/. corner of said Section 15; thence South 00 degrees 47 minutes 33 seconds East, along the east line of the SE '/< of said Section, 407.27 feet; thence South 89 degrees 08 minutes 15 seconds West 535.46 feet; thence South 14 degrees 10 minutes 34 seconds West 93.31 feet to a point on a 80.00 radius curve, concave southwesterly, whose central angle measures 25 degrees 34 minutes 33 seconds, whose chord bears North 54 degrees 32 minutes 33.5 seconds West and measures 35.41 feet; thence northwesterly along the arc of said curve, 35.71 feet; thence North 14 degrees 10 minutes 34 seconds East 76.12 feet; thence North 01 degrees 07 minutes 26 seconds West 400.07 feet to the monumented south line of Certified Survey Map recorded in Volume 1, page 217 at the St. Croix County Register of Deeds Office; thence North 88 degrees 51 minutes 13 seconds East, along said south line, 570.78 feet to the point of beginning. 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