Loading...
HomeMy WebLinkAbout040-1168-50-000 Wisconsin Department of Commerce G u g~ County: Safety and Building Division PRIVATE SEWAGE SYSTEM St. Croix 'WP/770tJ'f1 4*t I INSPECTION REPORT Sanitary Permit No: p61R7 J94' /-Z' yam- TTACH TO PERMIT) 579001 GENERAL INFORMATION 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: Lundgren, George & Sandra T Troy, Town of 040-1168-50-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: lUD - t, v a M v S6 7 C v (L41N 12- 35.28.20.641 D TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing o /AJ& O^/ ~'~S ~~.y IOO.vd Alt. BM Go Aeration Bldg. Sewer • 04 Holding 7 zO ` LS LZ /A/01-rifgTd~ PoL CZ) /000 a ao ~Inlet 7 Ir 2" TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. Vent to Air Intake R@4y9 Inlet !Z 33 ar~tuE / Alr 30? Septic Dt Bottom Dosing Header/Man. Aeration Dist. Pipe Holding 7!! I , Bot. System 7l Final Grade PUMP/SIPHON INFORMATION Ma ufacturer Demand over o,, GP Of' Model Numb TDH Lift riction System Head T Ft Forcemain Length Dia. Dist. to Well S IL ABSORPTION SYSTEM BED ENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENS SETBACK SYSTEM T WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR TYFe-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 r Mulched Bed/Trench Center Bed/Trench Edges Topsoil Fa Yes [id No Q Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:~O / Z4// Inspection #2: Location: 228 Ilwaco Rd River Falls, WI 54022 (Gov't Lot 5 35 T28N R20W) metes & bounds Lot Parcel No: 35.28.20.641 D 1.) Alt BM Description = g171 f V~~ Q Sj L (r'a /Ql (1? Q~- 2. Bldg sewer length $N = CW 346-Al 410, 97-37 1D- of ~QaSiO~/ Lv2LLf /4J PLlIGE (S€& PHat2iS -amount of cover = r ~~.r~,t j TK tll ~prvT(T slL'T VC7-/4*T ,~lR D $FN lCNDGI+r d r-EA TAA)IL 0 p Plan revision Required? ❑ Yes R No ZQ Use other side for additional information. SBD-6710 (R.3/97) Date Insepctor s Signature ~21i Cert. No. ,tr va * sit, T~uK -DP-y wElL *OWAV"M PAR 383. County Safety and Buildings Division &PO 1 s P r RECEIVE 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.) S j Madison, WI 53707-7162 ?00 1 JUN ~ Q 2015 7' S,8Wtq pR`~mlt Applica State Transaction Number in accordance with S$0~,,ViP9 WU s t~ssion 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 Servies. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law, s. 15.04 1 m , Stats. 1. Application Information - Please Print All Information _UC,f Property Owner's Name Parcel # U CCd VA - ~ 1/1 d 43110116 9.5? dA) Property Owner's ilin Address Property Location City, State Govt. Lot Zi Code Phone Number Yo e~ ''/o, Section-7 ~ ` Or + O 0 lW trcle one II. ype of uilding (check all that apply) Lot # T i / O-N; R E ~ 1 or 2 Family Dwelling - Number of Bedrooms Subdivision Name Block # ❑ Public/Commercial - Describe Use ❑ City of ❑ State Owned - Describe Use CSM Number ❑ Village of Town of rn III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. ❑ New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber List Previous Permit Number and Date Issued ❑ Permit Transfer to New Before Expiration Owner IV. Type of POWTS System/Component/Device: Check all that apply) ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound ? 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil .Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dispersal/Treatment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units ` L c n New Tanks Existing Tanks (n U w U p' C y N N 2 0.. U V] h on u, U p, Septic Holdin T e,00 Dosing Chamber u VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POW TS show hed plans. Plumber' Name (Print) Plu Signature MP Business Phone Number 66 Plumber's Address (Street, City, State, Zi ode) r ~ 1SVIII. Count /De artment Use Only Approved ❑ Disapproved Permit Fee Date Issued Issuing Agent Signature ❑ Owner Given Reason for Denials UD ~p - Z 3 1S IX. Conditions of Approval/Reasons for Disapproval ~l F So~GS W)eE' 0-ruA47& 9T Aw,5zvex) mute' S4/&w/j- fJAUOR SYSTEM OWNER: GAGGuG~~o~tJS 176-Z ,CX ;g';, y.$ (a~~ 1. Septic tank, effluent filter and #u SEi9VlcE' &zev /:I;&ST IMF 42-5- Fge,4* %I k'e,9179w- as dispersal cell must t serviced / maintained S per management plan provided by plumbe lDAJ 4 IA) )W2. All setback requirements must be maintained - /rI♦ it 2E ttach to co plete plans for he system and submit to the County only on paper not less than 8'as obindpkgWe code/ordinances. SBD-6398 (R. 11/11) Pg __Lof Private On-Site Wastewater Treatment System (POWTS) Index and Title Sheet Owner: (set) re t Project Name and System Type: l7 ~ l~ Jh111 A Location: C ZA) Legal ;m0lion S C~ r~d t ~c TownshCo ty Contents: Page 1: Page 2: Page 3: F 10t V t h Page 4: C1 tot V- S /r ax °L C !-t 4 Lt1 Fla Page 5• Page 6: _ T / • Sys --~~oi'~, Page 7: Page 8: Page 9: Attachments: ~ ~°~a s GHQ ~ Plumber/Designer: s~ ~ Signed: Credential Number: d tl? r 6 Date: -Z- ` ST. CROIX COUNTY pb SEPTIC TANK MAINTENANCE AGREEMENT .'AND OWNERSHIP CERTIFICATION FORM Own Buyer tJ eQ G Mailing Address - - = Property Address ~c a t J CSC Q (Verification required from Planning & Zoning Department for new construction.) City/State NtUtV' SA Parcel Identification Number LEGAL DES RI TION ©C / Property Location Yq , t!4 , Sec--, ~ , TA N R,2 ToVVrt of (C ti Subdivision Lot 9 Certified Survey Map # , Volume C9 Page It Warranty Deed # , Volume , page Spec house yes (no): Lot lines identifiable ESP tlo 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 farm, 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 fWI of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set ftirtlr, herein, as set by the Department of Coinrrce 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 this form are true to the best of my/our knowledge. Itwe am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of b oo A OF APPLICANT(S) DATE Any inforcrar ' 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 neap if reference is made in the warranty deed. (REV. 08/05) Celebrating 40 Years Portage, WI (800) 362-7220 O Excellence Spooner, WI (800) 336-3416 Fond du Lac, WI (800) 641-5937 1965-2005 Maiden Rock, WI (800) 325-8456 IIIIRETE Visit Us On the Web npcA www.wieserconcrete.com CERT~EQ PLANT a~ alp 1al-ih' , i' ! m t! 1 in Steil ilk r,1 n r r /t Fns 'w r' ups ~ CP: Fo _ I[N:IEIER Project Name:Ceople ~,Mh 1'C t) -146Id8vl(~ ~klq Computations By: Date: Location: aDChecked By: Date: Title/Item: 'riv TIJ A cd ~ Sheet: Of: POWTS OWNER'S MANUAL & MANAGEMENT PLAN Pao of FILE WFOISNATION SYSTEM 0"EC111WAT10" Owner k r P Q NA Permit Septic Tank Manufacturer D NA DESIGN PARAMETERS Effluent Filter Manufacturer 10A. A LUNA Number of Bedrooms DNA Effluent Filter Modal gzNA Number of Public Facility Units 4ANA Pump Tank Capacity al j2r-NA Estimated flow leverage) gal/day Pump Tank Manufacturer )a NA Design flow (peak), (Estimated x 1.5) 7777779914 Pump Manufacturer M~NA Soil Application Rata A~gallday/ft` Pump Model 11NA Standard Influent/Effluent Quality Monthly average* Pretreatment Unit qNA Fats, 011 & Grease (FOG) 530 mg/L D Sand/Gravel Filter D Peat Filter Biochemical Oxygen Demand (BOOS) 5220 mg/L ~r1 NA D Mechanical Aeration D Wetland Total Suspended Solids (TSS! 5150 mg/L D Disinfection D Other; Pretreated Eff uent Ouality Monthly average Dispersal Cell(s) 'Z NA Biochemical Oxygen Demand (SODS) 530 mg/L D In-Ground (gravity! D In-Ground (pressurized) Total Suspended Solids (TSS) S30 mg/L $ NA D At-Grade D Mound Fecal Coi'iform (geometric mean) 5104 du/1 OOml D Drip-Line p Other: Maximum Effluent Particle Size YS in die. ILNA Other: D NA Other: 'W NA Other. ❑ NA Values typical for dornestk: wastewater and septic tank effluent. Other: D NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: month(s) (Maximum 3 years) D NA Pryearls) Pump out contents of tank(s) When combined sludge and scum equals one-third (7S) of tank volume ;NA Q Inspect dispersal call(s) At least once every: Dmonth(s) (MaAnuin 3 years) WNA Clean effluent filter At least once every: E3 moth(s) OrNA Inspect pump. pump controls & alarm At least once every: a m onth(s) NA year(sl Flush laterals and pressure test At least once every: D month(s) &NA D earls) Other. D month(s) Aka ta At least once every: p NA Other: ~ f l r D Years! G✓E\~IL ~ 6 Qt!'` DNA MAINTENANCE INSTRUC71ONS 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 brokers 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 (Ye) 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. START UP AND OPERATION Page t of For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) 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 cell(s) 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: ❑ 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. ❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ❑ 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 Named V Name S Phone fj'~ p 5 Phone Z(~( ry L SEPTAGE SERVICING OPE ATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Yell c ) Name Phone Phone .r 3e j _"'411 c. t 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. Single Holding Tank Cross Section and Plan View Plan View :17C i: 1: 1 s s s r s r r r r s s} „ 414 4 4'4 t , Y S S { Typical ` { 24" I.D. Y Inlet Manhole Vent Pipe Opening { >s i'{ t > } , { { }S {'i s> s s, s s a s s r r s,>, r> s s r s s s, s s s " s s s s s> s s s s s s>, s s r s s,, s r s, s sisi i i{ R C{ G{ t 2 6 G{;{ L t{ S G< G S R G G< R{ S R< S{ G<<< G G{! R<{ G{ t 2{ G< G R{< t i Cross-Section 4 in. Dia. - - - Finished Grade Min. 4" Vent with Above Cap 12" Grade With 3 ~ Ft Cover Above Locking Manhole Cover ~ Grade Device Sealed Watertight } } } } } } } , } , } } } Y } } } } } } } } } S S S i; S S L S{; S S S S S;{{< i< S S t S S{ S}{}{}{}t}<}S}S}Stt>;'i'S'{ Tether Tank Manufacturer: K f ,4 y ; < L; * Weight 1' } Tank Capacity: } Gallons } Y ~ S Tank Maximum Depth of Bury: Ft > i } Alarm { L; Switch Depth of Soil Cover Over Tank 49 Ft. ' i On }i L ; } Tank Outside Dim.: Width gyp, Length Height > { } } ~ S } } i Alarm Switch Type: } Mercury ❑ Mechanical sis r s s} s s s r s r r} s}} s s s s r s}} a s>} s} s s s r s}}, s> s s s s s} s s r> s}}} }i } s < t i i{{ t{;;<{ S S S t{ i i i{{{ S S S S C C i S{{ i 5{{{{ S C{ C i t;{{{;; S{; S S S S GENERAL INSTALLATION: The tank is bedded and back filled in accordance with the manufacturer's product approval specifications. Maximum depth of bury as specified by the manufacturer may not be exceeded without prior approval. Manhole covers exposed to grade have an effective locking device (padlock) installed. Manhole covers below grade are sealed watertight. Piping at the inlet is of approved material, connected to the tank with watertight fittings, and laid on stable soil to prevent settling or sagging. Electrical is as per the National Electrical Code and applicable Wisconsin standards.. Electrical is as per the National Electrical Code and applicable Wisconsin standards. 03/05 lgj Page / of 6 SEPTIC or HOLDING TANK SERVICING CONTRACT Contract Date 5. ;6 -20/ r This contract is made between the Tank Owner(s) Name(s) and Pumpers Name, 0111, t,vvns~ ~ st rc. We acknowledge the installation of (a) septic/holding tank(s) on the following property: (Provide legal descrption): 3 20 w - - - - - LW TIL4 1- 1. The owner agrees to file a copy of this contract with the local governmental unit (St. Croix County Planning & Zoning Department) to document maintenance by a certified septage servicing operator as required in SPS 383.52(1)(c)2. Wis. Adm. Code and the approved Component Manual. 2. The owner agrees to have the septic/holding tank(s) serviced by the undersigned pumper and guarantees to permit the pumper to have access and to enter upon the property for the purpose of servicing the septic/holding tank(s). The owner agrees to maintain the access road or drive so that the pumper can service the septic/holding tank(s) with the pumping equipment. The owner further agrees to pay the pumper for all charges incurred in servicing the septic/holding tank(s) as mutually agreed upon by the owner and pumper. 3. The pumper agrees to submit to the local governmental unit (St. Croix County) a report for the servicing of+ the septic/holding tank(s) on a monthly basis. The pumper further agrees to include the following in the monthly report: a. The name and address of the person responsible for servicing the septic/holding tank; b. The name of the owner of the septic/holding tank; c. The location of the property on which the septic/holding tank is installed; d. The sanitary permit number issued for the septic/holding tank (if known); e. The dates on which the septic/holding tank was serviced; f. The volume in gallons of the contents pumped from the septic/holding tank for each servicing; g. The disposal sites to which the contents from the septic/holding tank were delivered. 4. This agreement will remain in effect until the owner or pumper terminates this contract. In the event of a change in this contract, the owner agrees to file a copy of any changes to this service contract or a copy of a new service contract with the local governmental unit named above within ten (10) business days from the date of change to this service contract. Owner(s) Name(s) (Print) Owner' gnatur Subscribed and sworn to me on this date: Today's Date Pumpers Name (Print) P er's Signature Notary Public Signature ~a rp t 11,0j4 o.•A. 1 '1.~ Pumper's Registration Number • ~ ~ ~ ~ ~ O Commission Expiration ss SHERRI ~r NELSON OF WIS . tt ve- •r