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HomeMy WebLinkAbout032-1004-10-001 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: Safety and Building Division St. Croix INSPECTION REPORT Sanitary Permit No: GENERAL INFORMATION (ATTACH TO PERMIT) 582032 State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, 5.15.04 (1)(m)], Permit Holder's Name: City Village Townshi Roger Kukowski p Parcel Tax No: TOWN OF SOMERSET 032-1004-10-_001 CST BM Elev: Insp. BM Elev: BM Description 2 Section/Town/Range/Map No: J 02.31.19.22A-01 TANK INFORMATION LEVATION DATA TYPE MANUFACTURER PACITY STATION BS HI FS ELEV. Septic ~ ~ Benchmark ~ V9 L.-V Q Alt. BM Aeration Bldg. Sewer Holding ~ • ~ St/ t Inlet 3 + / 7Z TANK SETBACK INFORMATION St/ Outlet TANK TO ~ WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic (~O(~ Dt Bottom Dosing Header an. qq Aeration Dist. Pipe 2 Holding ~ • J ' Bot. System •~f 10-~ PUMP/SIPHON INFORMATION Final Grade Manufacturer 0 e and St over rp~', J / GM 17, Model Numb r -Vrgllein TDH Lift ! Friction Loss Head TDH Ft I Forcemain Length Dist. to Well SOIL ABS ON SYSTEM BED/TRENCH Width } Length ( No. Of Trenches PIT DIM No. Of Pits Inside Dia. Li(o DIMENSIONS ENSI i ui d De rn q p~p~ SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer / •old INFORMATION CHAMBER OR / T ORq4~) a~) UNIT Model Number , I U IBUTION SYSTEM 41 Header/ anifold Distribution x Hole Size 4: U if I / x Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only ft)( j ' De Over Depth Over xx Depth of xx Seeded/Sodded Bed rench enter Bed/Trench Edges Topsoil ulched es No es ~ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1n Wei) Inspection #2: /Rk/ Location: 625 POLK/ST ROIX RD 1.) Alt BM Description g2.) Bldg sewer length = ~/1~D t~ 1(1( con nec fi~'lee -amount of cover = eQS-~-G I or tt >JID 16 S&IM ~ Z~ V Covtv- on a Plan revision Required? 0 Yes No Use other side for additional informati n. I t l SBD-6710 (R.3/97) Date I epctor s Signature Cert. No. ao~pArrr' County © ' We rvices Division P UN 23 205 4ashington Ave u . CROIX COUNTY P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.) UNITY DEVELOPMENT WI 53707-7162 ya i54 2 b?j Sanitary Permit Application State Transact'on/ umber in accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the ap the Department propriate governmental unit /t►~" is required prior obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to r Of dSafety and Professional Services. Personal information you provide may be used for secondary u oses in accordance with the Privacy Law, s. 15.04(1)(m), Slats. ProjeAddress (if different than mailing address) I. Application Information - Please P ' All Information Property Owner's Name 1 , - 1 P cel # , - - 03Z- APropertyOwner's ailing Address Property Location Govt. Lot Zip Code Phone Number / Yv Section c~ circle o g (check all that apply) Lot # N R E o> elling - Number of Bedrooms Subdivision Name ❑ Public/Commercial - Describe Use Block # . El '1rGi ° State Owned -Describe Use OJ ❑ City of A; tk: CSM her El Village of Z L W /44-/ cLA 9 2q Town of III. ermi ck only one box n line A. Complete line B if applicable) r New System Replacement System ❑ Treatment/Holding Tank Replacement only ❑ Other Modification to Existing System (explain) 0 B, ❑ Permit Renewal ❑ Permit Revision ❑ Change of Before Expiration ❑ Permit Transfer to New List Previous Permit Number and Date Issued Plumber Owner e of POW S Com onent/Device: (Check all that apply) Non-Pressurized In-Ground Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil tspersal Component (explain) ❑ Mound < 24 in. of suitable soil ❑ Pretreatment Device (explain) n V. Dis ersal/Treatmen rea In M Design Flow (gpd) Design Soil Application Dispersal Area Re uired s Rate(gpdsf) Q (fl Dispersal Area Proposed (sf) System Elevation VI. Tank Info Capacity in 9 Gallons Total # of New Tanks Existing Tanks Gallons Units anufacturer U W /~/of txk a U cf) , Septic or Holding Tank w a Dosing Chamber ❑ ❑ 11 E] VII. Resp nsibility Statement- I, the undersigned, assume respo ibili r installation of the POWTS shown on the attached plans. ❑ ❑ ❑ Plumb ame rint ~ Plumber's Signa MP/MPRS Number Business Phone Number Plumber's Address (Street, City, State, Zip Code) - 7- VIII. nt /Department Use Only Approved approve Permit Fee 'at Issue Issui gent Signa e even Reason for Denial $ . 00 /0 IX. Condis eftIns for Disapproval ptte a uen erand q~ pr, It I A*~. I dispersal cell must all be services / maintained ✓ p~ as per management plan provided by plumber, 2 .A'b Eck reqVkWa9nt*_ 4wm4irftk%d tia PW "M" Code / or~ Attach to complete plans for the system and submit to the County only on paper not less than 8 In x 11 inches in size SBD-6398 (R03/14) CONVENTIONAL COMPONENT DESIGN Residential application INDEX AND TITLE PAGE MR. Project • ~ ~a• Name: .N ,Y.:•A~ . ,Its . Owner's Name: Owner's - +MLi434~ s<'- } ~,`rA>- .+xa Address: + ~ :mom _1,~~ ~~~r „N \ 4y 4 Legal Description: l Subdivision:. Lot # Town: County: Parcel ID# Designer/Plumber.- License Signature-Dbte' Comments nccierncri nnrcimni• to i-ha )n_hrnnnA';AH Qhcnrntinn rmmnnnPnt Manual fnr Pn WT,S vprcinn 7.17 _f 46~tGc' g-1 , r 'U r /J14- 6e lmo ?s-,9 " Soil Absorption 5yatem Dross SqCfion 4° Sched* 4(? F'rnai Grade PVC Vent Po Vft Vent trap _ 7 Leaching Chamber ft - System Elevation Soil Ab ATdon §Pft tt Plan View ft l leaching Trench 9 i t Vent Or Observation Pipe DOM C'M 47 Dia_ Trench 2 Header FgpManufacturer And Mode( Rating~,~~ sq f t per chamber Soil Application Hate gpolsQ fr d Design Flow = 7 Soil Application Rate + , EISA = Chambers Z rows of chambers each. of Page INSTALLATIO PA NSTRUC* zabe? tic AatAdicf* 6~ PL-527 7a~~a L-625 FILTt INSTAL,L.A71ON INSTRUCTIONS : Centerfiar with opening ,sz ~iz.,, i• C.-i ~,.,f~-rn a ..a .mss r g~j s. er'F3i~ a ,a: n. a ate • 5 `y~_a t _ ~a v:.~ - ~ ~ _ r s~ ~ , Step 1: Step 2: (A) Locate the outlet of the septic tank (A) Before installation, place the (A) Step 3.- (A) the fi1#er how-rtg on the (8) Remove tank rover and pump tank after housing on to the outlet pipe. outlet pipe. if necessary. (B) Miake sure that the housing {8) kwe. rt the filter cartridge In #te is positioned so the#t~ter can be removed housing, rnalcing sure the after maintenance from ta and the t seervrc for Cartridge is properly aligned and vice. COMPleiely Inserted in the housing. MAINTENANCE INSTRUCTIONS r x} - ~ Asa :_s:-~: i . , r.. Rog C -a Y~ . { -i' ry t a 4n - 'r x 2 st3 ' a s Siti R r - jfVV 4P`' r~'• f r r" L .mom r ~ ~ ~ ~a,,~ ~~i .ra,t~ _ z y a• .,z -s _ y"= } . 'Peat' f-,E.~. •s_• r-ry}''r54~ v ~ C~h+"gi••.r. _~ss iYtis-?~~ ''a iy:- z~~=+ x~~.`a dAC.? Step 1: Step 2: Locate the outlet of the septic tank (A) Remove tank cover and pump Step 3' • ~ m e ~ r. if necessary. (A) li'tsettthe f't~tttitlge back into the Me housing nttakin sure 8 (B) Pull the 09rOMofthe housin g _ g. the owls ptaPerlY aGgheai =%r SSE IUBF ' CG Q ES' _ (C) Hose offt ova fly fartk arid completely inserted a.!VH (±t` cl iF I G FILi R 1 Make sure an solids tau back into the {8) Reptsce mastic t snk cover POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page 1_51~_`of FILE INFORMAT ON Owner SYSTEM SPECIFICATIONS Permit # Septic Tank Capacity ~ gal ❑ NA Septic Tank Manufacturer DESIGN PARAMETERS 13 NA Effluent Filter Manufacturer Number of Bedrooms ~ ❑ NA ❑ NA Effluent Filter Model Number of Public Facility Units - ❑ NA .~'NA Pump Tank Capacity Estimated flow (average) gal NA Design flow (peak), (Estimated x 1.5) gal/day Pump Tank Manufacturer J& NA al/day Pump Manufacturer Soil Application Rate NA Standard Influent/Effluent Quality Monthly average* IVA Fats, Oil & Grease (FOG) 530 mg/L Pretreatment Unit ❑ Sand/Gravel Filter CNA Biochemical Oxygen Demand (BODS) 5220 mg/L ❑ NA ❑ Peat Filter Total Suspended Solids (TSS) 5150 mglL ❑ Mechanical Aeration ❑ Wetland Pretreated Effluent Quality ❑ Disinfection ❑ Other: Monthly average Dispersal Cell(s) Biochemical Oxygen Demand (BODS) 530 mg/L ❑ NA Total Suspended Solids (TSS) 530 m /L )41n-Ground (gravity) ❑ In-Ground (pressurized) g NA ❑ At-Grade Fecal Coliform (geometric mean) 5104 cfu/100ml ❑ Mound Maximum Effluent Particle Size ❑ Drip-Line ❑ Other: in dia. ❑ NA Other: Other: ❑ NA Other: ❑ NA *Values typical for domestic wastewater and septic tank effluent. ❑ NA Other: MAINTENANCE SCHEDULE ❑ NA Service Event Inspect condition of tank(s) Service Frequency At least once every: ❑ month(s) Pump out contents of tank(s) Year(s) (Maximum 3 years) ❑ NA When combined sludge and scum equals one-third of tank volume ❑ NA Inspect dispersal cell(s) At least once every: ❑ month(s) Clean effluent filter year(s) (Maximum 3 years) ❑ NA At least once every: :7) ❑ month(s) Inspect pump, pump controls & alarm year(s) ❑ NA At least once every: ❑ month(s) Flush laterals and pressure test 13 Year(s) ZNA At least once every: ❑ month s) Other: ❑ year(s) NA At least once every: ❑ month(s) Other: ❑ year(s) ❑ NA MAINTENANCE INSTRUCTIONS ❑ NA 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 es, of effluent on the ground surface. The pondi gtof effluent onfthe groundtsurface may indicate a failing immediate notification of the local regulatory authority. Pipes and to check for any ponding condition and requires the When the combined accumulation of sludge and scum in any tank equals one-third (Y) or more of the tank volume the contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. entire 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. GMW (4/01) START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of Page ~ of 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. painting products or other chemicals 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 lie 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 INSTALL ` POWTS MAINTAINER Name Phone ° E Name Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name 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 TAN T -~IADNTTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer Mailing Address Property, Address s, erifi on required from Planning & Zonin D ` ` Zc g epartment for new construction.) 4 AI City/State Parcel Identification Number 632 160 ~D 4b / LEGAL DESCRIPTION Property Location_ V4,- -,~IA '14 , Sec. T,_~N R_,O_W, Town of Subdivision Plat: Lot # Cjertified Survey Map # 27 Volume Page # (p / Warranty Deed # $ 9 (before 2007)Volume # Page # Spec house D yes 0 no Lot lines identifiable$yes D no SYSTEM M-'TENANC'E 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, the system can affect the function of the septic tank as a treatment stage in the waste disposab system censed. maintenance responsibilities are specified in §SPS. 3 83.52(]) and in Chapter 12 - St Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix Coup Planning owner and by a master plumber; journeyman plumber, restricted plumber r a licensed eDepartment edDe a certification form, signed by the wastewater disposal system is in proper operating condition and/or (2) after inspection and per ve less than 1/3 full of sludge.7'mg that (I) the on-site pumping (if necessary), the septic tank is Uwe, the undersized have read the above requirements and standards set forth, herein, as set b , agree to maintain the private sewn e } the Department of Safety And Professional Services and the De pg disposal system with the State of a'"isconsin. Certification stating that your. septic system has been County Planning maintained must be completed ent returned i Resources, & Zoning Department within 30 days of the three year ex and returned to the St. Croix Pjmtion date. Uwe certify that ail statements on this form are true to the best of my/our know] °e. Property described above, by virtu Uwe am/are the owner(s) of the Y f a wairan deed recorded in Register of Deeds Office. Number of bedrooms G?NTATURE OF APPLICANT(S) -.D/ -ATT/S E Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning D menf Include with this application a recorded warranty deed from the Register of Deeds Office and a co s ePtuveY~map if reference is made in the warranty deed copy of the certified (RE, V. 04/12) 00 Pn t cll> r sm Q C t RECEIVED 111 ilk V JUN 2 3 2015 q-7 ~I aq Wis. Dept. of Safety and ProfQsFjd88"iQQUNTY SOIL EVALUATION REPORT Division of Safety and Bq@MUNITY DEVELOPMENT Page of in accordance with SPS 385, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County J include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. Please print all information. Revi ed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). pProperty EOwner r Property Location !O AM LI Govt. Lot 1/4 1/4 T N R E (oro/ 's Mai ling Address Lot # Block Subd. a or SM# State Zip Code Phone Number city ❑ Village Town Neares oad ( ) f New Construction User Residential / Number of bedrooms - Code derived design flow rate GPD ❑ Replacement ❑ Public or commercial - Describe: ' Parent material Flood, Plain elevation if applicable General comments ft. and recommendations: F-/1 Boring # 11 Boring 1G~J Pit Ground surface elev. ft. Depth to limiting factor /D in. Horizon Depth Dominant Color Redox Description Texture Structure onsistence ounda Roots Soil A lication Rate in. Munsell Qu. Sz. Cont. Color ry GPD/ft I Gr. Sz. Sh. * ff#1 * ff#2 Z 42 - /6 q Q -41 t-e- 4 Q 67- R Q 9~'7 Boring # ❑ Boring ® Pit Ground surface elev. ft. Depth to limiting factor in. Horizon Depth Dominant Color Redox Description Texture Structure onsistence oundary Roots Soil GPD fttion Rate in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. * ff#1 * ff#2 3 a ~ zl~ 4 ~ L * Effluen 1 = BOD > 30 < 220 mg/L and SS >30 _ 150 mg/L * Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L C_ Sign ` CST Number ~ Date Evaluation Conducted Telephone Number SBD-8330 (RI 1/11) Parcel ID # Page e,~, of Property Owner ❑ _ Boring # Boring Depth to limiting factor ,lam [9 Pit Ground surface elev. ~5 .S ft• in Soil A lication Rate ff#1 GPD/f 2 Horizon Depth Dominant Color Redox Description Texture GStSzcture onsistence oundary Roots = f1# in. Munsell Qu. Sz. Cont. Color Q ff# e 4 4 / Q ❑ E Boring # Boring pit Ground surface elev. f. Depth to limiting factor 1n Soil lication Rate ❑ Horizon Depth Dominant Color Redox Description Texture GStSzcture onsistence oundary Roots ff#1 GPD~ff#2 in. Munsell Qu. Sz. Cont. Color Boring ❑ goring # Ground surface elev. ft. Depth to limiting factor in. Pit Soil A lication Rate ❑ Horizon Depth Dominant Color Redox Description Texture ° Structure onsistence oundary Roots ff#1 GPD/f2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. • Effluent #1 = BOD 5 > 30 < 220 m9/L and TSS >30 < 150 mg/L " Effluent #2 = BOD 5 < 30 mg/L and TSS < 30 mg/L The Dept. of Safety rv ce or need material in an alternate format, contact the department at 608-266-3151 1or TTY through Relay. access se SBD-8330 (RI 1/11) Property Owner Parcel ID # Page { of J Boring # ❑ Boring 1-37 rg ~ Pit Ground surface elev. _ ft, Depth to limiting factor j5 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence oundary Roots GPD/ft z in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. * ff#1 * ff#2 Q. d Fea r3 ~ 4 e / G ❑ Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence boundary Roots GPD/ft z in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. * fF#1 * ff#2 ❑ Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Horizon Depth Dominant Color Redox Description Texture' Structure Soil Application Rate onsistence Boundary Roots GPD/ft 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *1: J: fF#1 fF#2 * Effluent #1 = BOD e > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD 5 < 30 mg/L and TSS < 30 mg/L The Dept. of Safety and Professional Services is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, contact the department at 608-266-3151 or TTY through Relay. SBD-8330 (RI I/I1) 40 Y , 1 r : i 1= safe - ; I °w t N '~i k~•' 4, bj~ t <v i i ~ ~ ~ 4 e 0 cs y E j A b ~ Z G1 Al 0 W ~ y 8 ,f i ~..T. 1 ~ E j5. y , 9 a~~~ t ~ P ~ I~ 1 ' 1 _ ~w ~ ' =~"a ~ ;.r„ U fit ~T y f , , ~ I i - - r7-~-3 00000 - _ D3z - 1001-1 D - D01 ~ 2- 31-