HomeMy WebLinkAbout038-1036-10-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No
(ATTACH TO PERMIT) 584758
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 Township Parcel Tax No,
Charles & Elizabeth Keefer TOWN OF STAR PRAIRIE 038-1036-10-000
CST BM Elev: Insp. BM Elev IBM Description: Section/Town/Range/Map No:
i . 'f w] , - 08.31.18.1580
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION S HI FS ELEV.
Septic Benchmarll[ .8
Dosing (j
Alt. BM A ~ c~► tl~. -7
Aeration Bldg. Sewer
f.5( Holding St/Ht Inlet
r
St/Ht Outlet
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. 'Vent to Air Intake ROAD Dt Inlet
Septic Dt Bottom
Dosing Header/Man.
Aeration Dist. Pipe
Holding Bot. System
Final Grade
PUMP/SIPHON INFORMATION
Manufacturer Demand St Cover
GPM dc. 41
+
Model Number " +
TDH Lift Friction Loss System Head TDH Ft f
Forcemain Length Dia. Dist. to Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT DI NSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS1 -1
SETBACK SYSTEUTO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: `r
INFORMATION CHAMBER OR
Type Of System: UNIT
Model Number:
DISTRIBUTION SYSTEM
Header/Manifold Distribution ix Hole Size ix Hole Spacing Vent to Air Intake
Pipe(s)
Length Dia Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systefhs Only
Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil El Yes No ❑ Yes ❑ No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location: 2216 CABIN LN V},~
40 4,,,1,0, 0-
1.) Alt BM Description =
2.) Bldg sewer length
-amount of cover ;err`; 60
Plan revision Required? Yes No
Use other side for additional information.
SBD-6710 (R.3/97) Date In sepctor'v'Signature Cert. No.
o~X.7Q r County _
Safety and Buildings vision 5/,
I
~l) Q ~~KI MAY 1 201 W. Washington Ave., BOX 7162 Sanitary Permit Number (to be filled in by Co.)
~S Madison, WI 5370 6
s
1w/ ST. CROIX COUNTY G fT / `75 Q
~~,OMMUNITY DEVELOPME J ( V
C. State Transaction Number
Sanitary Permit Application
In accordance with SPS 38321(2), Wis. Adm. Code, submission of this form to the appropriate governmental AA
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 Inform L
C y ~ CT U
Prop'em' ~WD er'sN~^ Parcel #
~I+ j 15y
Property Owner's Mailing Address Property Location a
~ - Govt. Lot
City, State Zip Cod Phone Number Section
(circle one) "
~ yt,r /-f ,J U ~ ~ t'C2S ✓ - ` / 7~ 'l / T ~ f N, R LPL!-_ E orU
R. Type of Building (check all that apply) Lot #
Subdivision
1 or 2 Family Dwelling - Number of Bedrooms Name
L ~ Block #
6
❑ Public/Commercial - Describe Use ❑ City of
J~~ Cry`
CSM Number ❑ Village of
❑ State Owned - Describe Use
,fSI. TOWrI Of zJ It,
a1 •tA
III. Type of Permit: (Check only one b x on line A. Complete line B if applicable)
A. ❑ New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain)
List Previous Permit Number and Date Issued
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New
Before Expiration Owner
IV. Type of POWTS System/Corn onent/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. Dis ersal/Treat nt Area Information:
. Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Eleva on
Design Fljrow (gpd) Design SoilAJpp~ljication Rate(gpdsf)
1
VI. Tank Info Capacity in Total # of Manufacturer
Gallons Gallons Units U D
U N
New Tanks Existing Tanks
U_V / '440, I)~' L c : ? J L
/N1 CL. U rn 'r.- vs w U F.
Septic or Holding Tank 3 cyLP o -3cjoei
Dosing Chamber
VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans.
RS Number Business Phone Number
i?P
/pz
Plumber's Nam (Print) Plumb s Sign re MP
Plumb s Addre (Street ity, t te, Zip Code) / v 1C 6C'
VIII ounty/De artment Use Only
Permit Fee Dat Issued Issuing Ag ignature
Approved ❑ D"c rnve $ AT
wne en Reason for De ial 456. CJV ,
IX. Condit$4ry0piReasons for Disapproval aa JS Gd
~ e ✓
1. Septic tank, a tymt filter evul J 0 J , r
disper.:d cell must all be sew ic_A t ro ~iTittkr2L
as per maragement plan pro sided by plumbel-. 1
2. A11 set?Ik i~egyirer-1en1s must k+e r lalnteiriad C J d ~S +'-a•~~ a ~UQ 2016-de
as per applkwe t o& / vdinanm.
Attach to complete plans for the system and submit to the County only o ern t less than $ 1 11 inches in size nfw~
SBD-6398 (R. 11/11) ~Al ` GL Q'
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HOLDING TANK SITE PLAN
pr ct CHARLES KEEPER
Leaai Description: SEr SEISS, s 3 !R11 8W
s
f} Subdivision Name: CSm
Scale: 1: Parcel ID: 038*10361-0000 Lot No_: ~
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1Transaction I. D,: Page 3 of 4 ~
1
CONCRETE HOLDING TANK DESIGN
INDEX AND TITLE SHEET
Project CHARLES KEEFER
Owner CHARLES KEEFER
Address 1102 EAGLE RIDGE CT.
STILLWATER MN 55082
Legal Description SE/SE/S8/T31/R18W
Township STAR PRAIRIE County ST. CROIX
Subdivision Name CSM Lot No.
Parcel ID Number 038"10361-0000
Plan Transaction ID Number
Index and title sheet Pagel
Holding tank specifications Page 2
Site plan Page 3
Maintenance and contingency plan Page 4
Designer BRA Y UTG D
Signature 411 Phone No. 715-268-6995
License Number _/220357 Date 05/10/16
Designed pursuant to:
Holding Tank Component Manual For POWTS
SBD-10571-P (R.6/99)
Version 2.0 (03/01) Pagel of 4
HOLDING TANK SPECIFICATIONS
3 Number of bedrooms
Non-residential estimated flow (gpd)
JMinimum holding tank volume required (gal)
3000.0 Proposed holding tank capacity (gal)
WIESER Tank Manufacturer
W3000MR Tank model number
LEVEL Alarm manufacturer
DLV Alarm model number
Tank Dimensions and Data Tank Anchor Calculations
X for round tank 20610 Ibs Weight of tank and cover
53.0 Liquid depth below inlet invert (in) 1.50 Safety factor
8.0 Maximum depth of soil cover (ft) 45915 s Weight of anchor required
71.0 Height (in) 39.9 in Soil cover req. for anchor or
186.0 Length (in) 11.3 yds Concrete counter weight
93.0 Width (in)
HOLDING TANK CROSS SECTION
manhole cover with
locking device and finished vent cap
junction r---~ warning label grade
box
4" min. 12" min.
24 in.
Manhole and vent locations
conduit may be reversed. vent pipe
18" min.
service 12.0 in building sewer
O ~
inlet
blind plug alarm on Note: All tank joints, and
to seal joints between tank
outlet openings and piping are
Electrical as per 41.0 in. sealed watertight. All pipe
NEC 300 and vent materials comply
and Comm 16 with Comm 84.
3 in. bedding under tank. Tank is anchored as necessary to negate buoyancy.
Project: CHARLES KEEFER
Transaction Number: Page 2 of 4
HOLDING TANK SITE PLAN
Project. CHARLES REEFER _
i
r Legal Description: SErSE1S $fT31/R18W
Subdivision Name- CSm
Scale: 1-1 MEL-00 Parcel ID: 038*10361-0000 Lot No.:
oe-
i
4 t'7 p ~l I '
i
!Transaction I.I.: Page 3 of 4
HOLDING TANK MANAGEMENT PLAN
This Private Onsite Wastewater Treatment System (POWTS) has been designed, and is to be installed and
maintained according to Comm 83, Wis. Admin. Code, the Holding Tank Component Manual (SBD-10571-P
6/11/1999), and the ST. CROIX County Sanitary Ordinance.
1. This POWTS is designed to accommodate an estimated domestic wastewater flow of 600.0 gpd.
2. The owner of this POWTS is responsible for system operation and maintenance, including all provisions in
the attached Holding Tank Servicing Contract and Maintenance Agreements.
3. Each time the wastewater in the tank reaches 90% of the tank(s) capacity or a level of 12" below the inlet
(at which time the alarm will activate), the pumper listed in the current Servicing Contract must be called to
empty the tank's contents and dispose of them in accordance with NR 113, Wis. Adm. Code.
4. At each service event, the service provider should visually inspect the condition of the tank, risers and
manhole cover(s) and verify that the alarm system functions and manhole locking devices are present.
Discrepancies are reported to the owner in a timely manner for corrective action. All corrective actions
shall comply with the county sanitary ordinance and Comm 83 and 84 Wis. Adm. Code.
5. All service events or inspections of this POWTS shall be reported to the county within 10 business days.
6. The owner may not remove any of the wastes from the holding tank(s), or cause such wastes to be
removed by any person not authorized to do so under Ch. 281, Wis. Statutes. The discharge of wastes
tank to the ground surface, including intentional discharges and discharges caused by neglect, constitutes
a failing POWTS and may result in issuance of correction orders or a citation by the county or state.
7. No one should enter a holding tank for any reason without being in full compliance with OSHA standards
for entering a confined space. The atmosphere within these tanks may contain lethal gases, and rescue
of a person from the interior of the tank may be difficult or impossible.
8. In the event that this POWTS fails and cannot be repaired, a code compliant replacement holding tank
may be installed in the same location (a new sanitary permit is required for such a replacement). Con-
nection to municipal services would also be considered at this time if they are deemed available to the
property.
9. If this POWTS is replaced, or its use discontinued, components no longer in use it shall be abandoned in
accordance with Comm 83.33 Wis. Adm. Code.
10. If there is a problem with, or question about this installation, the following persons should be contacted:
a. Installer UTGARD Phone: 715-760-0946
b. Service Provider POWERS Phone: 715-246-5738
c. Co. Zoning or Health Dept. ST. CROIX Phone: 715-386-4680
11.
Project: CHARLES KEEFER
Transaction Number: Page 4 of 4
i
SEPTIC or HOLDING TANK SERVICING CONTRACT
Contract Date
This contract is made between the
Tank Owner(s) Name(s) and Pumpers Name
C -5 H, ff
We acknowledge the installation of a se tic/holdin tanks on the following P 9 property:
(Provide legal description): -Sr /A/ - sr-c_: ~ - 7-3/ -~/9Iq
I
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 Comm 83.52(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
j 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 fiu-ther 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. j
I
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: j
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.
I
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.
II i
Owner(s) Name(s) (Print) Owner's Signature(s) , Subscribed and sworn to me on this date:
-41 Date
y~ r
r
PumPer's Name (Print) PumP er's na re Notary Public Signature
/ ✓ 1
Pumper's Registration Number Commi`! 5), t' xpira 9.,~~
201 A R ~
us
ututut%t
RECEIVED ST
Wiscun p4r~e (Tommerce SOIL EVALUATION REPO, o~ rage ~of~
o a
Diviai~n fety and Buildings
ST. CROIX COUNTY in accordance with Comm 85; Wis. Adm. Code
~ ~gPMENT County
Cs C
I I non paper lot less than ess than 8 1/2x 11 inches in size. Plan must
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. O 3 -191`316Y - b L 0 P
Please print all inf®rMation. Revie d by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). VVD I
!7 /
Property Owner Property Location
I- 1 S a V, G P- - Govt. -ot S E 1/4 S F, 1/4 S 3 N R E (or W
Property Owner's Mailing Address pp Lot # Block # Subd. Name or SM#
0to A t A G e.
City ate Zip Code Phone Number 'q city ❑ Village Fj9 Town Nearest Road
i ❑ New Construction Use: ® Residential / Number of bedrooms 3 _ Code derived design flow rate LI'5 c _ GPD
Replacement E] Public or commercial - Describe:
P:a.ron+- - _t
i i' Z7Inn-I Pl~ir pl.tro+nn if a.nnlirhlo
General comments T F ; 't w, I 1 a r k w h t N h o c. a a. °'t°f`i Q YV
and recommendations:
S`'3g~s+ aN x S6,aS' Shall~~a'►1tiN~`c~ K-t 9 7, a7 '
b4s~p v ,\j 9{, 77
S F N o'E" c Iq c 2 w, e o V1 a N 5 0 C or.-k~ v
Boring # ❑ Boring d C h 0 i G it .
DO E~ pit Ground surface elev. f I $1q ft. Depth to limiting factor 3 a in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff
in. Mansell Qu. Sz. Cont. Color
_Gr,_Sz, gh. `Eff#1 "Eff#2
3 ti -3a ~t ! s t U~= k~
- GL ` F 7,5 ~R bI SG L- S ' : uv 3
A0 c2 '0 pq r
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I I Boring # ❑ Boring V71
I ff Pit Ground surface elev. ft. Depth to limiting factor _ (0 1n.
Soil Application Rate
Horizon Depth Dominant Color Redox Description I exture Structure Consistence Boundary Roots GPD/f
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. - Eff#1 -Eff#2
ID 3 - ' L ~ vt M r Q s r~YR =r -e
3 -
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3L- .3
Effluent #1 = BOD > 30:< 220 mg/L and TSS >30 < 150 mg/L ` Effluent #2 = BOD{ 30 mg/L and TSS < 30 mg/L
CST Name (Please Print) Signature CST Number
Address
re 1 d D e l Date Evaluation Conducted Telephone Number
64
a q 39 - 14,
Property Owner Parcel ID # Page_ or
Boring # ❑ Boring
pit Ground surface elev. 1 ft, Depth to limiting factor in.
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Soil Application Rate
Boundary Roots GPD/f('
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *E .2
e ;
Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in,
Soil Application Rate
Horizon Depth Dominant Color Redox Descrotion Texture Structure Consistence Boundary
Roots GPD/ft
in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
8
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Boring # ❑ Boring
❑ pit Ground surface elev.. Depth to limiting factor in.
Horizon Depth Dominant Color Redox Description Texture ure tion ± Soil Application Rate
Structure Consistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh.
*Eff#1 *Eff#2
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Effluent = BOD. > 30 < 220 me/'L and TSS >30 < 150 mg/L Effluent #2 = BOD < 30 mg/L and TSS < 30 m /L
The Department of Commerce is an equal opportunity service provider and employer. 1f you need assistance to access services or
need material in an alternate format, please contact the department at 608-266-3151 or 'TTY 608-264-8777.
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Document Number Document Title 1029081
BETH PABST
St. Croix County REGISTER OF DEEDS
Holding Tank Agreement ST. CROIX CO., WI
RECEIVED FOR RECORD
Permit Number Sg5/7Sg1 05/17/2016 2:53 PM
EXEMPT
REC FEE: 30.00
COPY FEE: 2.00
Naine - (O,*vner•) Typed or hrintecl PAGES: 2
being duly Sworn, stales, under oath, that:
I. 1-Te/she is the owner/part owner of 11ie following parcel of land
located in St. Croix County, Wisconsin, recorded ill VOlume
Page DocumentNumberJo~s~7ySt. Croix County Register
of Deeds Office: Rec(ndmq A,ea
A parcel of land located iri the S/~_ r4 Of tlic l- t~, of section Name and Return Address
T N R 1 W, Town of
ST~~F St. Croix County, Wisconsin, being
duly described as I;ollows (include lot no. and subdivision/CSM or
detailed legal description): S FL f r~ r 03 /a / - (jac7
fq Parcel Identification Number (PIN)
Agreement Date:
We acknowledge that application is being made for the installation of (a) holding tank(s) on the above described property or that continued use of
the existing premises requires that a holding tank be installed on the property for the purpose of proper containment of sewage. Also, the property
cannot now be served by a municipal sewer, or any other type of private onsite wastewater treatment system as permitted under Ch. SPS 383, Wis.
Adm. Code, or Ch. 145, Wis. Slats.
As an inducement to the county to issue a sanitary permit for the above-described property, we agree to do the following:
1 - Owner agrees to conform to all applicable requirements of Ch- SPS 383, Wis- Adm. Code relating to holding tanks. If the owner fails to have
the holding lank properly serviced in response to orders issued by the governmental unit or the Department of Commerce to prevent or abate
a human health hazard as described in s- 254.59, Stats., the governmental unit (Town) may enter upon the property and service the tank or
cause to have the tank to be serviced and charge the owner by placing the charges on the tax bill as a special assessment for current
services rendered The charges will be assessed as prescribed by s. 66.0703, Stats-
2. The owner agrees, pursuant to s. SPS 383.54 (2), and SPS 3B2.40(3)(e), Wis. Adm- Code, to have a water meter Installed in the structure.
The water meter shall be installed by a plumber authorized by the Department to make such installations, with said installation complying
with State regulations and manufacturers specifications. The owner agrees to be financially responsible for the purchase, installation,
maintenance, and repair of the water meter, and agrees to allow the governmental unit or the Department of Commerce to enter the above-
described property on a regular basis to read and/or inspect the water meter.
3. Owner agrees to pay all charges and costs incurred by the governmental unit or county for inspection, pumping, hauling, or otherwise
servicing and maintaining the holding tank in such a manner as to prevent or abate any human health hazard caused by the holding tank.
The governmental unit shall notify the owner of any costs which shall be paid by the owner within thirty (30) days from the date of notice. In
the event the owner does net pay the costs within thirty (30) days, the owner specifically agrees that all the costs and charges may be placed
on the tax roll as a special assessment for the abatement of a hurnan health hazard, and the tax shall be collected as provided by law.
4. The owner agrees to contract with a person who is licensed under Ch. NR 1 13, Wis. Adm. Code, to have the holding tank serviced and to file
a copy of the contract with the governmental unit. The owner further agrees to file a copy of any changes to the service contract, or a copy of
a new service contract, with the governmental unit within ten (10) business days from the date of change to the service contract
5. The owner agrees to contract with a person licensed under Ch. NR 113, Wis. Adrn. Code, who shall submit to the county on a semiannual
basis a report detailing the servicing of the holding tank- The governmental unit or county may enter upon the property to investigate the
condition of the holding tank when pumping reports and meter readings may indicate that the holding tank is riot being properly maintained.
6. This agreement will remain in effect only until the county office responsible for the regulation of private onsite wastewater treatment systerns
certifies that the property is served by either a municipal sewer or a private onsite wastewater treatment system that complies with Ch. Cornm
83, Wis. Adm. Code. In addition, this agreement may be cancelled by executing and recording said certification with reference to this
agreement in such manner which will permit [tie existence of the certification to be determined by reference to the property.
7. This agreement shall be binding upon the owner, the heirs of the owner, and assignees of the owner. The owner shall submit this agreement -
to the register of deeds, and the agreement shall be recorded by the register of deeds in a manner which will permit the existence of the
agreement to be determined by reference to the property where the holding tank is installed-
T
Owner(s) Name(s) -Please Print Subscribed ed and -sworn to before me on this date: C N 4A --E15
- - ` st tiff
Ngtar ed Owner's Signature(s), Notary Public ---~`OO VWgHI
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Gov nimental Unit Ic al Na ee Title - Please Print My Commission Expires
J
Govern ial i to ure Drafted by: i~
ST. ~(-o; ~ ~GJ✓~`t~/ Gr~l~ rrrrnnnptt+ .
- - - - -
oral ii rmation you provvIde may be used for secondary purposes [Privacy Law s. 5.04(1)(m)]
"THIS PAGE IS PART OF THIS LEGAL DOCUMENT - DO NOT REMOVE"
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