HomeMy WebLinkAbout020-1170-20-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No
(ATTACH TO PERMIT) 597365
GENERAL INFORMATION State Plan ID No
Personal information you provide may be used for secondary purposes (Privacy Law, s.15.04 (1)(m)] 584747
Permit Holder's Name: City Village Township Parcel Tax No
CARRIE NASI TOWN OF HUDSON 020-1170-20-000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No
07.29.19.1058
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing Alt. BM
Aeration Bldg. Sewer
Holding St/Ht Inlet
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
Model Number
TDH Lift Friction Loss System Head TDH Ft
Forcemain Length Dia. Dist. to well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Liquid Depth
DIMENSIONS
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR
Type Of System: UNIT
Model Number:
DISTRIBUTION SYSTEM
Header/Manifold Distribution Ix 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 xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil Gi Yes ❑ No Yes ❑ No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location: 335 HARSHMAN DR
1.) Alt BM Description =
2.) Bldg sewer length =
- amount of cover =
Plan revision Required? ❑ Yes [ No
Use other side for additional information.
SBD-6710 (R.3/97) Date Insepctor's Signature Cert. No.
County
ECE t(~~ Safety and Buildings Division, SAS
t~ tll
aq ~1 ' 201 W. Washin ton Ave., P.O. Box 7162
g Sanitary Permit Number (to be filled in by Co.)
P Madison, WI 53707 62
, ~ ~ io,7 '7 3 to
JUN ~ ~cJ S
Appll State Transaction Number
In accordance with S , is. Adm. Code, submission of this f Propriate governmental unit 4 5_1 I/
is required prior to obtaining a sanitary permit. Note: Application f- _-owncd POWTS are submitted to Project Address (if different than mailing address)
the Department of Safety and Professional Servies. Personal info) you provide may be used for secondary #,?3.5 4a
purposes in accordance with the Privacy Law, s. I5.0 (m), Stats. ar~ , 6
1. Application Information -Please Prin"to anon TT~JJ
Pro ty Owner's Name Parcel #
► e 1~ 6ZO - 76 - - U06
Property Owner's Mailing Address Property Location 9. 11, 105
Govt. Lot
City, Slate Li Code Phone Number 7
~31(0- /4, Section
(circle one _
T2f N; R~', Eo1
IT. Type of Building (check all that apply) Lot # W
Subdivision Name
El 1 or 2 Family Dwelling - Number of Bedroom
a? N) - 77, 741
Q{- 416 Block #
❑ Public/Commercial - Describe Use ~
❑ City of
CSM Number ❑ Village of
UP % ❑ State Owned -Describe Use r
P/T'0wn of
A'~7 e✓
III. Type of Permit: (Check only one box on line A. Complete line B if applicable)
A. ❑ New Systcm ❑ Replacement System ❑ Treatment holding Tank Replacement Only Other Modification to Existing System (explain)
ue
13. istrevious Permit Number and Date Is of
El Permit Renewal [I Permit Revision change of Plumber ermit Transfer to New L 54747#7
Before Expiration wrier
IV. Type of POWTS System/Com onent/Device: (Check all that apply) d AD-
El 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:
Design Flow (gpd) Design Soi pplicatic, ate(gpdsf) Dispersal Area Required (sf) Dispersal Area Pro osed (sf) System Elevation
0~ • 5~
,3 0 t I/ 7e I
V1. Tank Info Capacity in Total # of Mandl acturer
Gallons Gallons Units o
c
Ncw Tanks Existing Tanks
+ ~ n. U rig ~ v: t~. C7 C1.
epti r Holding'l ank
C7 hamber >
J
VII. Responsibility Statement- 1, the undersigned, assume responsibility f pr installatio ` of t VTS shown on the attached plans.
Plumber's Name (Print) Plu lb *'s Sig ur MP/MPRS Number Business Phone Number
2 c" " "
tuber's //Address (Strez City, State, Zip Code)
(1 _ ~f
VIII ount /De art nt Use Only
P'r isapprov Permit Fee to Issued Issuing A Signature
p
X Cd proved
Own n Reason for Denia $ ' Cj ~L
IX. Condi._ Reasons for Disapproval
IL
~.ti cell trust nNbe ~ ~ tc:: s ! r ~Iit~.:~ eC ~ ` Q
has e'r.I ragement plan plc /iced by plumber. ` i
CS ust tit: Bail ire-i (1
M 11p co* e /narre~. d i~
Attach to complete plans for the system and submit to t 7e County onl ri paper of less than 8 1/2 X-1 I inches in size
SBD-6398 (R. 11/11)
I
PLOT PLAN
PROJECT Donny Moel;er ADDRESS _335 `Iarshman Lwc, Hucsor w _~;AD-6
SL I 'd '+P.V U4S T 24 `R 19 W TOW Hucs:7r,
C:QL"tiTI' ST. r` .,H .,X
SYSTEl2 EI.I:V a7'tU` '0 .3' '.3' sang lift! A
4 !6; . 4
BEDROOM
DATE
CONVENTIONAL IN GROUND PRESSLRE
i ('t)\NF.1TIQ\"iL LIFT HOLDING TA_tiIi
;IOL'"\G XXX SEPTIC T.k\F; SIZE 100:) gallo^s LIFT TANK SILT; DOSF TANK SIZE 632
HOLDING TANK SIZE LOXI3 R_AT'E '.v tBSORPTION AREA 45G. ~ of chambers cone
BENCHMARK V.R.P" Top of 1,12" . electrical concmit
_ 4tSlA1E. !•_LEV:%-TION ioo• Filter SlN1TEC
BOREHOLE WELL "H.R"P. sa-e asl.~=rr:hr=ids; `
:1l piping shalt be ASTM SI)R 303-4. within
I0' of tank, pi~>in- ,hall be ASTM F 91
To Hargftrnan Drive
I
Existing 3 Bedroom
HoU3e
t
° deck: vaz bui1 after septic tank
x'e1; was i',,s#aI led. -h. dick foot ncs
are nut sitting or :he tank. Trie
deck is not structural ly affecting j
Scale = 1,e`4" = 10'
the septic tank
p. I
1.5 Acre Lot
C
:Deck: , S ':!130 ga'Ion tank 1
fc `t Lsose Tank" 7,,nk is be
I
4 properly neddec and
provided w:th
Area 15' below s'„stem €ockdosen cover$
v itn approved
r 'arnIrig :absls
undisturbed
l
=SIC pe
E
3."1.*
i
f i
E'- 20'
'00'
❑ Gra:l,ng is tc be none to divert
? 03 p run-off awe$ i frarn system!
105. Property Lines
1 i ;_l ~
ST. CROIX COU'TY
SEPTIC TANK MAIl\TTEI1 TANCE AGREEME~
AND
OA t OWNERSHIP CERTIFICATION FORM
OwnerBuyer 0 c6(
Mailing Address " j+r' N YLW1 "Piz-
Property Address
(Verification required from Planning & Zoning Department for new construction.)
City/State i~k&~'L-) 1 \ ( Parcel Identification Number
LEG 4L DESCRIPTION
Property Location V4 , %4 , Sec. T Y _N R_L_LW, Town of
Subdivision Plat: Lot -7171
r
Certified Survey Map 9 , Volume , Page 4
Warranty Deed # (before 2007)Volume Page 7-
Spec house ❑ yes ❑ no Lot lines identifiable ❑ yes C no
SYSTEM KA-ENTENTANCE AND OWINTER CERTIFICATION
Improper use and maintenance of your septic system could result in its premature faDure 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 §SPS. 383.52(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.
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 Safety And Professional Services and the Department of Natuial 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. Uwe am/are the o-~Amer(s) of the
property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
Number of bedrooms
7
SIGMA OF APPLI ANTT(S) DATI
***Any information that is misrepresen d 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 m the warranty deed.
(REV. 04/12)
:'dsorsrr. C>°cartmsr., of ;;ommems PRIVATE SEWAGE SYSTEM
St. Cmix
....=.t~n anc Buuriut❑ Cm::sron
INSPECTION REPORT ISan:a~ ermr Nc SSA, 7
~3=-NERAL INFORMATION
Sta a Ptar IL N
=rsona! iniormaticr, VOL vDra'Jloe may be used to-se--onoarti nu•nos s Lava, s 1 c.C'4
62.0 11? r 26 -cc-AC)
i~enni: Hoia Nam?: X Towrsrn; {
Itar- Tax Nc
~o iA D e.~ ~u cQ o,rl 2 !0 9 600
>T 3N: =_t Ilcsr. 9h1 clsr BM Descripbar t~ a ?ovm r;ar?siNa Nc
-5w 41 8w\,
TANK INFORMATION ELEVATION DATA
~Y?~ MANU~ A~TJP.cR ~A=~,, ;A' I D N B° :1 13=nonrnarn 156 /A
d4 '4 4-A- 1
~ 31ac Szw=:
17olamc -1inie•
TANK SETBACK INFORMATION ~d
-4Nk: ?i. i,,r_ _ I 3C? v :n[. in;ar,[ rZ:~4D D' mi='
lG, ~ z Co
IDcstn_ / / I IHeaaerliatar.
-77-61 21 4
3x s,,st=rr
Ian. 5
Z-6
PUMP!SIPHON INFORMATION Irma Grape
b.3 /a7•Z
11~;6nu~2_turo: 1i Nmanc 'S: ~sDv
Itvi.•7°. Number
~H Lif I--man Less 'Svst~rr M_ac `D-
153 s z cl,
=_rr»':7,21" IL.'rof / IDt=. , r ~ :rrs'_ 1tiel /
SOIL ABSORPTION SYSTEM ~(o-5 S l~eu~
3_°D TRENCH 1^iiytr, _rtr IN, Of Trcn5 PI- DIMENSIONS No D, Pm cr.so_ ,e LicwC Depth
JIh1=_NSIONS g 7 6Z ~
SETBACK. EY S rr IV T'~> J rP!_ iLD;: WE-- -=iKEllS RlEAIf L_ACHINu f.4a,^,7acture'.
INrORMATION CHAMBER OR
SySter.. L,
UNIT idoas N.trr[,e
///~J~rr1 \11 U 7 7~
D!STRIBUTION SYSTEM
H_aue;Avani6~ld ! ( I sr. to vur Z / ( pie S:ce u' Hoe Soactni q,r in:ara_
=rte, s J z
Dia z ~Lenatr Sy Ut 2 S a~^c 4 3 u
SOIL COVER x Pressure Systems Onit• xx Mound O, At-'Grade Systems Oniy
I.,~utr Dve- Dectr Over ixx Geotr, n' Seeasd ooa° ;o: Mulme-
13ec7 ranc, e-re / 1- irenura?es \ 'Touso: -
/ ` I ht~, \ Y N-- ve<
rr ~ Nc
OMMENTS: lncluae :oie d:screDenc:ie~,, U`_rsUttb U'°S~n: 3iC.. InSD°--tlori S 2U Insa-mor _
o atior.: / P
10 arel Nc
~I 31~ r>sanpilor = v 1 I c)'KeX
310c s=_w iena`r L j ~:ar r=va,ar Reauir=.~' _ Ye Xo
~~3 q75
o
ther siae to- aadlt:nna. Information.
irate inssocror 5.. a[c e .r, N
-Ounry
Y' t a• Safety and Buii S D ~}I
x' O T~ 201 W. Wasnin on Av 0. 1
` f $ P$. tthadis~n, 9t 1M 5370x- _c Saito-} Permit Number (.it, be filled u: by Co)
ao(x courvrr 7q 7
"969fiw#lrPermit Application s Ttansactionxnmher
at wroanx with SPS 83.21(2), w'is A m- Codc, submission of this fow, :c; tlcc dpptvpnzc govemmcnial unit
1 v required prior to obtaining a saaita-y pe=L Note: Applicatim ferns for sate-owned A l k"fS arc submitted to Punlec:t iuluress (it dtlFerea. thaw mailing addrcss,,
tmine Department of Safery aad Professi ud Se.-vies. Personal information your pre» ide may be used for secondarv
purposes in ac cordana with the Priiacy iaK', s. 15.04!1)(m;. Sacs. _ _ l _
1. Application Information Please Print .431 Information
Property C)wnc s Name - - Par eJ k
n -4
Property Own. , him1mg css Property Lw-Woc C - -
(y2, l 0
I
^ ,ot
' , State -
-'7` Zip Code ~ Photrc Number GOT 14, Sect,
ole6W)
LL 'I Ype of Building (check all that apply) .1 )tN; R E 1 Or 1 antil}' Dwell n~ N.cmhw of Bccrc .5t Subdivr/stun ]game
❑ ?ublic.-'Cotnmerci:u - 1)ex,•rbe lase ~ r11f1~jj44J11
❑ Ciry o
I Statr ONned - Describe :lsc C_ M Ntar:xr ullagr o
l
x57 ORD of
C _
III. Type of Permit: (Check only one boa online A. Complete line B if applicable)
ew System e n System ❑ Ttcaunent;9olding Tank Replacement my ❑ Cah7 Modifieadoo to Existu4, System (xalam)
• Permit Rrnewa[ r Permit Revision I ( t 8.ge of Plumber _I P--nit i :a rsfe to ]vew List Previous Permit NumiKa and Bate Issued/
Before Expcatirn: Owner
I•t'. Type of POW" CS Systetn;Gomponent/Device: (Check all that apply)
i r. Non-Pressurized In-iround ❑ Pressurized in-QiraLnd C At-Grade ❑ Motau = 24 Lt of suitable soil ound < 24 in- of savable soil
L. HoldinP ,;.tlc G Cnher Dispersal Couipment (explair:) U PrMcaDncit Device o'explamj
V. Dispersat treat ut 4ren Iuformation: ,
Deli FSow ( •d i lkaip soil Application f isf) Dispersal .-,rea Rcqu ( 4' Ds ai Ara ep , (s S em ation
VL Tank Info Capacrty in l'uil of
i Ivianufacrures
Gallols Gallon: Unite v -
n n - -
Septic or Lamtlab afS
Dosm
Aos7~g Clu:ulxr r ►n-~l• :Y,l C 1 /f -
II Itespoasibility Statemen I the usdersigoe n c responsibility foritistalfanon of tlieFOM"I'S sbown on the attached plans
Pt Namc cFtint'i P tii restore T__
n~°`'r + MP.,W. RS Number Business Phone N
-71, &
7l.m-bc-.'s.-,ddress',%t,ett, Cary- A(-;e.
ounrwDe arttnent Use Oniv
provcA 1'etmn FecDate su Issuing. Si; to tin
i
7r, Reason n -)enrol IS
IX Condi ' ¢liaWYMM6soas for Disapproval n
. 'Septic tank, effluent lilte, and 3)(.6 ,~..;V-'Is C1
1AL.
tii5)ierr ;.i cell must all be pr . t_ca s ! na~inta r t . G
AN per management plan pra:ided by plumber.
1 z AIM seftpk requirements must be mint; ined ~
is psr WFIc" w6t / oWinances. 4
attacb to complete plain for the system and submit to a County ooh on Mw mot less than b is x 1 t inches in sou
SF3B-6398 (_%t. 1111)
PLOT PLAN
PROJECT Donna Moeller ADDRESS 335 Harshman Drive Hudson Wi 54016
SL 1/4 NW 1/4S IT 29 N/R 19 W TOWN Hudson COUNTY ST. CROIX
SYSTEM ELEVATION 104.3' 1.3'sand lift! 4/6116 BEDROOM 3
DATE
CONVENTIONAL IN-GROUND PRESSLRE CONVENTIONAL LIFT HOLDING TANK
MOUND XXX SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE 630
HOLDING TANK SIZE LOAD RATE 1 •0 ABSORPTION AREA 456 # of chambers none
BENCHMARK V.R.P. Top of 1/2° electrical conduit ASSUME ELEVATION 100' Filter SINITEC
❑ BOREHOLE O WELL * H . R. P . same as benchmark
All piping shall be :-NST\4 SDR 30'34, within
44 10' of tank, piping shall be AST1,1 F891
To Hershman Drive Existing 3 Bedroom
House
O Deck was built after septic tank
was i nsteI led. The deck footi ngs
are not sitting on the tank. The
deck is not structural ly affecti ng
Scale = 1/14" = 10' the septic tank
1.5 Acre Lot
Deck Weiser 1000 gallon tank
Huffcutt Dose Tank Tank is to be
properly bedded and
D provided with
I oc kdow n cove rs
Area 15' below system with approved
*---1gA-e~rmdi n o warn i ng7ab61s
undisturbed oo~
8% Slope
I
B. M.
B-2 B-1 120'
100'
102'
❑ Grading is to be done to divert
103'
B-3 run-off away from system
105' Property Lines
1 10'
r
>h:.•~`'. DIVISION OF INDUSTRY SERVICES
10541 N RANCH RD
D " HAYWARD WI 54843-6462
Contact Througl- Relay
N, S http-lidsps wi.gov.rprogramsiindustry-services
www.wisconsin.gcv
Scott Walker, Governor
Dave Ross, Secretary
I%la% U_t. 2016
OUST ID No. 226900 f TTA;. PO11'7S In+i.cctor
SHAITN R BIRD ZONING OFFICE
BIRD PLUMBING INC ST CROiX COUNTY SPCA
1432 12"01 H ST 1 101 CARMICH.AEL RD
NI-W RICHMOND WI 5 10 1 7-6409 HUDSON WI 54016-7708
CONDITIONAL APPROVAL _
PLAN APPROVAL EXPIRES: 05%03/2018 identification Numbers
Transaction ID No. 2696099
SITE: Site ID No. 823006
Donna Moellen Please refer to both identitieatien numbers.
3i5 Ilaishman Dr hove. in all correspondence with the a~cnc~
Town of Hudson
St Croix County
SE 1i4,NW14,S7, 1Z9N.RI"M
FOR:
Description: Mound, 3 br res
Object Type: POWTS Componcnt iVlant:al Reuulated Object TD No-: 151)6 184
Maintenance required: Replacement system. 450 GPD Flow rate, 21 in Soil nmwnunr depth :o lirnitim-, "actor trom
ork_,mal tzrade: Systernw. Mound Component Manual - Ver. 2 0. SBD -1069 t-P (N.01,0 1, R. I O I ' 1. Pre .ire
Distrinution Component Manual - Ver 2.0, SBD-10706-P (N.01r'01, R 1012).: Effluent Filter
fhc suhminal described above has been reviewed for conformance with applicable Wisconsin Administrative Code,
and Wisconsin Statutes. The submittal has been CONDt HONALLY APPROVED. This system is to be constructe,.
and located in accordance with the enclosed approved plans and with any component manual(s) referenced above.
The owner, as deemed in chapter 101.01(10), 1k'isconsin Statutes, is responsible for compliance with all code c, Ll
requirements. A
No person may engage in or %%ork at plumbin, in the state unless licensed to do so by the Department per s 145.06. DEPT C
stats. PROFESS/ -
I he folloNti im-, conditions ;hall be met durin! construction or installation and prior to occupancy or use: DIVISION OF IN
Key Item(s)
• In the event this soil absorption system or any of its component parts malfunctions so as to create a health
hazard, the property owner must follo%i' the contingency plan as described in the approved plans. In additi ,
oxmer must insure that the operation. maintenance and monitorin,, duties as described in section VIll of the
mound component manual are complied `.0th. 1 cop• of this in xmA60ri must he uiven to the owner upon
completion of the project.
• Per scale, the slope appears to %ary as indicated in the plan ,uhrni,L;d. The honom of the distribution cell shall
be level per the Hound Component Manual T he "D•• ~Anension Thal: he a minimum of 15•'. The matinatrn
tinistrcd Slope of the mound surface shall be equal to or less than 1 per the Mound Component Manual.
Reminder
• The orientation of the mourn/ system must be such that the Iom_,est dimension is oriented alone the surface
contour per SPS 383.44(6)(a)2 -
• limit activities in the area 15' beyond the down slope edge of the mound per Mound Component N'lannai.
• Surface water drainage shall be diverted a%kav from the systern area per Mound Component a7anual.
ti11A1 t K ~iIH[: :'ale;';;201h
.
• Materials shall conform to the requircmon.s of SPS 384
• The existing POW I S must be properly abandoned per SPS 383.3 Wis Adm. Code.
A copy of the approved plans, specifications and this letter shall be on-site during constriction and open to
inspection by authorized representatives of the Department. which may include local inspectors. All permits
required by the state or the local municipality shalt be obtained prior to commencement of
construction-installation.'operation.
In granting this approval the Division of Industry Services rescr,~es the right to require changes or additions should
conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review
shall relieve the designer of the responsibility for designing a safe building, structure. or component.
Inquiries concerning this c orrespo ride nce may be made to me at the telephone number I. i
on this letterhead.
The above left addressee shall provide a cop} of this letter and the POWTS managem., i
others who are responsible for the installation.. operation or maintenance of the PO\\'Tl
Sincerer;, Fer e Re(:u r..l i)
This !\mount Will Be Invoiced.
When You Receive That lnvoice.
Please Include a Copy With Your
Patricia L. Shandorl Payment Submittal.
POWTS Plan Reviewer , Division of Industrn Services WiSMART code: 7633
(715), 634-7 810, Fax: (;7115) 6-14-5150 . M - F 8:00 a.m. - 4:45 p.m.
pat-shandoifa':~i,isconsin.~-,ov
CC- I twin Ta lor. a'stew;ttcr Specialist, i 715) 6 14-3494 , ~tondav - Friday 84M am to 4:30 pm
SHAUN R MD Yom: 2 53"2010
• Materials shall conform to the requirements of SPS 384.
• The existing POWTS must be properly abandoned per s. SPS 8 ; Wis. Adm. Code.
A copy of the approved plans, specifications and this letter shall be on-site dutrin" construction and open to
inspection b~ authorized representatives of the Department, which may include local inspectors. All permits
rewired bN the state or the local municipalit} shall be obtained prior to commencement of
corstruction'installation, operation.
In granting this approval the Division of Industry Services reserves the right to require changes or additions should
conditions arise making them necessar\ for code compliance. As per state stats 101.:''(,). nothing ir this review
shat' relieve the designer of the responsioilit\ for designing a safe building. structure, or component.
Inquiries concerning this correspondence may be made to me at the telephone nwnber listed below, or at the address
or. this letterhead.
The above left addressee shall provide a copy of this letter and the POW' f S management plan to the owner and any
others who are responsible for the installation, operation or maintenance of the POWTS.
Sincerely. Fee Required S 250.00
This Amount Will Be Invoiced.
When You Receive That Invoice,
Please Include a Copy With Your
Patricia L Shando:-f Pa\ ment Submittal.
PCWTS Plan Reviewer , Division of Industry Services WiSMART code: 633
C,15) 63L-7810, Fax: !715j 6;4-;150 , %I -F 8:00 a.-n. -4.-4-:,' -,D.m.
pat. shandorf wisconsin. goy
cc: Edwtr. A Taylor, 'b'a to%vater Specialist. 1 h? 1"."I . NlOrda\ 7C \ am To 4.= i! pill
Cover Page
Shaun Bird
Bird Plumbing Inc.
1432 120th St.
New Richmond Wi 54017
715-246-4516
Date: 4/6/15
Owner:Donna Moeller
Location: SE1/4 NW1/4 S7 T29 N,R19 W 335 Harshman Drive Hudson
Manuals Used: Mound Component Manual Version 2.0 (N.01/01, R. 10/12)
Pressure Distribution Manual Version 2.0 (N.01 /01 R. 10/12)
Page#
1. Cover Page
2. Mound Plot Plan
3. Mound Cross Section
4. Pipe Cross Section/Pipe Layout
5. Pump Chamber Cross Section
-'OVED
6. Pump Curve ,AFETY AND
7-8. Maintance and Contigency plan JAL SERVICES
JS SERVICES
9. Filter Specifications and cross section
Attachments: Soil est +
-SPOINDL CE
Shaun Bird
Signature'.
License nu 226900
U7
Page 1 of 9
PLOT PLAN
PROJECT Donna Moelier ADDRESS 335 Harshman Drive Hudson Wi 54016
SE 1!4 NW 1/4S 7 /T 29 N/R 19 W TOWN Hudson COUNTY ST. CROIX
SYSTEM ELEVATION 104.3' 1.3' sand lift! 4/6/16 3
DATE BEDROOM
CONVENTIONAL IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND XXX SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE 630
HOLDING TANK SIZE LOAD RA'Z'E 1 .0 ABSORPTION AREA 456 # of chambers none
BENCHMARK V.R.P. Top of 1/2" electrical conduit
ASSUME ELEVATION 100 Filter SIMTEC
❑ BOREHOLE O WELL * H. R. P. same as benchmark
All piping shall be ASTM SDR 30134 within
10' of tank, piping shall be ASTM F891
To Hershman Drive Existing 3 Bedroom
House
o Deck was built after septic tank
Well was i nsteI led. The deck footi ngs
are not sitting on the tank. The
deck is not structural ly affecting
Scale = 1 /4 f' = 101 the septic tank
1.5 Acre Lot
Deck Weiser 1 000 gallon tank
Huffcutt Dose Tank Tank is to be
properly bedded and
provided with
Ares 15' below system lockdown covers
is to remain with approved
undisturbed warning labels
139 Slope
B.M.
B-2 0.4 B-1 120'
100'
102'
❑ Grading is to be done to divert
103'
B-3 run-off away from system
105' Property Lines
1 1 0'
Q
z__ 0
Mound System Cross Section and Plan View
- - Dimension Feet ~
J t A
B
R f. D Jz~
A
i
::ray
E
2,0
Lrti~1~t ti~
j I JL%i ii:iv y5~.~ 'fti ^~~.`~L.... L.L.L.L.L.i:~:i:
1~• ~ k}1~ 1 1 •~ri~t. ~fti✓••f Y f Jan ~fL.L•Lf•i}ftl.hf.f•f...: .:.f.f.f.f ~ F 44)J
' '1-S 1 S L .y..•.i. Y.
L l G S
-T
i
I
i ~
i
K I D,
W K 1 B i4l !
Z _
L - j Slope
- 1 = Topsoil - ASTM C-33 - Clean aggregate
O = 4 in. sch. 40 pvc
Cap Material sand fill 'NL ' z to 2 in. dia. observation pipe
Geotextilc
Fabric G lI
JLM f
fL F rt
D
E
Plowed Surface
~L~j r L7 Ft Contour
Slope Direction
GENERAL INSTALLATION: The mound area is staked out along the design contour. Existing
vegetation is mowed and raked off the site. The mound basal area (L x W) is plowed with a moldboard or
chisel plow. Plowing may not proceed if the soil is wet enough at the plow depth to form a '4 inch soil wire
when a sample is rolled between the palms of the hands. ASTNI C-33 quality sand is placed immediately
after plowing. Sand is placed with a tracked machine keeping 12 or more inches of sand under the tracks or
is placed overhead by a backhoe. Special care must be used when placing sand of less than one foot
thickness to minimize compaction of the plowed surface. After the topsoil cap is placed, the entire mound
is seeded and mulched to promote vegetative growth, limit erosion and protect from freezing. The
observation pipes are slotted in the lower 6 inches and secured in place with rebar or a closet flan ge.
10,''07 lgj Page ~ of
Pressure Lateral Layout
Two Laterals - End Manifold
4 Threaded
Cleanout
Lateral Turn-tip Plug
Manifold
- /
M
- ~1
h
-X -
Force Main , Long
r / Sweep
{ 90
/ Bend
.U
Distribution Network S ecifcations
Lateral Diameter --P X1 t pressure System Construction
-~Z- ---1
Manifold T)iatiieter ? In. Laterals are constructed of Schedule 40 PVC
Orifice Diameterl
X (Orifice Spacing) :3 in. pipe. Orifices are drilled perpendicular to
(O---ce v~ In. the pipe with a sharp drill bit and face down.
L ateral Len h Ft. Lateral turn-ups terminate with a threaded
m Manifold Length _ Ft. + c(eanotit plug and are enclosed in a 6-8 inch
Force Main. Diameter In. diameter lawn sprinkler valve box accessible
_Force Main Length Ft. liom finished grade.
Grade
6-8 Inch Lawn
Sprinkler Valve
Box
I
Page of l
03i05 19)
Dose Talk Cross Section And Pump Performance Specifications
Tank Manufacturer r r
Tank Model Number Minimum Pump Performance R equired
Total Tank Ca GPM J 7, Z it TDII
parity
Max. Bury Depth -
Total
Pump Manufacturer Dynamic Head (TDH) Feet
Pump Model Number Elevation Head 1~-2
Z- Dista
- I Pressure v
Alarm Manufacturer ,
~ &4ty ~l` IP,wo Network Pressure Loss
Alarm Model Number 1 -
Switch Type Force Main Pressure Loss ' -
G Total
Manhole Min. 4" Above Grade
With Locking Device
Vent Min. 12"
Above Grade / ) %Veather-proof
With Cap Junction Box
♦ i - - Finished Grade -
Depth of Cover t> Ft Disconnect
v M cans
I T M
~ S <
Outlet
Inlet Switch Settings and Reserve Capacity
Tank Volume = J GPI - - - -
Dimension
Inches Volume Gal.
A
(reserve) A oZ , „
< <
' (alarm} B 2
> < L7 B ~ Hole
(dose) C -7 '
e
UffElev. (dead) D
o , Ft C
> Total 1
1 630
Bottom of Tank Elev. D `
vFt ,
<<< t>t'<'c~SSrS>S'S'S'SrSr S'S'S't'S' _ I I I I S i C i
K S S C'<r<r<rC'S<r <>K'c S< t/< t t t t S><><<
G"T-RAL INSTALLATION: The dose 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. Piping at the inlet and outlet is of approved
material, connected to the tank with watertight fittings, and laid on stable soil to prevent settling or
sagging- The force main is sleeved with 4" Sch. 40 PVC to bridge the excavation and is sealed
watertight. Electrical service complies with NEC 300 and Comm 16.28 Wis. Adm. Code.
031051gj ~
Page o~L-
I---A,D C4PACiTY i RVE ors vlr~u'E
EULUENT ANC DEWATE:ZIn~,
VC'DtL 152 - 1 ~ -
MODEL 152
50- 1 J
Fee[ ; Me[ers Gal. liters Ocl. Liters
1J= # 5 1., 69 251 77 29
4v - - I
152 10 j -1 0; ~ 231 ~ 70 ~ 265 ,
5 4.6 53 I 201 61 231
1--
30 2C 61 4t 15" 52 l 197
2 $ ~ Z~j Ja 129 1 42 159
)Q y.? I 23 $7 zx 125
i 2iJ - 3t - ---i-
1 ' I 4. 12.2 i 42
2~ Eo ac
ALLCNS
UT;--RS --T-
c -EO 240 320 -
a
CONSULT FACTORY FOR SPECIAL APPLICATIONS 17/32
'irried dosing panels available. - _
Electrical alternators, for duplex systems; are available ant: supplied wi,F• 3 27/22
an alarm. e I T
Variable level cuntful switcnes are availab,e for controlling single phase
systems.
• Double piggyback variable level float switches are available for varable
:eve? long and short cycle controls.
• Sealed Qw:k-Box available for outdoor ins:allaticns. See =td11420. i _
• Over 130'F. (54°C.) special quotation reeu!red. -
1521153 Series 12 1
1 153 MODELS Control selection {I -e -T
I Model Volts- Mode Amps Sim lei ]uokx f a
_N152 115 1 Nbn 8.5 2n3
641521 115 1 Auto 8.5 Irc,uded 1 2r3~ r
E 152 230 1 Nor. 4.3 1 2 or 3 _ - - ~T
s uw.
rBE152 23D Aeo 4.3 Incio:ed 2or3
N153 115 Non 10.5 1 l 2 of 3
131,1153. 115 t Auto ' 10.5 tr !M ~cr3 SELECTION GJIDE
E 153 230 1 Non 5.3 1 2 ct 3
BE153 23C 1 5.3 ncludeC 2or 3 Single piggyback varo0ie level tloa: SwltC;t1 07 Jluut a piggyback varab:e, level coat
switch. Refer to F1.1047.
n UTITl0N l 2. See FM01712 for correct rrtcde at Electlwl Arena or E-?ak.
All instailation of controls, protection devices and wiring should be done by a qualified
licensed eleetrieian. All electrical and safety codes shotA be followed including the most 3. 'Jar3bl? IeVEi Cclnirol SHIiC,`I 10-0[25 l1:eC as a wrllrol e'7iVatCf, specfy dupiCZ
(3)
recent National[Electric Code (NEC) and the occupational Safety and HealM Act (OSHA'. or A i 10a; s~Stem.
RESERVE POWERED DESIGN
=or LnJSUaI conditions a reserve safety fac-or is enyineerec into the resign of every ceiler pump. _
AWW - - MA'L 70 P. 40"'634? -
pr
`JVSviA , 402,`p n pDa~
Man.d2~hlP1SGl. Q
SHIP 70: 364 45 tsar: Run Ap
owswlle, KY 40211-1951
' r f 1502) -E,27-1 • i (80T 923-PUMP r P vs jig E %93~
http:IMrww.zoeuer.com ° JI'UMP lO. FAY(S0) '14-3624
) Copyright 2000 Zoeller Co. All rights reserved - - - -
i
POWTS OWNER'S MANUAL & MANAGEMEN F PLAN page _s_ of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner , r n tI Septic Tank Capacity
~ al ❑ NA
Permit Septic Tank Manufacturer ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer
Number of Bedrooms ❑ ~
❑ NA Effluent Filter Model ),-/0-_7) ❑ NA
Number of Commercial Units V ~dNA Pump Tank Capacity al ❑ NA
Estimated flow (average) _ CT7 d Pump Tank Manufacturer
Design flow (peak), (Estimated x 1.5) /f ~ J j d . Pump Manufacturer ❑ NA
Soll Application Rate aUd /fe Pump Model , j L O NA
Influent/Effluent Quality Monthly average' Pretreatment Unit -~pNA
Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Grgvel Filter ❑ Peat Filter
Siochemkal Oxygen Demand (BODJ 420 mg/L ❑ Mechanical Aeration O Wetland
Total Suspended Solids 53) 5150 /L ❑ Disinfection U Other.
Manufacturer
Pretreated Effluent Quality NA Monthly average" Dispersal Cell(s)
Biochemical Oxygen Demand (BODS) 530 mg/L ❑ In-ground (gravity) ❑p-ground (pressurized)
Total Suspended Solids (TSS) s30 mg/L ❑ At-grade ound
Fecal Coliform (geometric mean) s1W cfu/100m1 ❑ Drip-line ❑ Other.
Maximum Effluent Particle Size Y. Inch diameter • Values
typicalfor domesfic(nOA-earmPC,~- , w,.>E...,;~te;
septic tank effluent.
Values typical for pretreated wastewater -
MAINTENANCE SCHEDULE
Service Event Service Frequency
Inspect condition of tank(s) At least once every
j ❑ months ear(s) (Maximum 3 yrs.)
Pump out contents of tank(s) When combined sludge and scum equals one third (Y,) of tank volume
Inspect dispersal cell(s) At least once every
month year(s) (Maximum 3 yrs.)
Clean effluent filter At least once every ❑ months year(s)
Inspect pump, pump controls & alarm At least once every J ❑ months year(s) ❑ NA
Flush laterals and pressure test At least once every months lNeaqs) 11 NA
Other: At least once every O months ❑ year(s) ❑ NA
outer. At least once every ❑ months ❑ year(s) ❑ 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 (X) 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 cit. NR
113, Wisconsin Administrative Code.
The servicing of effluent filters, m nical or pressurized POWTS components, pretreatgment components, and any
other maintenance or monitoring at i~ervals of 12 months or less shall be performed by a certified POWTS Maintainer.
A servigg report shall be provided to the local regulatory authority within 10 days of completion of any service event
START UP AND OPERATION
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.
- ~ 19
Page of
START UP AND OPERATION
For new cotrstruction, prior to use of the POWTS check treatment tank(s) for the presence of painting products ar other chemicals thkit
may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of th
tank(s) removed by a septage servicing operator prior to use.
System start up shall not occur when soil conditions am frozen at the infiltrative surface.
During power outages pump tanks may fill above normal higtrwater levels. When power is restored the excess wastewater will bo
discharged to the dispersal cell(s) in one large dose, overloading the oell(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 coftols to restore normal love s
within the pump tank.
Do not drive or park vehicles over tanks and dispersal cabs. 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.
Reductiun or elimination of the following from, the wastewater stream may improve the performance and prolong the life of the POWT,$:
antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drakn
(sump pump) water; fruit and vegetable peelings: gasoline; grease, herbicides; meat scraps; medications; oil; painting produces:
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 propeoy
and safety abandoned in compliance with chapter Comm W.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 falls and cannot be repaired the following measures have been, or must be taken, to provide a code compli;pnt
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 requirled
setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result In the neied
for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must corpty with the rulers in
effect at that time.
❑ A suitable replacement area is not available due to setback and/or soll limitations. Barring advances in POWTS technologkr a
holding tank may be installed as a last resort to replace the failed POWTS,
srte has not been evaluated to identify a suitable replacement area. Upon failure of the P'OWTS a soil and site evaluaton
i must be performed to locate a suitable replacement area. if no replacement area is available a holding tank may be installed/ as
last resort to replace the failed POWTS.
Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biu rna: at tl e irifiltratwe
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 Name 1 ;
Phone 'T /b Phone OLI
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHOR
Name j„~ ` h Name J
Phone ' f 'i .C7 1 6- f C Phone 1 J 6 o
This document was drafted in co viiance with chapter SPS 383.22(2){bx')(d)&(f) and 383.54(l),(2) &!3), Wisconsin Administrative Code.
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j' 105596 HORTON GAY NORM RO
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ST. C'ROI}c COUNTY ZONING
CERTIFICATION STATEMENT rr8
F'OR UTILIZATION OF AN EXISTING SEPTIC T
ANK
"e'tify Chat I have
;erv~Irg the Inspected
t
he sePt
is tank presently
-7 residence locate,,
- iTr<6J Section N, R
thta - upon inSpecti
nk and baffles to be in °n' T certify that, I
have [,,,Dune,
t,rnctioning properly, good condition, and it a
. ppears t-o he
'dj t' me serviced:
back occur, from absorption , Y,tem~ .
Yes .
No (1f no, ski
Approximate volume or length of time; f
r_•~~I~Strtict.lc~n ;
Prefab Concrete,°
(I f known,
; Lc
1J
t known) : .SvS":74L
01 Td
_ (Name) P e _
P - int
{License Number} - - -
t .,)rm to be com plet
Statutes °r Licensed ed ' licensed plumber
Disposer (s-145.06,
W1~;c~~irs! li
° e) (NR 113 W-isconsin Adminl.strativr-
!=.lumber (aPP1Ying for sanitary permit)` Cer ~ - _ - -
ti fi cat].on :
accepting the above
J i t statement
c:rian I Certify that the tank to 9 he ing existin
<,cn.forin to the y se~~Lic: t~.nk
re
quirements of I st of my knowledge will
J.!1SpeCtion openzn o e LHR 83, i Adm. Cade (except for
9 out]_et baffle
n% MP/MpRs, ~~C
ST. CROIX COUNTY
SEPTIC TANK MAINI'ENANCE ,,'kGREEMENT
AND
OWNTERSMPICERTIFICATKIN FORM
Owner/Buyer
Mailing Address r
1
Property Address Jet-,
(Verification required from Planning & Zoning Depart ment for new constrwtion.)
City/State Parcel Identification Number
LEGAL DESCRIPTION
<1 -7
Property Location
tf4 , A& %4 , Sec. T C.-'?N R r
. 1 W, Town of
Subdivision Lot # i- V.73
1
Certified Survey Map # . Vc4urne Page #
Warranty Deed # Volume , Page # _
Spec house y em) Lot line: identifiable yes no
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
Improper use and maintenance of your septic system could result in its pr mature failm to handle wastes. Proper
maintenance consists of Pumping out the septic tank every three years or sooner, d "needed, by a licensed puffer. What you put into
the system can affect the function of the septic tank as a treatment stage in the wash disposal system. Owner a amwnance
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 =Wication foim, signed uy the
owner and by a master plumber,.lammeyman 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 fiil1 of sludge.
I/we, the undersigned love read the above requirements and agim to maintain the private sewage disposal system with the
standards set forth, heroin, as set by the Department of Commerce and the Departtront of Natural Resouares, Sum 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 ,in are true to the best of my/our knowledge. Uwe am/&= the owner(s) of the
property described above, by virtue of a deed recorded in Register of Dmis Office.
Number of bedrooms_--)
SIGNATURE OF AP ANT(S)
DATE
***Any information that is misrepresented may result in the sanity 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
rcference is made in the warranty decd.
(REV. 08/05)
122-, DO Ao. 00' ! 44.
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r 100.00,