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HomeMy WebLinkAbout040-1066-60-001 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division Sanitary Permit No: INSPECTION REPORT 589756 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)] Permit Holder's Name: City Village Township Parcel Tax No: Ryan VanNurden TOWN OF TROY 040-1066-60-001 CST BM Elev: Insp. BM Elev: BM Description: „ Section/Town/Range/Map No: 15- ~ M I GS I 16.28.19.252A-1 TANK INFORMATION 2%,iA ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. 4 F, -j.r;~ Septic l , 7 Benchmark 2°f 161-Vi ~a t /Z Z Alt. BM T\« ~7 LAW Pb 67; 1 Aeration Bldg. Sewer 7 07 5 - Holding St/Ht Inlet St/Ht Outlet b, ( c Z S TANK SETBACK INFORMATION ~1 TANK TO P/~ WELL BLDG. Ve Air Intake ROAD Dt Inlet v -6 ~r~ Septic 75 b 15 to l Dt Bottom t Dosing Header/Man. 7.13 ?q. Aeration Dist. Pipe 1.17 / Z Holding Bot. System G L -7` . 3 I J n ~ 06 PUMP/SIPHON INFORMATION Final Grade Manufacturer Demand St Cover -1,177 J 1) - GPM Model Nu a- LL LL " TDH Lift Friction Loss System Head Ft j Forcemain Length- ia. Dist. to Well SOIL ABSORPTION SYSTEM 0.175 f- S S BED /TRENCH Width Length No. Of Trenches ( PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 7 [f G►~U SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: ~70 INFORMATION CHAMBER OR f f Type Of System: / UNIT Model Number: ~t .~J1a f o A J. P_ 1, " 756 ~ l 7Z ;~Vl L76- zz_ ' DISTRIBUTION SYSTEM I -7,:5 4-7.-5 f- 7 5:::7 Header/Manifold / ! Distribution Ix Hole Size x Hole Spacing JV~~ Air Intake r G~ Pipe(s) Length Dia 1 Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only So J~~ S Depth of xx Seeded/Sodded xx M Iched Depth Over Depth Over jxx No Bed/Trench Center / (V9 Bed/Trench Edges Topsoil Yes No es l f • COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 346 S GLOVER RD ~Q- ~~ca~- 6 l U / 1.) Alt BM Description = lam' T- " C,6 J-G~ 2.) Bldg sewer length - amount of cover = Yes ~S an Use others de for additional information No '7.111 (~3 Date rnsepctct~ s Sign re Cert. No. SBD-6710 (R.3/97) i S4N6- Industry Services Division County l~ \r 1440 6 Washington Ave ST Li X lyi, P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.) P: JUL 14 2016 Madison, WI 537716 ST. CROIX COUNTY &~& " 5 499 75 G7, WX2C8C1;1~QFQG, sty Transaction Numbea anltary wit Appficati~ In acwrdancc with SPS 383 21(2), Wis Adm. Code sihnvssion of this form to the aop,._ _ V'ft is regained prior to obledning a sanitary permit Note: Application farms for stOW-O rned POWIS we sttMrruw.. Project Address (if different than mailing address) the Department of Safety and Professional Services. PersorW information you provide may be used for secondary u oses in accordance with the Privacy law, s. 15. i m Slats. L A ication Information - Please Print All ation ✓✓✓III Property Owner's Name Paned # J~Y A ki \AN Aj uK DeJO 061 - 64 - odl Property Owner's Mailing Address Property Location A, 1 y S v2 r3 Govt. Lot VA City, State Zip Code Phone Number -'V., Section f /y -K(L E K :F-ALL-S ij: T- s~f @ ZZ~ z - z~z $ ✓ (tarcle one' N; R ~ E oV IL Type of Building (check all that apply) Lot 9 T i * I or 2 Family Dwelling-Number of Bedrooms 1 Subdivision Name bk gall, 6 9loek q ❑ PublidCommemial - Describe Use _ 0 City of State Owned - Describe Use +CSSM Number ❑ Village of r7 `a~ IDW7 Y1 ! Z 7 bi58 7'Townof 111. 'T'ype of Permit: (Check only o® box on line A. Complete line B if applicable) A. N. System ❑ Replacement System ❑ Tmdnwnt/Holdimg Tank Replant Only ❑ Other Modification to Existing System (explain) F3. Q Permit Renewal ❑ Permit Revision ❑ Change of Phtmber 0 Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration ow IV. Type of POW'! S SysUmlComponenUDevice. Check all that !Non-PressuAwd In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound ? 24 in. of suitable sail Q Mound <24 in_ of suitable soil Holding Tank ❑ Other Dispersal Component (explain) 0 Premmiment Device (explain) V. Ois rsal/Srea ent Area Information: Resign Flow (gpd) Design Soil Application Ralelfl Dispersal Area Required (so Dispersal Area Proposed System Elevation 7z 0,7 1,071 %rz~ 67 SZ~ VL Tank Info Capacity in Total # of Mamufactraer Gallons Gallons Units o u 0 New Tams Existing Tanks v a w n iz ~ V Z v t'n y Wc5 A, (big br Holding Tank Dosing chamber VIL Responsibility Statement- I, the undersigned, assume responsdAW for instaration of the PORTS shown on the attached plans Plumber's Name (Print) Pltrmba's =Si Bersffiess Phone Nnmber 3 jay _ ~z.'~ ~I 5' 7115 Phumbees Address (Street, City, State, Zip Code) 01 WIL un rtment Use Only Permit Fee Dgtq" Issuing S ivin Reason far Denial UL Cond Disapproval 13~ , dispems'l cell multtA be sLti'vicps ! memtzines,' as per tni#nagerrAM plan pro-tided by plumber. OA 2. lliil'aetbilck rests must be maintained P ' mu per ttpFiicable code / ordinanew. 1 J~ J-.. a e t le Aux* to complete plans for the system avast sainut to the I'ally only an paper not than 8 r/t s I I inches in sue - - 1 Paget of q I Plot plea i propeny, 'ALE 40 ~A ~t L T(d jl~-~ 2 = Backkoe pit R "fC~ ~D ST C ~°n►s J. '725 r~G'5 Nor h S ~J FtGL . z ~ Sc~ ~.1~t~v vt't~S~`~- 1ST ~ ~LLC: vl FILT1~ } 1 o % r ~ 4, C~7~pu.njD - 68~• t9, ~ ~ - $RusK~ C D a; Z5?7 0 IEM • n: s ° CO,AV - F PAGE 1 OF 4 In-Ground Gravity Plan Index & Cover Sheet Component Manua! Design References: Version 2.0, SBD-10705-P (N.01/01, R. 10/12) Pg 1 of 4 Index & Cover Sheet Pg 2 of 4 Plot Plan Pg 3 of 4 Dispersal Area Cross-Section & Plan View Pg 4 of 4 Management Plan Attachments: Enclosures: Tank Specs POWTS Application for Review Filter Specs Soil Evaluation Report & Site Map -rAA'K AF~~ ,v GA i 'W tv UE r b Project Name / Description Owner Name(s): f, \ A,\; \,",A jU ) a R b er'g` Phone: 7- - Z(O - 3 z' Owner Address: tZi~~eK FALL_-~, t_k; Zip: !59ezz Project Address: Govt. Lot: .v A, = 1 /4 of _5e1 /4, Section T 79 N-R I el E 0 or W Township: -,&(-)Y- County: 5 i c RC1)( Project Parcel ID Designer Information Designer Name: A iti,Y Phone: ILa - y - ►7 i Designer Address: ,ZSrf-F~7 I: ~k+~~~+ tz's L~ P~zCP-`~ Zip: f54X3C E-mail: I~Li ( i st e(_r~ f ~cnr t ufIC64. e&A"A License Number: Remarks: VARY JO HUPPE~RT D 1859 00 :RIMER FALLS,. % WI i nature: Date: "'~--ze'/L} Signature: Orininal anature required ach submitted copy. Pagel ®f `l Plat Pl" propeny Owner auy ~ : KNAA VAN 1JuKLU- a = Boe pit _f 2gA~ i R ! i vi ~o~~~~ OF TI~DtiI C ROti~ ."n►1 5. ~75~ '5 UlIS~oA; Si.~` North sue- ri C TAN K l AN r, F~~ )l el t tpLP F-b ZD GKDa.,VD - 6py. ~9 D 83 ~ ~ 681.00 •.9 sue Lq~a ` V) am "yan; Usti Nc~1t/ mm ~N °8 I PAGE 3 OF 4 U c yac -s$ c - O ~'G U O _ w _ N 10 _E o~ 0? m lU F `cm L` ° h n ~ o 'c W a _°o m _e 1! U Q- m U) a m m 8 $ c y 3 m o- w m Q C W cn 0 U U$ m$ o i m a •O w n m CL m X m U E co co co 2 ¢ cyp t m von t U N N a° v~ c _ m V cA a ~R v _o _ 2 rn @ v 4f O = ( o E ti € LU ! i( I m I ~ (D E = W t I u II CL < U> CV) I n m m z Z c c LLI W o = c co ~ a) 2 II N J V U) 3 U U) Z O m D ! II I © C4 m vii co U) 2 'c6 CL 4--0 C. CL qr, ° I NM a Of a) C: elf w 0- < CV) U m o it I O I+ 11 it u CD CD CN &Z Q r U c n ~ U Z: C v n N ~ ° E ~ ! ! I v CO X co -E ® w -.1 ( I cn cn Q ! o I I Q 3 I I C) Ln d_L io 0 a ii = Lo N i J > ( w a) I zU U~ a LLI in m> w ( a a l~ ° > $ °L) t(Da° U) ! :3 Z ID ° Q~ C'7 ° ° _ ! a O w U I p„ o Ln I E ~ o F- > U I q 1 o C) U) I jj ! z ~t Q o 0 U__IZ ! a a ! + PAGE 4OF4 In-ground Gravity Management Plan IMPORTANT: The owner of this in-ground gravity system shall be responsible for its perpetual operation and maintenance pursuant to requirements of SPS 382-384, Wisc. Admin. Code. Pursuant to SPS 383.52 (2), Wisc. Admin. Code, this system shall be considered a human health hazard if not maintained in accordance with this approved management plan. Further mi ore, all inspection and maintenance activities shall be performed by a registered POWTS Maintainer in accordance with SPS 383.52 (3), Wisc_ Admin. Code. Maximum Dispersal Area Operating Limits: Design Flow gpd; BODS :5 220 m9U'; TSS <--150 mgL"'; FOG :5 30 mgU1 Inspection Checklist INSPECT EVERY 3 YEARS o type of use o age of system o nuisance factors (i.e. odors, user complaints, etc.) o mechanical malfunction (i.e., pumps, valves, switches, floats, etc.) o material fatigue (i.e_, leaks, breaks, corrosion, etc.) o solids volume in anaerobic treatment tank(s) and any distribution appurtenance(s) (i.e., distribution / drop boxes) o neglect or improper use (i.e., exceeding design capacities, prohibited activities, etc.) o extent of ponding in distribution cell prior to dosing o dosing irregularities - if applicable (i.e., pump re-cycling, float switch settings, etc.) o electrical components - if applicable (i.e., wiring, connections, switches, controls, timers, alarms, etc.) o distribution lateral or lateral orifice plugging (measure lateral distal pressure - compare to design specification) o surface discharge of effluent or sewage back-up into structure served Maintenance Checklist MAINTAIN EVERY 3 YEARS (or when necessary) o Septic and dose tank(s) shall be pumped by a certified septage servicing operator licensed under s. 281.48 Wis_ Stats. when the volume of solids in the tank(s) exceeds one-third (1/3) the liquid volume of the tank(s) or as required by local ordinance. Disposal of contents shall be pursuant to NR 113, Wisc. Admin. Code. o Effluent filter(s) shall be inspected every 3 years and shall be cleaned when necessary to remove any accumulated solids according to manufacturer's specifications. A servicing period will always be greater than 12 months. System maintenance reports shall be submitted to the proper local government unit in accordance with SPS 383.55 Wisc. Admin. Code. Report any component failure or malfunction to: Name of individual or company: v,LA 1 1 T -Y Phone: rJ i{ i, r,: i _ l L 1 Local government unit: Phone: Local government unit address: ZIP: Any defective part of this system shall be repaired, replaced, or removed pursuant to SPS 383.51 (1), Wisc. Admin. Code. Repair or replacement of failed or malfunctioning components shall comply with SPS 383, Wisc. Admin. Code. No product for chemical or physical restoration of the POWTS may be used unless approved by the department in accordance with SPS 384, Wisc. Admin. Code. Contin enc Plan In the event that any failed treatment component of this POWTS cannot be repaired, it shall be replaced pursuant to a plan submitted to the appropriate agency for review and approval. A failed in-ground dispersal component may be abandoned and replaced by a code-complying dispersal component in a pre-determined area of suitable soils. System Abandonment If use of this POWTS is discontinued, it shall be abandoned in accordance with SPS 383.33, Wisc. Admin. 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I Z i, i I I I ' L - - I t. - I i J G`pVER PRp1R1E G SOUTH GLOVER ROAD-, JNPLAT T ED LANDS r~ ~ 500'00'56"4V 7327.66' ~ 111228.S2' 99.14' Z~ li l 0, e ~ ~ p J ^ S o W LL ~ O V Q m Z G b W eo Z O U J N C N F 1918E 3..ES.10.005 ti ti p Z £ 507-54-43"E v Q 177.55" li u < < ~ W r s e F- to 3 e a g o aI v 2~ ~p 2 W o ~f Q N C Q X H FZ- :n d 6 F.. Q a W O O v+ p~ z O0 0 •88-yg13 `F tr ~9n BF '1i 'moo c~ Orb ti o ~f. 2 SOl'22"59"E 600.40' NOIl` iS V3A0l9 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMFNT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer RYAN VAN N U RD EN 153 BJERSTEDT COURT, RIVER FALLS, WI 54022 Mailing Address Pro erty Addk346 SOUTH GLOVER ROAD, RIVER FALLS, WI 54022 p (Verification required from Planning & Zoning Department for new construction.) RIVER FALLS, WI 040-1066-60-000 Ciri~IState Parcel Identification Number LEGAL DESCRIPTION W, Town of _ Property Location N E '/4 , SE 'A , Sec. 16.,1'28 N R 19 TROY Subdivision Plat: , Lot # 1 1019359 , Volume 27 Page 4 6158 Certified Survey Map # Warranty Deed # (before 2007)Volume Pace # Spec house ElyesDio Lot lines identifiable 0yes[]no 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 mto 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, si-ned 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- I/we, the undersigned have read the above requirements and agree to maintain the private scwage disposal system with the standards set lorth, herein, as set by the Department of Safety And Professional Services 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. l Ave am.`are the owner(s) ofthe property described above, by virtue of a arranty deed recorded in Register of Deeds Office. 5 Number of bedrooms 6 30 16 SIGNATURE OF APPLICANT(S) DATE ***Any information 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 map if reference is rnade in the warranty deed. 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W 4 r Z z B w L 6K W o N d g a m S ~ k a PEPEPE A Y csf - zar<S~~3N a~ Wisconsin Depart r nit if~S ist^y i l t ional Services Division of Industry 8etvfc 7 r SOIL EV RT Page 1 of 3 in accordance with SPS 383, Wis. Adm. Code 0l Y County ST. CROIX Attach complete site plan onpappr nol Wjh$tFi 8 1/2 x 11 inches in size. Plan must include, but gjX"lted to,ve'rtid'al and horizontal reference point (BM), direction and Parcel I.D. (Pending) percent slope, scale or dimensions, north arrow, and location and distance to nearest road. 090- 0 - C Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). I-eva, 3d Property Owner Property Location DALE VANNURDEN (Buyer: Ryan VanNurden) Govt. Lot NE 1/4 SE 1/4 S 16 T 28 N R 19 ©r)® Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 6900 Sioux Trail 1 (Pending) City State Zip Code Phone Number []City OVillage ■ Town Nearest Road Rockford, MN 55373 ( 612) 282 - 8524 yip S. Glover Road Q New Construction Usef -7 Residential / Number of bedrooms 5 Code derived design flow rate 750 GPD Replacement ® Public or commercial - Describe: Parent material sandy outwash Flood Plain elevation if applicable n LD~F X ft. General comments Conventional in-ground Trenches 0.7 loading rate and recommendations: SYS!►'1 lG fLEI/ inc~s f BE 0_7-5' dK ~ v,✓6'X, uJqxC sTA'/iN~ Aea 04(ZY pEP~K ~+(z- pj~Ot7~.~c1' B6_1Aj6W Boring f}(,pA I~t►'2 /~Q ~/9 = 0" 166(40- o- 0 Boring # F1 R Pit Ground ft. Depth to limiting factor 127 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/f? in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 `Eff#2 1 0-9 10YR3/2 1 if-ma&sbk mvfr as 2vf-co 0.4 0.6 2 9-25 7.5YR4/4 sl If--mabk ds cs 2vf-m 0.4 0.7 3 25-33 7.5YR4/4 Is lmsbk dl cs lvf--m 0.7 1.6 4 33-78 7.5YR4/4 s Osg dl gw Ivf-f 0.7 1.6 5 78-127 10YR4/4 s Osg dl - 0.7 1.6 some gr; few cobs. Horizon 2 is a heavy sl. ❑2 Boring # n Boring 685.30 128 • pit Ground surface elev. ft. Depth to limiting factor in, Soil A lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/f1? in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 "Eff#2 1 0-14 1OYR2/2 1 2f-ms&sbk mvfr as 2vf-co 0.6 0.8 2 14-19 1OYR3/4 cl lfabk mfi es 2vf-m 0.2 0.3 3 19-30 7.5YR4/4 sl 1 f-msbk mvfr es 1 of-m 0.4 0.7 4 30-48 7.5YR4/4 is Ifabk mfvr cs lvf-f 0.7 1.6 5 48-128 7.5YR4/4 s Osg dl 0.7 1.6 some gr; few cobs e stone. * Effluent #1 = BODS > 30:E 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD5 < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Si t r CST Number Ma Jo Hu ert Hollister's Soil Testing & Design) 224832 Address Date Evaluatin Conducted Telephone Number W9875 690th Avenue, River Falls, Wl 54022 05 - 28 -2015 715-426-1775 SBD-8330 (R07/13) Property Owner VAN NURDEN, Dale(Buyer:Ryan) Parcel ID # (Pending) Page 2 of 3 FTI E] Boring # Boring pit Ground surface elev. 684.00 ft. Depth to limiting factor 130 in Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-12 1OYR2/2 - 1 2f-mabk ds as 2vf-m 0.6 0.8 2 12-34 10YR3/4 sil 2fabk dsh as lvf-m 0.6 0.8 3 34-56 1 OYR4/4 sil 2fabk dsh as 1 of-m 0.6 0.8 4 56-66 10YR4/4 m2f10YR4/6&10YR6/2 sil if-mabk ds as 0.4c 0.6 5 66-78 7.5YR4/4 sl Om mfr as 0.2 0.6 6 78-130 10YR4/4 s Osg ml 0.7 1.6 Redox in Horizon 4 meets SPS code. ❑ Boring # Boring n Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 El Boring # Boring Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fg in. Munsell Qu. Sz. Cont. Color Gr. Sz. 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