HomeMy WebLinkAbout002-1061-50-011
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
(ATTACH TO PERMIT) 589743
GENERAL INFORMATION State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. AA
Permit Holder's Name: City Village Township Parcel Tax No:
Zack & Hailey Nelson TOWN OF BALDWIN 002-1061-50-010
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
25.29.16.379A-10
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTUPER S CAPACITY STATION BS HI FS ELEV.
Septic IN ID'
I Benchmark L4F IF I LTL1% 84 %W1
bg~ 5 OD .
q Alt. BM
1 LPL
As~atien Bldg. Sewer
(Q
++a9 t Inlet 0, T
ANK SETBACK INFORMATION t Outlet iFa,
lU. /
WELL BLDG. Vent to Air Intake ROAD Dt Inlet
TANK TO
L _T_
Septic i I i Dt Bottom
Dosing eade an. I.2
Aer ion Dist. Pipe ~ J
r °I7'
Hol g -6o-t. System
Final Grade g. / L~►~o
PUMP/SIPHON INFORMATION
Manu Demand St CTVer71,1
O// 3
GPM .J~ TT J
Model Number
H Lift Friction Loss System Head T Ft
Forcemain Length Dia. Dist. to Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width ~f Len W No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dial Liquid Depth
DIMENSIONS
1 Z:7~ /
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufa urer:
INFORMATION CHAMBER OR
T. e Of S S,t m: . I 1 I_ O f UNIT Model um e
DI IBUTI N SYSTEM G T U
eader anifo d Distribution x Hole Size Ix Hole Spacing Vent o Air Intake
Pipe(s)
Length Da Length Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over 1XX Depth of xx Seeded/Sodded Ixx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil / Yes No Yes No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: In peecctionn #2: /
Location: 2626 70TH AVE ~ µ'I' S ~
ILIM coves Will m @p s~ S►~ d
1.) Alt BM Description - _ F
2.) Bldg sewer length = 1 / t ' rt V 1
- amount of cover = L`7
1711 0 f C ow pn oil
Plan revision Required? I Yes i~ No l'~ 'I'j b
SBDUse-6710other(Rside.3/97) for additional information. u ` 8 ~(JJ Date ISignature e . No.
I
S
RECEIVED C county ~
1 201Industry Services Div' ' n
D S js 1400 E Washington Slqtary permit Number (to be filled in by Co.)
l' P S % T. CROIX COUNTY P.O. Box 7' /VjQ
MUNITY DEVELOPMENT Madison, WI 53it..- 2S8GGSgOQ J~ 546 9 7LI 3
E `si~wnL
Sanitary Permit Application Star .:ansactionNumber
In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit
is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to
the Department of Safety and Professional Services. Personal information you provide may be used for secondary Project Address (if different than mailing address)
purposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats. 2 &Z Co 7644,
Ar-
1. Application Information - ease Print All In rm 'on
Property Owner's Name Red I Parcel #
C7c~~ -0 u iU
Property Owner's Mailing Address Property Location) 5,1 i P 16 3 7719' 10
~?_4 Govt. Lot
City, State/J ) //J Zip Code ~j Phone Number S~~a/., Section ZJ
!/v~~/~[ v" ~ T ; / N R /~ciE lo&
H. Type of Building (check all that apply) Lot #
1~A I or 2 Family Dwelling - Number of Bedrooms 0) Subdivision Name
❑ Public/Commercial - Describe Use _ Ok LZA d~ Block #
O J F4 ❑ City of
❑ State Owned - Describe Use q
4,15.k_ ~ -5 W / Z"5 C M Number El Village of U4- Town of
III. Type of Permit: (Check only A e box on line A. Complete line B if applicable)
A. New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain)
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued
Before Expiration Plumber Owner It d d•'
IV. Type of POWTS System/Component/Device: (Check all that apply)
§;L !on-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable so
Holding Tank Other Dispersal Component (explain) ❑ Pretreatment Device (explain)
V. Dis ersal/Treatmen rea Information: G Ot..~
Design Flow (gpd) Design Soil Applliiccation Dispersal Area Required (sf) Dispersal Area Pr/opossed (st) System Elevation
/ a D Rate(gpds~ (O 4 / d
VI. Tank Info Capacity in
a n
Gallons Total # of i Manufacturer ro U ti
Gallons Units a .25 0
New Tanks Existing Tanks 0 P.
11 -Pi ivA- rl 'L
Septic or Woldi %-Tank Z~ / ❑ ❑ ❑ ❑
Dosing Chamber ❑ ❑ ❑ ❑ ❑ 141 1_41 I VII. Responsibility Statement- I, the undersigned, ass ,06 r ponsibil ty for' stailation of the POWTS
shown on the attached plans.
Plumber's Name (Print) Plumber's Sign &e
MP/MPRS Number Business Phone Number
Todd L Sinz MP139462 715-235-2644
Plumber's Address (Street, City, State, Zip Code)
E5609 708u' Ave Menomonie Wi 54751 U X
VIII. un /De artment Use Only
Fee Dat Issu Issu" gent Sign
t
Approved lsapprove FPem
uwopk'eason for Denial UVV
IX. Condit °e ct Disapproval 2 l4GQ. fotW
~ ' reOr'
•vi cell must nlsint ine
disper~ all ¢g,.~•q ~ ,._,_-,5,
_os per ingnagement pion pro jided by plumber,
2 I oMb t *Mw ,"ft muel; j raoint#k4d
a pr gVft blo code / ardinanaa.
Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size
SBD-6398 (R03/14)
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Private Onsite Wastewater Treatment System
Index and Title Page
Project Name:
Owner's Name:/
Owner's Address: 749
P /4-_
Legal Description: -6-7- Z-~'~KJ f c" .1
Municipality: Town V4gc; eitl of A
County: S:7- 1/-Q I Y
Subdivision Naive:
Lot Number: Block Number:
Parcel I.D. Number:
Page 1 ; 4-6 7-
Page 2
Page 3,/~r~»p
Page 4
Page S
Page 6
Page 7
Page 8
Page 9
Name of Designer: *Foll License Number: Signature: Date: Designed PursuaWTS Component Manual and Comm 81-85:
In-Ground Soil Absorption Component Manual for POWTS (Ver. 2 2.0) SBD 10705 P (N 01/01)
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Leaching Chamber Dispersal Cell Cross-Section
ft
Vent Cap at - 0 ft
Distal Ends Final Grade Elevation
Water Tight Cap 4' Schedule 40
at Manifold End Pipe With Vent
Cap (typical) ft
Top Elevation
Leaching 10 - -7 °
Chamber nCelll Cell2 ft
System Elevation
2.84 ft -57 ft
Dispersal Cell Plan View
ASTM
ft 4" PVC Pipe
2.84 ft
{
le Leaching Cell 1
ft l ft (typical) Chambers
Cell 2
Leaching Chamber Specifications
Infiltrator Quick4WO Chambers
rows of ;Z chambers each plus 2 end caps on each row
(20ells (20 sq. ft. EISA) + # (2.9 sq. ft. EISA/endcap) = D sq. ft. total
This dispersal system is designed at 150% of design flow and only 2/3 of the system needs to be
in use at any one time. Therefore, one cell in rotation may be turned off to rest each year.
ject a e.
4
ec. , T c N, R E o, Town of
Signature: License Number: Date:
Page of
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The Best Just Got Better
~Boa
The most efficient, the lowest
maintenance, the most economical
effluent filter!
Nearly Twice the Filtering Capacity •
• Estimated to go 3 Times •
Longer Between Cleanings
Cleaning Made Easy •
• Does Not Retain Solids Between Plates •
;
• Lowest Price •
i
0 Colvin
- Eliminates the collection of solids inside the cartridge.
- Nearly twice the filtering capacity of any other filter.
- By eliminating solids between plates
drastically reduces the need to clean.
- Cleaning made simple and efficient. -
oil in I III
- LT-1/8: 3500 GPD/Residential Strength
Filtration 1/8"
- LT -1 /16: 3350 GPD/ Residential Strength
Filtration 1/16"
- LT -1 /32: 3000 GPD/Recommended for Commercial use with Residential
Strength - Filtration 1/32" - LT - 1/64: 2500 GPD/Recommended' for Commercial usage with Residential
Strength - Filtration 1/64"
- 2700 Inches of Linear Filtration (Nearly Twice the Competition)
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of
FILE INFORMATION SYSTEM SPECIFICATIONS
d
Owner: ❑ NA
Tank Manufacturer.
gal
Permit# ['Septic ❑ Dose ❑ Holding Volume
DESIGN PARAMETERS Tank Manufacturer: NE~"A
Number of Bedrooms: ❑ NA ❑ Septic ❑ Dose ❑ Holding Volume: gal
Number of Public Facility Units: Ej NA Vertical Distance Tank Bottom(s) to Service Pad: ft
Estimated (average) Flow : gal/day Horizontal Distance Tank(s) to Service Pad: ft
Specific servicing mechanics must be provide if vertical is >15 feet or if
Design (peak) Flow = estimated x 1.5:!? gal/day horizontal is >150 feet. Specific instructions to be provided on back.
In Situ Soil Application Rate: It gal/day/ft' Effluent Filter Manufacturer:
El NA
t
Standard Domestic Influent/Effluent Monthly average Effluent Filter Model: L_
Fats, Oil & Grease (FOG) s30 mg/L Pump Manufacturer:
Biochemical Oxygen Demand (BODS) <220 mg/L ❑ NA
Total Suspended Solids (TSS) <150 m /L Pump Model:
High Strength Influent/Effluent Monthly average Pretreatment Unit
Fats, Oil & Grease (FOG) >30 mg/L Manufacturer:
Biochemical Oxygen Demand (BODS) >220 mg/L ❑ NA
Total Suspended Solids (TSS) >150 mg/L ❑ Mechanical Aeration ❑ Peat Filter
El Pretreated Effluent Monthly average e Disinfection ❑ wetland
Y 9 ❑ Sand/Gravel Filter ❑ Other:
Biochemical Oxygen Demand (BOD5) <30 mg/L Soil Absorption System
Total Suspended Solids (TSS) <30 mg/L ❑ NA
Fecal Coliform (geometric mean) <104cfu/100m1 ~n-Ground (gravity) ❑ In-Ground (pressure) p NA
Maximum Effluent Particle Size: in dia. ❑ NA El At-Grade El Mound
❑ Drip-Line ❑ Other:
Other: ❑ NA Other: ❑ NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Pump out contents of tank(s) *R,-Ollhen combined sludge and scum equals one-third (16) of tank volume
❑ When the high water alarm is activated
Inspect condition of tank(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA
Inspect dispersal cell(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA
ear(s)
Clean effluent filter At least once every: / ❑ month(s) ~-"r'~ ❑ NA
'year(s)
Inspect pump, pump controls & alarm At least once every: ❑ month(s) NA
❑ year(s)
Flush laterals and pressure test At least once every: ❑ month(s) ❑ A
❑ year(s)
Other: ❑ month(s)
At least once every: El year(s) NA
Other:
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 (pumper). 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 a 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 treatment 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 chapter NR 113, Wisconsin
Administrative Code.
All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units,
and any servicing at intervals of <12 months, shall be performed by a certified POWTS Maintainer.
A service report shall be provided to the local regulatory authority within 30 days of completion of any service event.
(Rev.8/14)
Page of
START UP AND OPERATION
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products, solvents or other
chemicals or sediment that may impede the treatment process and/or damage the soil dispersal cell(s). If high concentrations are
detected have the contents of the tank(s) removed by a septage servicing operator prior to use.
System start up shall not occur when soil conditions are frozen at the infiltrative surface.
During extended 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 and may overload them resulting 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) discharge; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products;
pesticides; sanitary napkins; tampons; and water softener brine.
ABANDONMENT
When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly
and safely abandoned in compliance with chapter SPS 383.33, Wisconsin Administrative Code:
• All piping to tanks, pits and other soil absorption systems 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 the opportunity to obtain a
sanitary permit for 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 the time of their permit issuance.
❑ A suitable replacement area is not available due to setback and/or soil limitations. If the soil absorption system cannot be
rehabilitated and barring advances in POWTS technology, a holding tank may be installed as a last resort.
❑ 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: TREATMENT TANKS AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES AND LACK SUFFICIENT
OXYGEN TO SUPPORT LIFE. NEVER ENTER A TREATMENT TANK OR HOLDING TANK UNDER ANY
CIRCUMSTANCE. DEATH MAY RESULT. ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK IS VERY
DIFFICULT.
s'
ADDITIONAL INFORMATION:
POWTS INSTALLER POWTS MAINTAINER
Name:
" Name: w„, ~t„l /,.•a ,
1 L.
Phone: A~ a M Phone:
SEPTAGE SERVICING OPERATOR PUMPER LOCAL REGULATORY AUTHORITY
Name:_ " Name:- t~`"a ' ~I?f
Phone: m" = f «m:",~ Phone: f`.
This document is intended to meet minimum requirements of Ch. SPS 383.22(2)(b)(1)(d)&(f) and 383.54(1), (2) & (3), Wisconsin Administrative Code. Use
of this document does not guarantee the performance of the POWTS.
(Rev. 3/13)
ST. CROIX t,.L}"UNn,
SEPTIC TANK M AINTEN,ANCE AGREEMENT,
AND
OWNERSHIP CERT IFICA`I,ION FORl~
Ovmer/Buyer -X11-s \ _
NMai!itlgAddress
Property Address ZtoZ-U ~
(Verification required from Planning & Ze~nling i?epartment for ncvv cnaS ruc`io }
Parcel lsael3iaU,-~{~c,;lNun -iiocl--~_'
City State s: -
r
LE GALL DE:SCI'a YPT I ON
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tipec 1 Lot
101)Se C
Ys, rid Pv AI-`v'I'EN A ACE -.NTD OWNER CERMTFICATION
f!D-Mper use and liminterlance of your scpiic system could resuh in its picmattire failure to handle wustt P,ot er
maintenance consists of pumping out the septic tank every three year Or saoncr, if needed, U a l;ccns - I pumps r What! ou plr
fife system can affect the funiction of the septic tank as a treatment stage in the .paste disposal system. Owi cr i.ta,n?cnamco
vtsponsibilities are specified in §Comm. 83,52(t) and in Chapter l2 - St. Croix Curn:il S<atitary Cardin=rice.
The property o-wncr agrees to submit to St. Croix County Planning Zoning Depart meat a certifi:'ation *om:, signed i)v szh(;
owner and t-)y a master plu riber, ioumce m an plumber, restricted plur_)Ler or a licensed ptill tpct ve, if"'mg that k I i the un t
wastci+Inter disposal system is in proper operating condition sndlor (L) aver inpecLOn an3 pumping (tt '.;eces_c ry i, the septic tank i.,
less than i>` 11111 u I- Sludge.
liwe, the undersigned have read the above rccu ncnncnts and i ee to maintain the Private sewng-c ;isit :ys n,
standards set forth, herein. as set by tre Department of onunerce an,d u,c )eparnnarit of'.vatural i2CSOU t ut5, S,aw of ~rvr5_cz.~u_
C:eitdficatinn stafiiI6 that your sct,r.., and rWi tined to tti . ~,i. f):o:x C'otrrti, Y?any ray, ri_
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