HomeMy WebLinkAbout042-1077-20-002
tvuconsm Depanment of Comr-ercc PRIVATE SEWAGE SYSTEM County: St. CFOIX
Solely and Bcildmg Ovslar•.
INSPECTION REPORT sanitary Permit No:
(A I I ACH TO PERMIT) 589799
GENERAL INFORMATION Stale Plar ID No
Personal inlorrnahor you provide may he fixed for secondary purpcses p•ivacy Lava. h 114 11;01,11
Pe'mit Holcer•5 Nj-e city Villape Toanshir. Panel Tax No:
Stephen Steigauf TOWN OF WARREN 042-1077-20-002
CSI Bxd Ele,•: 11,RWAFlevr BIf Qesnia~ort Sccl w.,IO -'unrawNl,p No.
g, ~R - Z e6T 28.29.18.440A-02
TANK INFORMATION ELEVATION DATA
TYPE 10ANUFACTUNFR CAPACITY STAI ION BS HI FS ELEV.
3
Septic SM1UJr 1 565 Bemthtalk An. IJtak~e ~ ; l 7 /Lb . Dq
Aeration Bldq. Sewer O
i
Holding SUHI Inlet h
131: Outlet i
TANK SETBACK INFORMATION 522 75 941,
TANK TO PA WFI I. BLDG. Vuol Ic Air Fdaku ROAD Dt filet
Septic 7 r Dt Bottom
Doling HcaderfMan.
Aerahun Dist. Pipe •7 9s•
Ali
HuL•:iny Got. System
PUMP/SIPHON INFORMATION final Grade J' d J! 7. 6', r
Marufaclurer - Demand St Cover pq, C
GPM L / [G 7
Model Number
TDH Lift Friction I oss System, Hoad TDH
kocomain Le 1%51 to Neu
SOIL ABSORPTION SYSTEM
BEDffRENClI 'i:idln Length N~+. OI I•c•n3a:: 7tT DIMENSIONS No. O'Vl:: Insiae Dia. Li DopP~
DIMENSIONS ZZ6
SETBACK 3YSItfd IO P!L BLDG WLLL LAKE~SI REAM LEACHING r•...... :,aIwmwr
INFORMATION T • of S stem: CHAMBER OR F-
1p D ->d•w ~i y u 1 UNIT M1fodel Number
DISTRIBUTION SYSTEM /fI Z7 L7 111,-6
Fc~
HeaderAlawfol L`i::Inbul on zHOlc Situ xHcle SP r•y Ven I;Air Intake/
Spacing -
Leng:h~ D n I u•nltl• p).
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Duplh Over 4Dnrln Over xx Depth of xx Sceunn•Fitrdded xx Mulr nee
6edJlrcucb Center . YI BroJicnch Ldp--, Iops:cI e5 No 1y Nc
COMMENTS: (include coop drscreponcies. persons present. etc-) Inspection fill: Inspection 42.
Location: 784 112 T H ST ~I I qcO? -
All BM Description + &*6
2.1 Bldg sewer length - I (e 4, 42
- alrount of cover
2.5
Plan revision Required? Yes No 71,
Use other side for additional information. J Y 1EwV r
Dam f~ Insepc is Sig me (:e l Nn
SBO .
-47101R 3191)
4i4 J Irv - O-c11,-6 3
RECEIVER
Safety and Buildings Div'sion , l 4¢
S 2 9 ~Q b 201 W. Washington Ave., P.O. box 7162 Swii,an PermitNumbar(to be filled in by co.)
P T' AUG Madison V-11 r 07- 162
v ST. CRON COUNTY c2QQ 7 1 7
` _gpLyITY DEVELOPMENT O /
Santart PermitApplicatic74WZQYZENSP6T StafcTrmsaactiioiiNumS:r
1 Curdance sigh 5PS .53III' l1'>. Adnt (ntc, subuu v n ;:'tits lams 1, the irpr.rna:e }<:rvcmmcntA unit / V
i rcyutred ry cn, I.r min mnuy perm) \ :I xp} a l l n r. m<. r.-I V mvr.:l POWTS sc>uhrnillcJ to Project Address (if dtlicrenr d1:ul mailim addres<)
:he Des m tun f \aluv ana+ I n. -IJnal C nI Pcr.oi I m gt.Ialion y, u p .,vide may be used for secortJal
rune in a-co daucc v,ith Ole Pr va v Las I i lib l ~i m sr.ls.
Appbt ltion Information_ Please 1 I Inl All Information Ir rem/)•.u..c Pr. 'tyl n.. nd .3,,, 18- If 40 PT
c itl ' S4ttc /.Ip ('rd: r'I:u-: Ntrtbc: I
pe`t~ " « S 7C7~ /~S q 5/ Irl onci
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- 1 ll type of Bu11dn1,-(cheek Jl that apply) I Lrl*
I or J Fa:'., U C1Iin~ rtL. r redo+srrls Subdivision Name _
nlock ,
❑PuSIi:X'omr:ercial-I)scribc C>: -
-1 - ❑ city of
gco
I statc o'lle" Descuhe Use C.S11 Num cr ❑ \'ilLk f
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III. Type of Permit: (Check only u e box on line A. Complete line 6 if:>~tjilicnble)
kNc , S tnl acp:acane .I SvStclll -
n1r,aiment I Idr:=Two F tD :~;-.rn'O~tll vOther W"ificaii:m to Fxishng System(cxrlain)
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1 ~ 'n ::.e,,ul PCrmit li;.isio ❑ i h.nu c of l'Imn`:r Ll Prmil'I mn>r"e: to Nes List Pre,'ious Permit M:mhcr and Date ls.wcd
13ct2,rc l yn: ati..nl cl"nct rr /x ~ d µ
I\ Tvpr of PCl)1 l b tic stem Conlponell De, ir,•c1lChecl. all that apple)
,KN uI f10.:u: J I cr:r_nd I 1 I i In (rrocnJ ❑ AH;r,is _ ?Ao.utJ '?4 in. of ,nr,blc• soil Mrn nd •:'4 ht- of smiahlc sell ' ❑ H fin 7a.-L ~
I (%thc f) pu s.l C'om nt (rxplain; _ I Pint aLnaa 0.rrt (caplair,. _ - - ~ _ ~.Q
1)6 persal/I ream 'nt Arra Information: vNr1VR•
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}_:f:.,o n Int-9erd,ll Uispcrs`+ .'uca 1..q..red (>fl Dlsrm Arc Pre sed W, Sy.:cm 1;I Oati,V1
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If Responsibility Slntcmcnl- 1, the undcl sl md, a some nspnnsihiliry for installation of the Pr111-I /S\^sh~mn on thr .Itta bed plans.
PI into - N j:: /
F v❑ ^ ^ I I imbu rta.::re I. - C \.Im`cr Bnsirtes+ Phone No-[,. ;
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Plum r . .:Jn - CrtC- ('it Zip ( od,.)
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CONVENTIONAL COMPONENT DESIGN
Resioental Apolicaton
INDEX AND TITLE PAGE
i
`,ooer's Nan E.
awnshiF CL( CLL~~-~
div ion Na:T,e `C S /t1 - %b 1.5-5-7
-
I ,t Numoer ~ -
Page ' Inoex anti ;it
Page c' Plot P,ar _
'age 3 Syster Sizing & Cross-Sectors
Paeae c Filter Specs -
nae c _ Maintenance loformatior
.-'aae 6 Management Pian
Pane - S:. Croix Ctv Septic Tani, Mair term, z~
r'ege 8 VvIarranw Deed
age = cSM or Pta- _
Attachments Soil nest & Noise Pov
'ijn,-,-r.
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a
133
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,oil-Absorption System Cross Section
'4 4" Schedule b I a r,•a~L
PVC VW# Pipe
With Verd cap
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Soil Abso tion System Plan Vie,n-
/OS fi
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r rvahon . renctr t
Chambers
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Leaching Chamber Specifications
~,nd Model TIV
lm9 sp k per chamber -
SOtlAppiiceliun R;tlr r ~iu~USy ft
7s~" SIP') Desipn Fl.~m~ ;
7 Sod .Application Rate ~n S j, ~i
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POWTS OWNER'S MANUAL & MANAGEMENT PLAN Pageol
FILE INFORMATION SYSTEM SPECIFICATIONS
O:vnel Tank Manufacturer. ❑ NA
Perri) t# &Septic ❑ Dose ❑ Holding Volume -`C 7 (gall
DESIGN PARAMETERS Tank Manufacturer. )~NA
Number of Bedrooms. ❑ NA ❑ Septic F1 Dose ❑ Holding Volume (gar,
Number o` Public Facility Units* Ft NA Vertical Distance Tank Bottom(s) to Service Pad (n)
Estimated (average) I-low: , j f` g)atiday; Horizontal Distance Tank(s) to Service Pad (n)
sperifir. servi::ing mechanics must be provided if vert cal is >I 5 feet or
Design (peak) Flow = (estimated x 1.5): ! S - (gatiday' if horicontal is>m50 feet. Speeiliu instructions to be provided oo back.
In Situ Soil Application Rate (galmay412) Effluent Filter Manufacturer- ❑ NA
Standard (Domestic) InfuenUEffluent Monthly average Effluent Filter Model 5-
Fats. Oil & Grease (FOG) sx30 mg:L Pump Manufacturer.
Birchemiral Oxygen Demand (BOD,) -:220 mgll ❑ NA NA
Tota; Suspended Solids (TSS) 2150 mg+L Pump Model.
I ligh Strength Influent-'Effluent Monthly average Pretreatment Unit
(FOG) 130 mgrL Manufacturer.
(BOD,) >220 mg:L (XNA Y~I NA
(TSS) >150 mg:L ❑ Meehan cal Aeration LI Peat Filter
❑ Disin`ect,on ❑ Welland
Pretreated Effluent Monthly average ❑ Sand:Giavel Filter ❑ Other: _
(BOD,) <30 mg:) Soil Absorption Systern
(TSS) s30 mgR 91 NA
Fecal Coldorm (geornetric mean) <10` R111-Ground (gravity) ❑ In-Ground (pressure) ❑ NA
Maximum Fff cent Particle Size in dia. I I NA ❑ At-pane ❑ Olned
F Drip One ❑ Other.
-Other F1 NA Othe" I I NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Punt ou: Centel,.,.; cf tarkfS) ~ ).Vhen combined sludge and scum equals one-third ('r„ of lana volurle
p F When the high water alarm is activated
,cntn; (Maximum 3 years) NA
Inspect cond Lion of tank(s) At least once every: j ❑ n ; sl
yoan
Inspect dispersal cel:(s) At least once every. ~j 0'n`''o°~' (Maximum 3 years) ❑ NA
ycai;sl
Clcan effluent filter At least once every. Z ~t n'omnjsb ❑ NA
I I years? _ _
Inspect punip. pump controls & alarm At least once every. LI r'orth(s) NA
[I y'eans)
rJ
Flush laterals and pressure test At least once every month(s)
. ❑ year(s) ANA
OIPer. At least once every manlPU NA
J y'ea'r:
IINA
MAINTENANCE INSTRUCTIONS
Inspect ons of tanks a^d soil absorp: on systems snaI he made by an ird •vidual carry Ana cne ar the follo:Jng licenses o- ceddications.
Master Plurnbe-, Master Plumber Restricted Sewer POV'!IS Inspect(>•, PO'ArTS fvlai•rainer or Sep-,ago Serv.cing Operator (pumper).
I ank Inspections •nus: rrlude a visual inspect on of the tank(s) to identify any missing or broken harda+are identify any cracks or leaks,
measure the VOlume of combined sludge and scum and a check for any hack up or pond ig of effluent on the gro.ind surface. The soil
absorption system shall be visually msoected to check the effluent levels in the observation pipes and to check for any ponding of effluent
on the ground surface. Tine ponding of effluent on the ground surface may indicate a failing condition and requires the immediate
nclification of the local regulatory autho,ity.
When Lie combined accumulation of sludge and sc:un) in any treatment tank equals one-third (A) or more of the tank volume, the entire
contents of the tank shall be removed by a Seplage Servicing Operator (pumper) and disposed of in accordance with chapter NR 113
W.socnsin Administrative Code
All othe, services. including but not I.mited to the servicing of off .ion', filters, mechanical or pressurized components pretreatment units,
anti any servicing at intervals of _12 months. shall be performed by a cer, fled PObVTS Maintainer.
A service report shal be provided to Inc local regulatory aCtncrry within 30 days o` cornpletion of any service event
GV-N-005 (02)'05)
Page _ e` _
START UP AND OPERATION
For new constructior. pror to use of tie 1106NIS check treatment tack(s) for the presence o` painting products, solvents or othor
chernicas et sedimew that way impede the treatment process and;or damage the soil absorption system. If high concentrations are
detected have the contents of the tank(s) removed by a Septage. Servicing Operator (pumpe') prior to use.
Pump tanks may fit above normal highwater levels prior to startup or due to pump failures. Stan up or restoration of power under these
cx)dit ons is not recommended, as the excess wastevate• will be discharged to the soil absorption system in one large dose causing an
overload that may result in the backup o: surface discharge of effeeot and damage to the system. To avoid this situation have the
wctents of the pump tank removed by a Septage Servicing Operator (p.imper) prior to restoring power to the pump or contact a Plumber
or POWTS f•,dainlairer to assist in manua'ly operating the pump controls until normal effluent levels are restored within the pump tank.
System start up shall riot occur when soil Bondi; ons are fm7en at the infiltrative surface.
Do not drive or park vehicles over tanks or the soil absorption system Do not drive or park over, or otherwise disturb or compact, the
al ea within 15 fee: down slope of any mound or at-grade sal absorption area.
Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the treatment
tanks and soil absorption system: acids antibiotics. baby wipes. cigarette bitis, condoms, cotton swabs, degreasers, dental floss,
diapers, d sinfectants. fats foundat on d•ain (sump pump) discharge fruit and vegetable peelings, gasoline. greases, herbicides, meal
scraps, medic tons oIs, painting products, pesticides, sanitary napk'rs. solvents. tampons arld water softener brine discharge.
ABANDONMENT
Wren hie I'0'v:?S fails andrer 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 s. Comm 83.33, Wisconsin Administrative Code
• All piping to tanks pi's and other soil absorption systems shat: be disconnected and the abandoned pipe openings sealed.
• 1 he contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator (punper).
• After purnping, 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 POWYS fats and cannot be repared the fo'.lo•,ning measures have been, or must be taken, to provide a code compliant
replacement system'
❑ A suitable replacement area has been eva:uated and may be utilized for the location of a replacement soil absorption system
The replacement area sho.,ld be protected frorn disturbance and compaction and should not be infringed upon by required
setbacks from exist ng and proposed struC.u'e. lot Ines and wells Failure to protect the replacement a,ea will result in the need
for a new soil and site evaluat on to establish a suitable replacement area. Replacement systems must comply with the rules in
effect at the time of their permit issuance.
❑ A s,ntab.e replacement area is not available due to setback and.'or soil limitations. If the soil absorption system cannot be
rehabilitated and barring advances in PO4VTS technology, a holdrg tank may be installed as a last resort
I I The site has not been evaluated to identify a suitable replacement area. Upon fai:ure of the POINTS a soil and site evaluation
must be performed to locate a suilab'e replacement area If no replacement area is available a holding tank may be installed as a
last resort to rep'ace the failed POV•1'fS.
❑ Muurd and at-grade soil absorption systems may be reconstructed m place follo•edno removal of the biomat at the Infiltrative
surface Rccorstruct ens of such systems must comply wilh the rules it effect at that time
WARNING TREATMENT TANKS, PUMP TANKS, AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES OR LACK
SUFFICIENT OXYGEN TO SUSTAIN LIFE. NEVER ENTER ANY TANK UNDER ANY CIRCUMSTANCE. DEATH MAY
` RESULT. ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK MAY NOT BE POSSIBLE.
ADDITIONAL INSTRUCTIONS:
POWYS INSTALLER POWYS MAINTAINER
n
Name j~ 1 Name
Pncne S _ - 7 G p^ C, % yG Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name G
Phone - _ - Phone 7l5,~: ~'F €'n
T•iis doc.1 -,erI wigs drall,J gj Pi+_ Staffs cf the Green I a<, r•.'a•q.rette aiA 1,vaushara county POWTS regulatory agencies in con-plance with sr.-.liors
Cerln' E3 27_(2;r;b1; );djF:i': and 53 5A(1y (2.4(31 . 4b5soorsm Administrative Code.
Page of
START UP AND OPERATION
For new construction, prig to use of the Pi check t,ealrlent tank;s} for the presone o` carding products, solvents o, other
chemicals or sediment that may impeoe the treatment process andior damage the soil absorption system If high concentrations are
detected have the contents of the tanks) removed by a Septage Se'vicing Operator (pumpor) prior to use.
Pump tanks may fill above normal hig^t,a:er levels prior to startup or due to pump failures. Start up or restoration of power under these
conditions is not recommended, as Inv excess w'asle'.vator will be discharged to Yre sot' absorption system in one prce dose causing an
overload that may res.,lt in the backup r surface discha,ge o` effluent and damage to the system. To avoid this siluatioc have the
contents of the pump tank removed by a Septage Se'vic:.ng Operator ;purrper) prior to restoring power to the pump or contact a Plumber
or POb'VTS Maintainer to assist ir. manually operatnc the pump controls until normal effluent ievels are restored within the pump tank
System stag up shall not occur when soi. conditions ae frozen at the infiltrative surface.
Do no. dive or park vehicles ove' tanks or the soil absorption system. Do not drive or park over, or otherwise disturb or compact. the
area w-tnin 15 feet down slope of any mound or at-grade soil absorption area.
Reduction or elimination of the following from tine wastewater strear. may improve the performance and prolong the life of the treatment
tanks and soil absorption systcrc' adds, antibiotics, baby wipes, cigarette butts, condoms cotton swabs, degreasers, dents: floss.
d apers disinfectants fats. foundation drain (sump pump) discharge, fruit and vegetable peelings gascane greases, herbicides, meat
scraps medications. oils, paintng products, pesticides.. sanitary napkins, solvents. tampons, and water softener brine discharge.
ABANDONMENT
When the POWTS fairs andior is perrnanenlly take° out of service the following step=_ shall be taken to insure that the system is properly
and safely abandoned in companx lwth s Comm 83 33, Wisconsin Administrative Code
• Al: piping to tanks pits and other suit absorption systems shall be disconnected and I!* abandoned pipe openings sealed
• The contents of all tanks and pits shal be removed and properly disposed of by a Septage Senvidng Operator (pumper).
• 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 ine-t solid material
CONTINGENCY PLAN
If the P0'04TS fats and cannot be repaired the following measures have been, or must be taken, to p:ovde a code compliant
replacement system:
❑ A sui:aUe replacement area has been eva uated anc may be utilized for the location of a replacement soil absorption system
The 'eplacennont area should be protected from disturbance and compact.ion arid should not be infringed upon by required
setbacks from existing and proposed structwe, lot I-.res and wells Failure to protect the replacement area will result in the need
for a new soi: and site evaluation io ostablish a sadabie replacement area. Roplac-oment systems must comply with the rules in
effect at tine time of ther permit issuance.
❑ A suitable replacement area is no: available due to setback andv soil limitat-ons If the soil absorption system cannot be
rehabilitated and barring advance=_ in POW TS technology. a holding tank may be installed as a last resort.
❑ The site has not beer. cva uated to identify a suitable replacement area Upon failure of Ina PO'dVTS a soil and site evaluation
must be perfosned to Iota:e a suitable replacement area If no rep:acernent area is available a holding tang may be installed as a
last resort to replace the failed POVdTS.
Id.o.md and at grade soi absorption systems may be reconstructed ir. place following ronoval of the biomat at the infiltrative
s.aface. Reconstructions of such systems rr.:st compy win the riles i^ effect a: that time.
WARNING TREATMENT TANKS. PUMP TANKS, AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES OR LACK
SUFFICIENT OXYGEN TO SUSTAIN LIFE. NEVER ENTER ANY TANK UNDER ANY CIRCUMSTANCE. DEATH MAY
RESULT. ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK MAY NOT BE POSSIBLE.
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~
ADDITIONAL INSTRUCTIONS:
POWTS INSTALLER POWTS MAINTAINER
Name ti-1-1-114 9 Name
Phone 7115, - 76 r C `/YG Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Narr-e A
Phone Phone 715- v/C ~-C•
This do::unleot Wa6 drafted Dy the staffs of the Green Lake. Va-gwttc anc V.'adshara Coamy P01.18 regu7alory ageni it compllan~e trith sP'Aions
Comm 83.22;2);b)(1)(d)s('; aaC 835411). (2i & (3;. Wiscons n Admmishalive Code.
ST. CROIX COUNTY
SEPHC I-ANY, NIAINTL••NANCF AGREEMENT
AND
OWNERSHIP CERTIFICATION FORNI
OwncdBuyer- 9C ~t"I $j" ^av~ -
\4ailing Address )Oil Ah 1 P ~qe hur i}5 LJ qv2
Property AddreSS4 7414 I o r- 5,-t (Verification required Irvin Planning & Zoning Department for new construction.)
City 'State Parcel Identification Number lf. 0 0'7-5--
LEGAL DESCRIPTION QQ
Property Location IL( , _Nu{ !G , Sec. C . I N R I W, Town of Z yti1 ti
Subdivision Plat Lot 4
Certified Survey liap # L IF 575-7 Volume Page
Warranh• Deed # before 2007 Volume Page
Spec house yeskno Lot litres identifiable)ryes ,to
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
Improper use and maintenance of your septic system could result in its premature lai!ure 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 owt.er a,,Tees 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 (I ) 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!, full of sludge.
Iwe, the undersigned have read the above requirements and agree to ni e private sewage disposal system with the
standards set forth, herein, as set by the Department of Safery And Professiona Services a N the Department of Katt:rai Resources,
State of Wisconsin. Certification staring that your septic system has been main aincd must b ,ourpleted and returned to the St. Croix
County Planning & Zoning Department within 30 days of the three year expiration date.
I,'we certify that all statements on this form are true to the best of myour knowledge. Ilw•e am are the owner(s) of the
property described above, by vuTue of a waryazmv deed recorded in Register of Deeds Office.
Number of bed ooms J
S17CINATGRF OF APPLICANT(S) n.ATE
«««Auy information that is misrcpresentcd may result in the san itary permit being revoked by the Planning & Zoning Department.
Include with this application a recorded warranty deed fr ont the Re_•ster of Deeds Otlice and a copy of the certified survey map if
reference is made in the warranty deed.
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