HomeMy WebLinkAbout030-2110-60-000
. Croix
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St
Safety and Building Division Sanitary Permit No:
INSPECTION REPORT 592104
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:
John Gavic TOWN OF SAINT JOSEPH 030-2110-60-000
CST BM Elev: Insp. BM Elev: BM pescription: Section/Town/Range/Map No:
06.29.19.910
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
5V Benchmark 'hto, OD,
Septic ~ - i1. !5' A V l/
Bldg. Sewer I I
t ye 4~ 12124 /0,5 , l o
J• 41 1QOI 6 5.1
TANK SETBACK INFORMATION t Outlet l
TANK TO 'lP/ WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic Dt Bottom
Dosing r Header an. Qg,
Aera on Dist. Pipe , M to
Holding Bot. System (J(o 10- 7 17,7
Grade / /y 166,22
PUMPISIPHON INFORMATION Final Manufactur Demand St Cover
Mode umber J { V
TDH Lift Friction Loss System TDH Ft
Forcem in Length Dia. Dist. to Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Le Eth~ ` No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Di;, Liquid Dept
DIMENSIONS
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufa c
INFORMATION CHAMBER OR
T p f System: UNIT Model Nu r: ; ~
QJM, IBUTION SYSTEM b 613
ead anifold Distribution x Hole Size x Hole S acin Vent to Air Inta e
if Pipe(s)
Length Dia Length is 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 I Bed/Trench Edges Vy Topsoil Yes No L] Yes [ No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: /
Location: 333 BUCK RUN r h /4' S j a 6
1.) Alt BM Description= r1~,~ Cov p V 0 ttl~i~ V"`
2.) Bldg sewer length = j~ I (
- amount of cover = aV lH~Cd~ 1 J 1Y vl InS ~~e W h br Zo~nn►1 WAS
HV, 9 Cover o all !
Plan revision Required? [ YesI to l I
Use other side for additional information.
Date ~Va-r's Signature Cert. No.
SBD-6710 (R.3/97)
I
J Count? REQUVW 1"
Safety and Buildings Division P
_ST C, 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.)
AUG Madison, W 707 7162 q7
rya / 4
ST. GF(dIX COU 3GEH5 ,
unitary Permit Application MJVR2~;7J State TrarrsactionNumber
In accordance with SPS 38321(2), Wis. Adm. Code, submission of this form to the appropriate govermnei,.... R4
is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to Project Address (if different than mailing addre:
the Department of Safety and Professional Servies. Personal information you provide may be used for secondary
purposes in accordance with the Privacy Law; s. 15.04(1 m), Stats. tjL Rio,%
L Application Information - Pleas r t All Information
Property Owner's Name ' Parcel #
03 6 -21 10 ~66-0M)
Property Owner's Mailing Address
n n property Location e r , l ~i.9 e
C lRe Lic Govt. Lot-~~
City, State Zip Code Phone Number S J `y
`h, Section (p
r 1 1 F /J~~ W IV " T ~Q' R fq (cycle orb
~p
11. Type of Building (check all that apply) Lot # N.
or 2 Family Dwelling - Number of Bedrooms Subdivision Name
~
`f/ n, Block # ADGER, D Public/Commercial - Describe Use ❑ City of
❑ State Owned -Describe Use 6SM Number D Village of
Z l.J * CL. ` Town of ~ 171
0'isk-CeU6 IZ7Z7 ,Aft" ;Z _ pI 1
LL -
III. Type of Permit: (Check only a box on line A. Complete line B if applicable)
A' )(New System D Replacement System D Treatmer t/Holding Tank Replacement Only ❑ Other Modification to Existing System (expl.
B. D Permit Renewal D Permit Revision D Change of Plumber D Permit Transfer to New List Previous Permit Number and Date Issued
Before-Expiration Owner I t, 11
A'. Type of POWTS Svstem/Com onent/Device: Check all that apply)
KNon-Pressurized In-Ground 11 Pressurized In-Ground D At-Grade D Mound > 24 in. of suitable soil D Mound < 24 in. T suitable oil~'v
D Holding Tank D Other Dispersal Component (explain) Pretreatment Device (explain) 4- C12 (5
V. Dis ersal/Treat ent Area Information: J A
Design Flow (gpd) Design Soil Application Rate( f) Dispersal Area Requir Dispersal Area Propo (sf) System Elevation
D71 > / 071 VL Tank Info Capacity in Total # of Manufacturer
Gallons Gallons Units o a r
New Tanks Existing Tanks n
a
ir. c3
d 3f k, U y 75
Septic or Holding Tank { j C I {wV p
r
Dosing Chamber 66J
VII. Responsibility Statement- I, the undersigned, assume responsibility f installation of the POR TS shown a attached plans.
Plumber's Name (Print) Plumber's S' ature MP umber Business Phone Number
Plumber's Address (Street, City, State, Zip Code)
V10 - 6_6 S_ VV( Is 1~ 00
VIII. County/Department Use Only A
-Date u Issuin ent Signature
Approved D Permit Fee Od Z 1
tven Reason for Denial dV f
DL Conditions of Approval/Reasons for Disapproval I ow
4 M G- kV AftS7' G /YiNGj Q a A27~fZ S 1. 'tom +oM rtttaE t4
ATr Si n w cT U 8,64. 1 - 1 pno*kd by'pbw.
/N o SE r iC2
2 >
ao Nr,,plio~eU oedR ~ a~t1eK.
3) Ch to com leA to plans for tlf system dap submit to.the County o on piper not less than 8 in i 11 inches in size
a O ~truS 4rLzw%• VM kk.~ r~...
SBD-6398 (R. 11/11)
4J Qom` 76 30
7 u - 1'1n arK,Q~ D 7uF J~ ,a .
v
r
1 /
1. P ~3 70" 1
C4,! p
la kl
L
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ct.
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zt o ac
41 -a.
PAGE 1 OF 4
In-Ground Gravity Plan
Index & Cover Sheet
Component Manual 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:
Ct~' ` (I) POWTS Application for Review
Evaluation Report & Site Map
Project Name / Description
Owner Name(s): I~ Phone: - -
Owner Address: - ~ Ct"Z ,C -4y()5610 W f Zip: -S-410)
Project Address: &JCxRvI-S +AUG&cp IV( gziolto -1
Govt. Lot: Se7 1 /4 of 1/4, Section_ , T?q_N-R/_E or W
Township: County: '8 C
Project Parcel ID 3C) I j 0 0 -6 t Q
Designer Information
Designer Name: Jk-`F y F(-) Phone: I NI -31,58
Designer Address: PCB- ~OX 5~ S DW-5Ee Zip: 51100 2
E-mail: This space reserved for approvat stamp.
License Number: I~ P 9.!S: Z
Remarks:
Signature: J7Y Date: .;k 71k
Ori al gnature required on each submitted copy.
V
CF~
VI
VII
7~
42,
~ E
r
rj
J
Soil Absorption Svstem Cross Section
'10 ft
4- SW iedtde 40 Final Grade
PVC Vent Pipe
With Vent Cap ft
Leaching
Chamber ft
System Elevation
ft ft
Soil Absorption System Plan View
~Z ft
ft Leaching Trench 1
Vent Or Observation Pipe Chambers
IIIIHMI III 4°Dim
Trench 2 Header
Leaching Chamber Saeciftcations
Manufacturer And Model -J Q I- IL ATQO- &OC, K C./
EISA Rating sq ft per chamber Soil Application Rate gpd/sq ft
jr1 gpd Design Flow Soil Application Rate = '70 EISA Chambers
2 rows of 7 chambers each.
Page of
POWTS OWNER'S MANUAL AND MANAGEMENT PLAN
FILE IlvF_ORMATiON SYSTEM SPECMCATIONS
Owner U Septic Tank Cap!Eity gal D NA
Permit # c Tank Manufactarer 0 NA
DESIGN PARAMETERS Effhient Filter M L C M NA
Number of Bedrooms 100 p NA Effluent Filter Model Z ❑ NA
Pump gm 921
Tank aci 2L NA
Number of Caner aer9cial Units NA
Estimated flow (average)* ; gaYday Pump Tank Manufaat>m CINA
Design flow (peak), estimated i-1.5* -I 6~6 Vda Manufacturer a[NA
Soil Application Rate Uda Model
Pretreatment Unit J9rNA
Influent/Effluent Quality (NAM) Monthly Average** ® Sand/Gmvel Filter E3 Peat Filter
Fats. Oil & Grease (FOCI) 5 30 mg/L M Mechanical Aeration O Weiland
Biochemical Oxygen Demand (GODS) < 220 mg/L O Disinfection p Other:
Total Suspended Solids (TSS) Manufacturer. Model:
5 250 mgtL D' ersal Cell(s)
Pretreated Effluent Quality M Monthly Averages**
In-ground {gravit3►} D bgrmmd (P)
Biochemical Oxygen Demand (GODS) < 30 mg/L ❑ At grade 0 Mound
Total Suspended Solids (TSS)
Fecal Coliform (geometric mean) < 30 mgjL D'
<10 cfu1l00mI C1 Leaching Chanta Manufactured' ki Fl
Maximum Effluent Particle Size 118 inch diainetr Model r~V ~ K Laying Lengdi/C2iamber
*Wastewater Flow Verification and Calculations: Soil Application Rate/$ Area Req. 71 fe
(Other than bedroom based) Infiltrative SurfaceJChamber-ESIA Rating fe
Minimum Number of Chambers
® A"ylate Des' Flour Rates min
Values typical for domestic (non-commercial wastewater Materials: all inaftials must comply with WI Adm. Code
and septic tank of Ittent. COMM84 and be installed per m ens specifics*w
***Vahws qj~ical for Prefteated wastewater. and letters.
DESIGN CRITERIA
❑ "Wisconsin At-grade Soil Absorption System, Siting, Design & Construction Manual" (Converse etal.1990)
p -Wisconsin Mound Soil Absorption System: Siting, Design & Construction Manual" Converse, J.C. and EJ. Tyler.
Publication 15.22
C3 -Design of Pm mm Distribution Networks for Septic Tank-Soil Absorption Systems„ Publications 9.6
E3 "Design of CowmntionaI Soil Absorption Trenches and Beds". R.J. Otis - ASAE Publications 5-77 and "Design Manual -
Onsite Wastewater Tmatment and Disposal Systems". EPA 625/1-80-012 October 1980
E3 SBD -1057" (3.6199) "At Grade Component Manual Using Pressure Distnbution"
C3 SBD -10567--P (8.6199) -In Ground Absorption Component Manual'.
C3 SBD -10705-P (N.01101) "In Ground Soil Absorption Component Manual" Version 2.0
® SBD -10628-P (N.6/99) "Recirculating Sand Filter System Component Manual"
O SBD -10656-P (N.6199) "Split Bed Recirculating Sand Filter System Component Manual"
p SBD -10572 P (k.6199) "Mound Component Manual"
SBD - 10691!-P (N.01101) "Mound Component Manual" Version 2.0
p SBD - 10:595-P (IL6/99) 'Single Pass Sand Filter Component Mannar
D SBD - 10657-P (3.6199) -Drip-line Effluent Disposal Component Mannar
D SBD - 10573-P (R 6199) "Pressure Distribution Component Manual"
p SBD -107 ' (N.0 1(01) `Tic ore Distribbution Component Manual!" Vcraian 2.0
Q Drip-line Ef@uent Dispersal Component M utal for Multi flo Onsite Wastewater Treatment Units
MAINTENANCE AND MANAGEMENT
MAINTRNANCE MONITORING" SCHEDULE
Sa rvice Event Service Fralumey
Inspect condition of tmlqs) At least once every r3 months CZyce, s 3
Pump out contents of s When combined sludge and scum male one-tldrd 113 of tank vatttme
s At least once every p months s 3
Clean effluent filter At least owe ev Cl months s
Inspect pump~ pump controls & alarm At least once every O months ® a O NA
Flush laterals am ptessm test At least once every C3 moil D you Q 3 NA
• t.9 . ,i tPAC! nVU-M P'VP"P1r rl months ❑ vear(s) 0 NA
® Mound, At-Grade, In-Ground Pressure
Thee inspection shall include recording the levels of ponding, if any in the observation tubes and a visual inspection for any
evidence of surface seepage or discharge. Any discharge to the ground surface must be promptly reported to the regulatory
authority. Ponding greeter than 756 of the height of the component may indicate overloading or impending hydraulic failure
neitating more frequent monitoring.
The pressure distribution system is provided with an opening at the end of each lateral to be used for flushing. Thu laterals
should be flushed at least once every three (3) years. Pressure checks of system with multiple laterals should be done to
ensure that equal distribution of effluent is occurring to promote the longevity of the system.
REPORTS
Reports for maintenance, inspection, and monitoring shall be submitted in accordance with COMM 83.55 Wisconsin Administrative
Code.
ABANDONMENT
When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to ensure that fire system is
properly and safely abandoned in compliance with Ch. COMM 83.33, 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 other inert solid material.
CONTINGENCY PLAN
If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant
replacement system:
p A suitable replacement area has been evaluated and may be utilized for the location of a replacement sod alon system.
The replacement area should be protected from disturbance and compaction and should not be inf miged upon by required
sedmis from existing and proposed structure, lot lines and wells. Fm7ure to protect the Teplacement area vn11 resole in the
need for a new soil from existing. and proposed structure, lot lines and wells. Failure to protect the reps area will
result in the need for a new soil and site evaluation to establish a suitable replacement area.. Replacement system must
comply with the rules in effect at that time.
CI A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS bonology a
holding tank may be installed as a last resort to replace the failed POWTS.
® 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.
p 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>> SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTIAN 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 MAMAINER
Name - Fc:1C [Name
Phone -7 S° q1t S Phone
S3~PTAGE SERVICING OPERATOR LOCAL REGUI ATORY AUTHORTPY
Name A 1u U
Phone Phone