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HomeMy WebLinkAbout042-1086-95-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 592132 GENERAL INFORMATION 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: Dana Cottrell TOWN OF WARREN 042-1086-95-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: app 19 a 14 31.29.18.4858 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. i Septic L r ' Qi s e/~ ! 10 00 Benchmark r U,g / ~z Alt. BMA a', Aeration Bldg. Sewer r R Holding St/Ht Inlet 74 TANK SETBACK INFORMATION St/Ht outlet 7, s9 9y Z~. TANK TO A -PA WELL BLDG. /Vent t Air intake ROAD Dt Inlet \ Septic Dt Bottom ' z_ 49"13 Dosing Header/Man. 7 $ - Aeration Dist. Pipe Holding Bot. System 12 d/ 9• y2• PUMP/SIPHON INFORMATION Final Grade .3• Z_ Manufacturer GP Demand St Cover' Jar 2O ~a0 . ~f .T Model Nu 71r \ ( JO TDH Li Friction Loss System Head TDH \ Ft Forcemain Eeq th Dia. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of its Inside Dia. Liquid Depth - DIMENSIONS 3 Z_ SETBACK SYSTEM TO ;J1 /BLDG IWELL LAKE/STREAM LEACHING ManufactuINFORMATION TCHAMBER OR 4O tem~~ . S C7 I3 UNIT Model Number 5 a v` ~ tl S DISTRIBUTION SYSTEM J / It L- f (0 3 L Header/Manifold Distribution Ix Hole Si e Ix Hole Spacing Vent to Air I ake Pipe(s) Length Dia Length Dia pacing I I., ev SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only d.*5 is A- a5 Depth Over TDe Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trenh Centerrench Edges Topsoil E] Yes E] No n Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 650 93RD ST C`~ / ~ J~_ I ~Q G►4 ~J ~ 1.) Alt BM Description = , / v \ 2.) Bldg sewer length = Agnat.re -amount of cover L+ Plan revision Required? Yes 1fCC No I f b SBD-6710 (R.3/97) Use other side for additional information. Date InsCert. No. ~~xrtntsyT RECEIVE Safety and Buildings Division ~ 201 W. Washington Ave., P.Q. Box 7162 Sanitary Permit Number (to be filled in by Co.) T~ P S ~l SEP 2 7 20 1 6 Madison, WI 53707-7162 A~i 7 Z / _3~ ST: CROIX COUNTY ~t~ State Transaction u ber 13 In ~OMM ~IIIZl 11 1011 NZSR8 WE In accordance with SPS 383.21(2), Wis. Adm. Cole, timnom, to the approprialc XFV is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are a Y Project Address (i£ different than mailing address) the Department of Safety and Professional Servies. Person ormati °)u provid4ay ba:jised for secol.- b 13,1 purposes in accordance with the Privacy Law, s. 15.04(1)(m au. OVD 1. Application Information - Please Print All ation ZS429 Parcel # Property Owner's Name ' Cj ` Property Owner's Mailing Address Property Location J2 ;t9, a- 1185 Q J Govt. Lot City, State Zip Code Phone Number 6i 5- 6L1 Section / (circle one`s Tel` N; R/ EoJ 11. Type of Building (check all that apply) Lot # Subdivision Name N..1 or 2 Family Dwelling -Number of Bedroom Block # ❑ Public/Commercial - Describe Use ~4CG ❑ City of CSM Number ❑ Village of 11 State Owned -Describe Use ❑ Town of _ 6),A-Y ACS 111. Type of Permit: (Check only one 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) - List Previous Permit Number and Date Issued B. ❑ Permit Renewal El Permit Revision El Change of Plumber ❑ Permit Transfer to New Before Expiration Owner % IV. Type of POWTS System/Component/Device: (Check all that apply) x, Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Hol mg Tank Other Dispersal Component (explain)__` ❑ Pretreatment Device (explain) _ V. Dispersal/Trea ent Area Information: Design Flow (gpd) Design Soil Application Rate( gp f) Dispersal Area Required (sf) D=AreaProposed System Elevation A t ~ ,at may- ~ VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units o New Tanks Existing Tanks v. ~A 0.U v~ ~n r/~ u. C7 0.* Septic or Holding Tank r Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWT wn on the attached plans. Plumber's Name (Print) Phimber's Signature RS Number Business Phone Number ~1 E1 ~r, rv~"sPCet ~lL t:,z S ch y-n- Plumber's Address (Street, City, State, Zip Code) VIII. tun /Department Use Only Permit Fee Dat Issued Issui Agent Si atu Approved ❑ $ ~ / en Rea=o, enial V✓' I3:. Condi as is for Disapproval 2\ itk, a ta int t or ✓ /1 3Q. P ! rtla nt irgc Osper ns i Cell must all *s per management plan pro-jided by plumber. pp~ 2 NM asefbeck reciWoements must.be mointiirisd I n per applk:atble code I tirdiniancea, Attach to complete plans for the system and submit to the County only on paper not less than 8 112 z 11 inches in size SBD-6398 (R. 11/11) c~lL = mod' i s I ~1 E G '~J ~b ~V ,ve-. Lv c d d v 4 ficC o v ST• G ~ pE E ~ ~N~ SoMMN CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: ~Z7`v-e Owner's Name: Owner's Address: 7'_ Legal Description Township: L,_r, Q ci County: Subdivision Name: /1rd f Lot Number: Parcel ID Number: Page 1 Index and title Page 2 Plot Plan Page 3 System Sizing & Cross-Section Page 4 Filter Specs Page 5 Maintenance Information Page 6 Management Plan Page 7 St. Croix Cty Septic Tank Maintenance Form Page 8 Warranty Deed Page 9 CSM or Plat Attachments: Soil Test & House Plans Designer/Plumber: t~•4 c,,,;,t ,;.icense Number: e?~ 7 cJ Dater Phone Number ins c c Signature Designed pursuant to the in-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01/01). Paae 1 u,L GC3 7rQ~~4 SCE C~3rt~ ~'T AJ Ll~cay?-`~ /v r Y3µ V sY ~ Ile- 67A T ~ e-Y i 1 Soil Absorption System Cross Section F5 ft Finai Grade k4'V' Schedule 40 C Vent Pipe th Ve nt Cap ft Leaching ► y I . ft Chamber System Elevation _ ft ft Soil Absorptlon~System Plan View ft 3 ft ft TZTrench 9 Lea Leaching Vent Or Observation Pipe Chambers 47131a. Trench 2 Header Leachina Chamber Specifications Manufacturer And Model 5 EISA Rating sq ft per chamber Soil Application Rate , 7 gpd/sq ft gpd Design Flow +_~.Z Soil Application Rate y3 EISA = ! Chambers 2 rows of /0 chambers each. 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Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank{s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA _ ❑ ear(s) Pump out contents of tank(s) When combined sludge and scum equals one-third (Y3) of tank volume ❑ NA Inspect dispersal cell(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA ❑ year(s) Clean effluent filter At least once every: ❑ month(sl ❑ NA (t 9 year(s) Inspect pump, pump controls & alarm At feast once every: ❑ month(s) ❑ NA ❑ year(s) Flush laterals and pressure test At least once every: ❑ month(s) 11 NA ❑yearls) Other: ❑ month(s) ❑ NA At least once every: ❑ year(s) 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. 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 (Y3) 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 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. 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 or other chemical that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the content 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 power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will b discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge o effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restorin power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls t 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 are 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 th POWTS; antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; far foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps, medications; of 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 i properly and safely abandoned in compliance with chapter Comm 63.33, 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 witt, 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 a code complian replacement system: ❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorptio, system. The replacement area should be protected from disturbance and compaction and should not be infringed upon b required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area wi result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems mu- 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 POWT~ technology a holding tank may be installed as a last resort to replace the failed POWTS. sit 13 Tlig sit h and ® tan ❑ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at th infiltrative surface. Reconstructions of such systIems 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 NO' ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF s PERSON FROM THE INTERIOR OF A TANK MAY SE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS - POWTS INSTALLER POWTS MAINTAINER E L Name `,ff,' u , ~,~G y Name Phone Phone SEPTAGE SERVICING OPERATOR {PUMPER) LOCAL REGULATORY AUTHORITY Name Name - Phone Phone _17165 - This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(dl&(f) and 83.5411), (2) & (3), Wisconsin Administrative Code. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Dana Cottrell Mailing Address 650 93rd Street Property Address same (Verification required from Planning & Zoning Department for new construction.) c~ City/State Roberts Parcel Identification Number ® r lo 5~ " 5- 00-0 LEGAL DESCRIPTION Property Location r 0d '/4 , 5(d , Sec. 31 , To'Z N R W, Town of f ~fd Subdivision Plat: , Lot # Certified -Survey Map # , Volume , Page # Warranty Deed # (before 2007)Volume j f "3r , Page # Spec house Dyes[no Lot lines identifiable Oyes[]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 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 ~~.after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, the undersrbned 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 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. I/we certify that all statements on is form are true to the best of my/our knowledge. I/we am/are the owner(s) of the property described above, by virtue of a w rranty deed recorded in Register of Deeds Office. 7 Nu r of bedrooms 3 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 made in the warranty deed. (REV. 04/12) IL 2342 Wisconsin Department of Commerce SOIL EVALUATION REPORT Page I of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Codf, A.C.E. Soil & Site Evaluations County Attach complete site plan ova t less than 8'% x 11 inches in size. Plan must St. Croix include, but not li ed ve orizontal reference point (BM), direction and< Par ons, n h arrow, and location and distance to nearest road. ' f. I ~ P 042-1086-95-000 7{ S 8 percent slope, 771-s-e-printaffinforynation. v Frye Date Personal ihA ation you provide may be used for secondary purposes (Privacy law, s. 15.04 (1) (m)). Property Owner Property Location Dana & Nancy Cottrell Govt. Lot NW 1/4 SW 1/4 S 31 T 29 N R 18 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 650 93rd St na na Na City State Zip Code Phone Number City Village NI Town Nearest Road Roberts j WI 54023 715-749-0138 Warren 65Th Ave. New Construction Use: ✓ Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD ✓ Replacement Public or commercial - Describe: Parent material Glacial Outwash Flood plain elevation, if applicable - na General comments and recommendations: Site suitable for conventional POWTS dispersal cell with 0.5 gpd/scIft/day loading rate. Recommended infiltrative surface elevation = 92.00'. G _t4,d,e a Boring # Boring Pit Ground Surface elev. 98.79 ft. Depth to limiting factor >125" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 1 0-9 10yr3/3 none sil 2fgr dsh cs 2fm1c 0.6 0.8 2 9-20 10yr3/2 none sil 2msbk dh cw 2fmc 0.6 0.8 3 20-27 7.5yr4/4 none sl 2msbk dsh cvr 1fm 0.6 1.0 4 27-35 7.5yr4/6 none gr Is Osg dl 9w 1vf,f 0.7 1.6 5 35:AN 10yr5/6 none s Osg dl gw - 0.7 1.6 6 -1 10yr5/4 none s Osg di - - 0.7 1.6 ❑ Boring # Boring j7' Pit Ground Surface elev. 97.81 ft. Depth to limiting factor >118#1 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. -Eff#1 'Eff#2 1 0-10 10yr3/3 none sit 2fgr dsh cs 2mf 0.6 1.0 2 10-16 10yr4/4 none sl 2msbk mfr cis 1fm 0.6 1.0 3 16-24 10yr4/6 none Is Osg ml cw 1vf,f 0.7 1.6 4 2 -76- 10yr5/6 none s Osg ml gw - 0.7 1.6 5 7 118 10yr5/4 none s Osg ml - - 0.7 1.6 oil " Effluent #1 = BODS> 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signature: CST Number James K. Thompson 3602 Address A.C.E. Soil & Site Evalweftbns Date Evaluation Conducted Telephone Number 340 Paulson Lake Lane, Osceola, WI 54020 8/22/2013 715-248-7767 Property Owner Dana & Nancy Cottrell _ Parcel ID # 042-1086-95-000 Page 2 of 3 F ]Boring # Boring Pit Ground Surface elev. _ 94.66 ft. Depth to limiting factor >98" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots PD in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-9 10yr3/3 none sil 2fgr dsh cs 2mf 0.6 1.0 2 9-30 10yr4/4 none sl 2msbk mfr cs 1fm 0.6 1.0 3 30-36 10yr4/6 none Is Osg MI Cw 1vf,f 0.7 1.6 4 36-48 10yr5/6 none ifs Osg ml gw - 0.5 1.0 5 - 8 10yr5/4 none s Osg ml - - 0.7 1.6 ❑ 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 GPDfft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz, Sh. *Eff#1 *Eff#2 ❑ Boring # i 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/fr Munsell Qu. Sz. Cont. Color Gr, Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BODS> 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BODS <_30 mg/L and TSS <30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330 (8.07/00) A.C.E. 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