HomeMy WebLinkAbout020-1166-40-300
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No
(ATTACH TO PERMIT) 582024
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:
James Berling TOWN OF HUDSON 020-1166-40-300
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
BUM 17.29.19.P1027
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTU R CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing Alt. BM v
Aeration Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD
Septic -
Dosing Header/Man.
Aeration Dist. Pipe qX7Holding Bot. u~d ! f3.2-7
Z , L
PUMP/SIPHON INFORMATION iFinrGrad6 q, o 3
Manufacturer Demand St Cover
GPM
Model Number
TDH Lift Frictionyess System Head TDH Ft 7, ` R clJl. 7 Z'~
Forcemain Le h Dia. Dist. to Well 5
SOIL ABSORPTION SYSTEM
BEDITRENCH DIMENSIONS Width 1-ength No. Of Trenches PIT DIMENSIONS No. Of PitInside Dia. Liquid Dept, h
DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: In INFORMATION Typ t r CHAMBER OR 1 1 , t Y ( {P1
'2jPl UNIT Model /b R: ~ll l/L ~d64d
DISTRIBUTION SYSTEM (~f $ 71--
Header/Manifold Distribution x Hole Size 11-11' r ole Spacing Vent to Air Inca
L-
--~Spacing Uf
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Pth Over r ' Depth Over xx Depth of xx Seeded/Sodded I't Mulched
e/Trench Center l.. • fz " Bed/Trench Edges / Topsoil Yes 1-1 No Yes No
r) U s
COMMENTS: (Include code discrepencies, persons present, etc.....)//) Inspection #1: Inspection #2:
Location: 451 BROOKWOOD DR /I l jn D ~n , /l ~fr -eq w v) l A tl d I ~i V► `a"
1.) Alt BM Description = + I/ Y I 'Ylt V ~ p 0 I 1 r fps I I A0
2.) Bldg sewer length = X (ST/J 1 t l l
- amount of cover = ~ t 0 4-V
Plan revision Required? ❑ Yes Ll.lt* } Use other side for additional informati n. J - fff '~J
Date I ctor's Signature Cert. No.
SBD-6710 (R.3/97)
Count}'
_ Safety and Buildings Division r Cli
S ) 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.)
P S Madison, WI 53707-7162
to~~
DOMMUNITSRA,i ' Illt Application Transaction Number
In accordance with SPS 383.21(2). Wis. Adm. Code, submission of this form to the appropriate governmental urrlt_
is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to ct Address (if different than math e address)
the Department of Safety and Professional Servies. Personal information you provide may be used for secondary *r
T ~1eck
purposes in accordance with the Privacy Law. s. 1.04(1 (m), Stars. '
L Application Information - Please Print All Information a ~
Property Owner's Name Parcel 4
/ t
Property Owner's Mailing Address Property Location n ~6'
1
a ! tip ✓ Govt. Lot
Cittyyy, State Zip Code /Phone Number Section
ctrcle one)
H. Type of Building (check all that apply) Lot f T c j N; R E or W
1 or 2 Family Dwelling - Number of Bedrooms Subdivision Name
r_~ 1
❑ Public/Commercial - Describe Use
❑ City of
El State Owned -Describe Use CSM Number ❑ Village of
11
i~bt~ ~ I` ♦ r L~ d ~ Town of
III. Type of ermit: (Check only one box on line A. Complete line B if applicable)
A. ❑ New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Onl} ~ Other Modification to Existing System (explain)
f'l: / j
B El Permit Renewal Permit Revision El Chantre of Plumber List Previous Permit Number and Date Issued
❑ ermit Transfer to New
Before Expiration [02,e, -4&o o 7 Z O
IV. Type of POWTS Slstem/Com onent/Device: Check all that apply
CO 6
A Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil r~! 1
❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain)
V. Dis ersal/Trea ent Area Information: ~J
Design Flow (gpd) Design Soil Application Rate(gpd Dispersal Area Required (sf) Dispersal Area Proposed (sf System Elevation
VI. Tank Info Capacity in Total # of Manufacturer 04
Gallons Gallons Units o v
New Tanks Existing Tanks 4-.
Septic or Holding Tank X
IN i
Dosing Cbamber
VIL Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print) Plumber's Si Vae MP/MPJRS Number Business PhJOne Number
Plumber's Address (Street, City, State, Zip Code)
14 I-If
N71 ao'County/Department -Use Only
~,KA pproved tsap Permit Fee Date Issued Issuin Bent Signa re
00 /a z3 /5
X75 en Reason for enial
A. Condi1MTMM1►N iWeasons for Disapproval f ZA^-Qt 1
1. Septic tank, effluent fitter and 3) r'a,. t G
dispersal cell must all be services / maintained
as per ,management plan provided by plumber.
2. Aq 1411*0k:requifemetft must be maintained
ss PK applicaae code / ordinances.
Attach to complete plans for the system and submit to the County only on paper not less than 8 1/z x 11 inches in size
SBD-6398 (R 11/11)
Pg of
Private On-Site Wastewater Treatment System (POWTS)
PLOT PLAN
FILE INFORMATION PROPERTY LOCATION
Owner ~
/a, /d ,Section ,
T ~i_ N,R /,~7 EorW
PIN # C]City, OVillage, lTown of
r/
: •
7G
rr 1
11
/900
t e' t Gt~f. !f r ~gga'l ra,, lr61%
e, is
Carn~~ -y
C~ .r7{ 1 CJ K ISM I
4- 10
01
I
i
7 r 4
l
i
ji
i
t
7
Pg of
Private On-Site Wastewater Treatment System (POWTS)
Index and Title Sheet
Owner's Name:
Z/,~
Site address: `tea PxJ~'Uif~✓C~~ ~,L/~ 1?
Location: Lot, Block Subdivision/CSM tl !1~' ~T~rl
k,
being part of the i/a of the-`-/a, Section, Town N, Range-Z;L-W,
Town of l~t?L,:: Pierce County, WI.
Parcel Identification #
Design: In accordance with Department of Safety & Professional Services (SPS) Wisconsin
Administrative Code ch. SPS 381 through 387 and 391. Design manual (choose one):
❑ Holding Tank Component Manual [VER 2.0, SBD-10855-P (N. 03/07, R. 1/12)]
❑ In-ground Soil Absorption Component Manual [SBD-10705-P (N.01101)]
Contents: Page 1:~
Page 2: `f l cen
Page 3: L ~d~s' ~.~~Icrr~
✓ JJ ~
Page 4: T rx s h u~'1/1~
Page 5:
Page 6:Cl~~i
Page 7: c,
Page 8: ~dk'z
Page 9: T
Attachments:
Plumber/Designer:.u . W*1~14' .ZV
V Signed:
Credential Number: U^e~.i`• Date:
Pg of
Private On-Site Wastewater Treatment System (POWTS)
PLOT PLAN
FILE INFORMATION PROPERTY LOCATION
Owner
1/4, '/4 , Section 17 ,
TIN, R_Zl E or W
PIN # OCity, OVillage, MTown of
7-77 root" WU T VC,
I
we-//
i
S I
- I 1
~ n5
Bo~/~~ of
sr~rn~ Q/n~~~ + wi~eSer
Tap or Ird, , 7 9a% ~ ! IObQ ~~p~,C
CKgc)// run va/(.
J4, /,q di/cr i~
041X01 )r51 Pr a~ sr t ' (2 X 1S4Ckl,5 /ax,'
V prp~~i^~ 7c1 Q Oh=1r1
row o ~ 0,h"'r`
S ~
O
1
I
i
1- or 2- Family Dwelling In-ground Soil Absorption System (1-cell Conventional)
Daily Wastewater Flow (DWF) _ # of bedrooms x 150 gal/day/bedroom = 65& gal/day
M
Design Loading Rate (DLR) or Soil Application Rate = c / gpd/ftZ (per SPS Table 383.44-1, 2, or 3)
Required Distribution cell area = DWF - gal/day _ DLR gpd/ftZ = ftZ
# Chambers = Required Distribution cell area ftZ _ ftZ/ unit EISA Chambers
Chamber Manufacturer and Model: J "7 t/ / rra X'2'"
Actual Distribution cell area = Require el cell area - ftZ + -4~~4e) ftZ/ unit EISA End Cap Pair ftZ
Cross-Section In-ground Soil Absorption System (1-cell):
4" Schedule 40 PVC
vent pipe with vent cap
12 inches minimum(
ft Final Grade Elevation
~71f inches Soil Cover
inch Chamber Height
ft System Elevation
--I
-3--ft
Leaching Chamber Width
ft to limiting factor
Plan View In-ground Soil Absorption System (1-cell):
r Leaching Chambers
4 inch Header Sch.
ft with end camps
Draw O for a Vent and for Observation Pipe above. They will be located tLnj ft from the end of the cell.
Vent pipes shall be Schedule 40 PVC and extend at least 12 inches above finished grade.
Observation pipes that extend above finished grade must also be 4 inch Schedule 40 PVC.
Page y:~ of
VOWTS OWNER'S MANUAL & MANAGEMEW PLAN Page 7_ of
FILE INFO'RMATIUN SYSTEM SPECIFICATIONS
Owner Septic Tank Capacity S- al ❑ NA
Permit # Septic Tank Manufacturer ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer f -Ml~❑ NA
Number of Bedrooms ❑ NA Effluent Filter Model 0 NA
Number of Commercial Units 9 NA Pump Tank Capacity gal Z NA
Estimated flow (average) -l gal/day Pump Tank Manufacturer 9 NA
Design flow (peak), (Estimated x 1.5) ) gal/day Pump Manufacturer RNA
Soil Application Rate gal/day/ft2 Pump Model NA
Influent/Effluent Quality (Monthly average* Pretreatment Unit .R NA
Fats, Oil & Grease (FOG) <30 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BQDS) <220 mg/L Mechanical Aeration ❑ Wetland
❑ Disinfection ❑ Other:
Total Suspended Solids (TSS) <1 50 mg/L Manufacturer
Pretreated Effluent Quality ❑ NA Monthly average** Dispersal Cell(s)
Biochemical Oxygen Demand (BOD5) <_30 mg/L ❑ In-ground (gravity) ❑ In-ground (pressurized)
Total Suspended Solids (TSS) <_30 mg/L ❑ At-grade ❑ Mound
Fecal Coliform (geometric mean) 5104 cfu/100m1 ❑ Drip-line ❑ Other:
Maximum Effluent Particle Size Y. inch diameter
* Values typical for domestic (non-commercial) wastewater and
septic tank effluent.
MAINTENANCE SCHEDULE * * Values typical for pretreated wastewater.
Service Event Service Frequency
Inspect condition of tank(s) At least once every ❑ months 0 year(s) (Maximum 3 yrs.)
Pump out contents of tank(s) When combined sludge and scum equals one-third (%3) of tank volume
Inspect dispersal cell(s) At least once every ❑ months IR year(s) (Maximum 3 yrs.)
Clean effluent filter At least once every ❑ months L~ year(s)
Inspect pump, pump controls & alarm At least once every ❑ months ❑ year(s) Z NA
Flush laterals and pressure test At least once every ❑ months D year(s) 9 NA
Other: At least once every ❑ months ❑ year(s) W NA
Other: At least once every ❑ months ❑ year(s) 4 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 sul`face. 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 (%3) 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 ch. NR
113, Wisconsin Administrative Code.
The servicing of effluent filters, mechanical or pressurized POWTS components, pretreatement components, and any
other maintenance or monitoring at intervals of 12 months or less 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.
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 chemicals that may impede the treatment process and/or damage the 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.
Page R of 8
During 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, overloading the cell(s) and may result 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) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat
scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine.
ABANDONEMENT: 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 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 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 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 that time.
❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS
technology 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.
❑ 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 CONTAIN 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 MAINTAINER
Name
Name
Phone
Phone
LOCAL REGULATORY AUTHORITY
SEPTAGE SERVICING OPERATOR (PUMPER)
Agency
Name
Phone Phone This This document was drafted by the staffs of the Green Lake, Marquette and Wausharra County Z nning nd Sanitation agencies.
of this document doeetnot
the minimum requirements of ch. Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) $ O.
Page of 8
During 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, overloading the cell(s) and may result 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) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat
scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine.
ABANDONEMENT: 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 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 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 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 that time.
❑ A suitable replacement area is not available due to setback and"/or soil limitations. Barring advances in POINTS
technology 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.
❑ 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 CONTAIN 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 MAINTAINER
Name Name
Phone Phone.
SEPTAGE SERVICING, OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Agency
Phone Phone
This document was drafted by the staffs of the Green Lake, Marquette and Waushara County Zoning and Sanitation agencies,
this doocumenttdoestnot
the minimum requirements of ch. Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative'Code. Use of
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
1 '77. 1 /9
Owner/Buyer
4 G
Mailing Address
Property Address
(Verification required from Planning & Zoning Department for new construction.)
City/State Z~/u d? Parcel Identification Number
LEGAL DESCRIPTION
Property Location '/4 , \ '/4, S ' Sec.T _,2&N R__~y W, Town of
Subdivision -por , IZ, -Y:" u) /y dell --~n/4 '~Vv/ Al19 Lot#
Certified Survey Map # , Volume , Page #
Warranty Deed # , Volume , Page #
Spec house yes no Lot lines identifiable yes 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 §Comm. 83.52(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 (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 sewage disposal system with the
standards set forth, herein, as set by the Department of Commerce 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 this 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 warr ty deed recorded in Register of Deeds Office.
Number of bedrooms
Xf SIGNATURE OF APP ICANT(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. 08/05)
Wisconsin Department of Commerce County: St. Croix
Safety and Building Division
Sanitary Permit No:
430180 0
(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 Holders Name: City Village Township Parcel Tax No:
Henry, James Hudson Townshi 020-1166-40-300
CST BM Elev: Insgp. BM Elev: BM Dcri 60 rcnge/Map tion/TowNRaNo:
elly _1 3 Z 17.29.19.P1027
TYPE MANUFACTURER CAPACITY STATION BS FS ELEV.
Septic
41 -v,.a ~ Benchmark
!7
~V Alt. BM
Aeration
Bid . er 35-
-17
Holding t Inlet G D'~ cl y 01
S Ht Outlet
g 27 q(3- `I
TANK TO VZ/LL~ WELL BLDG Vent to Air Intake ROAD DtInlet
f h ~u Qom,
Septic ` CI O ~ I ~ I I Dt Bottom f ~
Header/Man. IV
` I 3• ~f
Aeration Dist. Pipe
Holding Bot. System a
Final Grade _CX
Manufacturer Demand St Coved
Model Numb
TDH Lift Loss System Head TDH F
Forcem ' Length Dia. is .
Width + Lenfl I No. Of Trenches No. Of Pits Inside Dia. Liquid Depth
3 SYSTEM TO P/L BLDG WEL LAKE/ST EAM Manufac .
Typ Of System:
Model Number.
av, ~IDD - )k~.A-A-
36
Hea anifold Distribution x Hole Size Ix Hole Spacing Vent to Air Intake
Pipe(s
9th ~j 11-ength)
Len 12_ DiDia pacing----2
Depth Over 'e- Depth Over xx Depth of xx Seeded/Sodded xx Mulched
Bed/Trench Center S BedlTrench is Topsoil Yes No [,n j Yes r ii No
(Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:__/ /
451 Brookwood Dr udson, WI 54P16 (NW 1/4 SE 1/4 117`T~29N _R-19nW)- Park View Es aces ddn. VI Lot 110 17.29.19.131027
1.) Alt BM Description = f U ~Y-- ~ A It~ / ~0
2.) Bldg sewer length = 3&"
- amount of cover = "7 4~ -t 77 6 ~c e
iJ /No ~ i - -
Plan Use other revision side for Required additional Yes Information. U GGZ 1/~L~ - (rt. Nof.,li -
SBD~710 (R.3/97) Date Insepcto Signature Cert. No.
't Safety & Buildings Qivision
S
~~sCO anitary Permit Application AID\ 201 W. W"hin O Box Ave.
resin to accord with Comm 83.21, Wis. Adm. Code PO Box ?302
Department of commerce Personal,information you provide may be used for secondary purposes Madison, WI 53707-7302
[Privacy Law, s. 15.04(1)(m)] (Submit completed form to county if not
Attach com lete tans to the count co onl for the system. on paer not less than 8-1/2 x 11 inches in size. state owned,
County State Sanitary P emit Number ❑ Chec evision to previous application State Plan 1. D. Number
art) / '2 O
I. Application Information -Please Print all Information
Property Owner Namc Location:
a Properly Location
"I A!
Prop vowner'sMailin Addre JC j ,v~l/4J 1/4 S 1 T~9 N R'9E or W
J ~U.i Lot Number Block Number
011141/e,
City.S to G .
Zip Code Phone Su ivision Name or CSM Number
fJY Q ~ 1
II Type of Building: (check one) ~IL -ti"j ~s l p S l
I or 2 Family Dwelling - No. of Bedrooms:- ❑ City
❑ Village
Public/Commercial (describe use):'t•owr,
❑ State-owned aJ
III Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Rid S t
A) I- ❑ New System 2. Replacement 3. ❑ Replacement of 4. ❑ Addition to Parcel Tax Numbers ~JU A v
S tem Tank Only Existing System Q / to 0
B) Permit Number Date sued
❑ A Sanitary Permit was Previously issued
IV. Type of POWT System: (Check all that apply)
'Non-pressurized In-ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland
❑ Pressurized In-ground ❑ Bolding Tank ❑ Single Pass ❑ Drip Line .
❑ At-grade ix Aerobic Treatment it ❑ Re irculating Ot r
2
?(2P
s
V Dis ersaL/Trea ment Area InformnDispersal 1. Design Flow (8Pd) 2. I)ispersalArea 7Rate pplicati on S. Percolation Rate 6. System Elevation 7. Final Grade
Required ls./day/sq. ft.) (Min./inch) EI stion
b.U 93-00 78,
VI Tan k Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic
Information Gallons Gallons Tanks Con- Con- glass
New Existing crete structed
T ks Tanks 24 _
Se v .3 ❑ ❑ ❑ ❑
(z (a U) - ❑ ❑ ❑ ❑ ❑
VII Responsibility Statement,
1 the undersi nut assume res nsibilit for installation of the POWTS shown on the attached plans.
Plumber's Name rint) Plumber's Si txm..(no tits MP/MPRS No. Business Phone Number
C_ 6. fe
Plumber's Address (Stmt, City, State, Zip Code
VIII County/Depart nt Use Only
IRf, ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued 1 uin geol Signature o stamps)
Approved Owner Given Initial Adverse Surcharge Fee)
mi nation .2~ Z3j
IX. Conditions of Approval rReasons for Disapproval:'
0 L
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1
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 'D
Division of Safety and Buikftrtgg in accordance with Comm 85, Wis. Adm. Code A.C.E. Sal & Site Eval s
Attach complete site County
on on paper not less than 8'h x 11 inches in size. Plan must St. Croix
include, but not limited to: vertical and horizontal reference pant (BM), direction and
percent slope, scale or dimemsions, north arrow, and location and distance to nearest road. Parcel I. D. 020-1166-40-300
Please print all infonnation. Date
Personal information you pwide y be used fdr, samndery piupos@ lPrivecy Law, s. 15.04 (1) (m)). R By T2 3 /0
Property Owner Property Location
Jim & Barb Henry Govt. Lot NW 1/4 SE 19 S 17 T 29 N R 19 W
Property Owner's Mailing Addres# Lot # Block # Subd. Name or CSM#
451 Brookwood Drive 110 Parkview Estates 4Th Addition
City }State Zip Code `Phone Number j' J City _j Village 16 Town Nearest Road
Hudson WI` 14016 -----..715-3$6-1 20 Hudson Brookwoood Drive
j New Construction Use: Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD
✓J Replacement Public or commercial - Describe:
Parent material Glacial outwash Flood plain elevation, if applicable _ na
General comments
and recommendations: Install 2 trenches at elev. = 93.00' using 28 leaching chambers. Each trench to be 3'x 87.50' using 14
chambers per trench.
Boring # -j Boring
e Pit Ground Surface elev. 98.27 ft. Depth to limiting factor >121" in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDKF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
1 0-12 10yr2/1 noone sit 2fcr mvfr as 2f 0.5 0.8
2 12-22 10yr4/4 none sl 2msbk mvfr cs - 0.5 0.9
3 22-27 7.5yr4/6 none gr Is 0 sg ml gs - 0.7 1.2
4 27-53 10yr5/6 none gr s 0 sg ml aw - 0.7 1.2
5 53-121 10yr6/4 none s t 0 sg ml - - 0.7 1.2
I 93.0 / U. 4,lqql v'
H #3 contains approx. 1 % gr., 04 contains approx. 10% gr.
qv 2_q 2
Boring # Boring
Id Pit Ground Surface elev. 97.88 ft. Depth to limiting factor >118" in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
1 0-19 10yr2/1 noone sit 2fcr mvfr as 2f 0.5 0.8
2 19-33 10yr4/4 none sl 2msbk mvfr es - 0.5 0.9
3 3340 7.5yr4/6 none gr Is 0 sg ml gs - 0.7 1.2
4 40-58 10yr5/6 none gr s 0 sg ml aw - 0.7
5 58-118 10yr6/4 none s 0 s ml - - 0.7 1.2
H prox. 10% r_40 t a 10% gr.
* Effluent #1 = SOD 30 < 220 mg/L and T >30 < 150 mg/ fn #2 = BOD < 30 mg/L and TSS <-0 mg/L
CST Name (Please Print) >ture: CST Number
James K. Thompson `G 3602
Address A.C.E. Sal & Site Evaluations Date Evaluation Conducted Telephone Number
340 Paulson Lake Lane Osceola, WI 54020 6/252003 715-248-7767
Scale:- t-00
~o~t~1 oi0d Dave
is cam'
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ete%a~ ovii-C 6 --s
8
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o ,f•ou~~ Sty„ Arm
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Property owner Jim & Barb Henry Parcel l!) # 020-1166-40-300 Page 2 of 3
Boring # ~j Boring
-e Pit - Ground Surface elev. 97.63 ft. Depth to limiting factor >119" in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *EfI#2
1 0-16 10yr2/1 noone sil 2fcr mvfr as 2f 0.5 0.8
2 16-27 10yr4/4 none sl 2msbk mvfr cs - 0.5 0.9
3 27-34 7.5yr4/6 none gr Is 0 sg ml 9s - 0.7 1.2
4 34-80 10yr5/6 none gr s 0 sg ml aW - 0.7 1.2
5 80-119 10yr6/4 none s 0 sg ml - - 0.7 1.2
H #3 contains approx. 15% gr., # -contains approx. 10% gr.
~-S~O/91 • no
E Boring # J Boring
_f Pit Ground Surface elev. ft. Depth to limiting factor In. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots QPD/fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
❑ 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 GPDIT
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *EfI#2
* Effluent #1 = BOD 30 < 220 L and TSS >30 < 150
~ - ~ _ mg/L * Effluent #2 = BODS <_30 mgJL 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.
.d
ci~ - uimt of-isin APPLICATION FOR SANITARY PERMIT
D I L H R COUNTY
iEnT OF (PLB 67).1 J
~ OOST Y UNIFORM SANITARY PERMIT #
~ " MIDUSTRV, LR LR9O R 6 1.1~mRr7 RELRTlOr15
s'~/966
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 81/2x 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY OWNER MAILING ADDRESS
Sal I RA0 ,80 _"'Z p' Z_
PROPERTY LOCATION
G!/114 5E 1/4, S , T , N, R 8(Or)
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
E IC
~fo
TYPE OF BUILDING OR USE SERVEDU ~l
1 or 2 Family Number of Bedrooms: L Public (Specify): -
THIS PERMIT IS FOR A:
New System ❑ Tank Replacement ❑ Repair
Replacement Soil Absorption System ❑ Revision ❑ Privy
❑ Alternate System ❑ Reconnection ❑ Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank
System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy
❑ Existing, For Which A Previous Permit Is On File, Permit # issued -
D An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions.
Total #of Prefab. Site
Gallons Tanks Concrete Constructed Steel Fiberglass Plastic
Septic Tank Capacity d OO
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer: `d
IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure
NA Total *of Prefab. Site Steel Fiberglass Plastic
Gallons. Tanks Concrete Constructed
Septic ank Capacity
Lift ump/Siphon Chamber
Ma facturer:
(M0 sTION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY:
Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet):
& Private ❑ Joint ❑ Public
/ 1, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber (Print): Signature: MP/MPRSW No.: Phone Number:
~1~J'1 M 3: (Lys 3 z 3
Plumbe Address: Name of Designer:
Nuv
J 17 wf s x•
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date:
❑ Disapproved
1-4 1 13- ❑ Owner Given Initial
~Approved Adverse Determination OF .01'
Reason for Disapproval:
Alternate course(s) of Action Available:
DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR ~f SAFETY & BUILDING:
LABOR 8; HUMAN RELATIONS
DIVISIOP
P.O. BOX 7969 PRIVATE SEWAGE SYSTEMS
MADISON', WI 53707 BUREAU OF PLUMBIN(
M~CONVENTIONAL ❑ALTERNATIVE State Plan l.D.Number.
❑ Holding Tank F-1 In-Ground Pressure F-1 Mound (If a,.lanedl
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER
;INSPECTION DATE:
Sam Miller Trout Brook Road, Hudson, WI _
BENCH MARK (Permanent reference point! DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.
NW SE, Sec.17,T29N-R19W,Town of Hudson,Lot#110,ParkView Est. IV
Name of Plumber: MP/MPRSW No.
County: Sanitary Permit Number .
Douglas Strohbeen 5432 St. Croix 54966
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY- TANK INLET ELEV. TANKKJ~OUTLET kLLEV WARNING LABEL LOCKI D.
NG COVER
~ / ~,,~~r,,.P OV OEO PROVIDE
ifV YES ❑NO ❑YES ❑NO
BEDDING: VENT DIA.: VENT MAT HIGH WAT R NUMBER OF ROAD: PROPERT WELL. BUILDING. VENT 70 FRESF
ALARM FEET FROM LI E' AIR'NLET'
YES ❑NO ❑YES ❑NO NEAREST p~
D S NG CHAMBER:
MANUFACTURER. BEDDING: LI0U11D CA P AC17v PUMP MODEL. PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PROPERTY WELL BUILDING. VENT TO FRESF
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET
PUMP ON AND OFF) ❑YES ❑NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH DIAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire, construction shall cease until
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
BED/TRENCh1' WIDTH LENGTH NO. OF DISTR. PIPE SPACING. COVER - INSIDE DIA *PITS: LIQUID
TRENCH E87 M L: I,I,T DEPTH.
D1Mi5NSIC7INS , (J/)
GHELWPIPS AVELL DEEPTH FILL DE H DIST PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER OF ` PROPERTY WELL. BUILDING: V NT TO FRESI
BUVEC VE12: ELEV. INLET ELEV. END PIPES FEET FROM E AIR INLET.
9~ 0 NEAREST
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
meets the criteria for medium sand. TIONS MEASURED.
❑
OIL COVER TEXTURE PERMANENT MARKERS: OBSERVATION WELLS
❑YES ❑NO ❑YES ❑NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED SEEDED IMDLCHED.
CENTER EDGES:
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH LENGTH NO OF EELEV. ING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER
TRENCHES:
DIMENSIONS ' .
MANIFOLD PUMP MANIFOLD MANIFOLD MATERIAL. NO. DISTR. DISTR. PIPE DISFR IBU TI ON PIPE MATERIAL & MARKING:
ELE V.. ELE V.. DIA. PIPES. D
ELEVATION AN IA. :
DISTRIBUTION
INFORM,ATIOy, -HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS.
❑YES ❑NO ❑YES ❑NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBERPROPERTY WELL: BUILDING:
FEET FROM", LIE.
❑YES ❑NO ❑YES ❑NO NEAREST
Sketch System on Retain in county file for audit.
Reverse Side.
SI NA U E: TITLE
DILHR SBD 6710 (R. 01/82) 4~t -
Form - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER _50 TOWNSHIP L ' N a/ SON SEC. 17 T alf N-R I W
ADDRESS A q I D,F S~ ST. CROIX COUNTY, WISCONSIN
4.4 k S a r V / r s c o n S f rt
5' gof G
SUBDIVISION p,A l'n V P i w LOT [ (b LOT SIZE.
5 ~a (vq
PLAN VIEW
Distances and dimensions to meet requirements of H 63
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
r
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- Al o o A L- ~ t L r h
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INDICATE NORTH ARROW
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DEPARTMEN70,~ PORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUS TRY, DIVISION
LABOR AN P.O. BOX 7969
HUMAN R'E XIONS eo 1.r J ERCOLATION TESTS (115) MADISON, WI 53707
(H63.09(1) & Chapter 145.045)
LO AY ON: SECT TOWNSHIP/I...... G~AthTY: OT No .:BLK. NO. SU DIVISION NAME:
COUNTY: AME: MAILIN ADDR SS:
'Wig
USE DATES OBSERV IONS MADE
NO. BEDRMS : COMMERCIAL D SCRIPTION: toy PROFILE D ONS: TESTS:
Residence ,piNew ❑Replace 7_~
RATING: S= Site suitable for system U= Site unsuitable for system r Ogg
ONVENTI NAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-1 -FILL 0LDING TANK: RECOMMENDED SYSTEM: (optional
R S DU &S FA
; S ❑U ❑ S 1RU ❑ S RU
If Percolation Tests are NOT required DESIGN RATE-
If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: 401/~
P FI E DESCRIPTIONS
BORING TOTALS ELEVATION P H T R UNDWATER-)MP= CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH OBSERVED S IGHE TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- / j ? 7.,; 1 0 7,~.T' d- 6 /s/, . 7 40A s/, . s e,% /f, 3.4 An cs t~r~
- Co 16
B- •Z , f' , , /•,t 8/ s&.r/, . 7 /'x ,S 6n CS V~* rJ
-0,07 a7 opt 0.9
B- -3 We-Ace -49- / ee k,
B-.~ S' er 7 S' .7 ~~I~ c /3n /fi 7 c
B-
PERCOLATION TESTS
TEST DEPTHO WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER W4Qk FC AFTER SWELLING INTERVAL-MIN. P 10r) 1 P R10132 R PER INCH
P- o L 3
P- •Z OX L 3
P- ~ p 62 6 <.3
P
:P
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION Tees 7 f _ ; - . _r
V -
F
• f I
7 I
I
I 1 I t J -
I
i
-
- I O
1 Itynl 1