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HomeMy WebLinkAbout040-1310-00-026 County: St. Croix Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division Sanitary Permit No: 5921 38 INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No NA Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 11 Parcel Tax No: Permit HEEIev: s Name: City Village Township 040-1310-00-026 DaviDarlene Broughton c/o McCoy TOWN OF TROY No: CST BM Insp. BM E lev: BM Description: Section/Town/Range/Map No- 9.201 3 TANK INFORMATION ELEVATION DATA CAPACITY STATION BS HI FFS ELEV TYPE MANUFACTURER Benchmark 4 Septic N : . 00, I @0 51 Alt. BM Ion Bldg. Sewer H ~ N a, t Inlet ~ . St/ t Outlet I~ TANK SETBACK INFORMATION TANK TO P WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic 1 Dt Botto . 'J H Dosing m / Dist. Pipe ' 1-l •7~ Ns 7 Aeration Holding Bot. System / ~ / T r~~ Final Grade 9y v PUMP/SIPHON INFORMATION Manufacturer D nd St Cover • ( J , OS PM t G Model mbEDDia. TD Lift System Head TDH Ft Forcemain Dist. to well r SOIL ABSORPTION SYSTEM PIT DIMENSIONS No. Of Pits / Inside Dia. Ld Dept BED/TRENCH Width Lengt No. Of Trenches DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/ EAM LEACHING Manufacturer: ' YA CHAMBER OR INFORMATION Ty eOf,S st m: NA- UNIT M Nulnb /L) D BUTION SYSTEM 01/y' S acin ven to Air Int ke l~3 ea Manifold Distribution Pipe(s) ~j([ Length Dia Length Dia Spacing SOIL COVER X Pressure Systems Only xx Mound Or xx Seeded/Sodded xx Mulche h Depth Over epl of Dept /h Over C Bed/Trench Edged Topsoil Yes No L Yes No BedTrencenter ~I Inspection #2: COMMENTS: (Include code discrepencies, persons present, etc.) \ Inspection #1: Location: 316 MEADOW RIDGE CTw 1.) Alt BM Description 2.) Bldg sewer length - amount of cover cove r On Ot l -6%tAA ~a4eQ Plan revision Required? Yes `N-o f Use other side for additional informatidh. nsepctor's Signature Cert. No. Date SBD-6710 (R.3/97) s 59 - ti SEf[] ~ 6 '101 eJ r ,r v(t ttmgttart A ti e ~3~ L ac~x , I ' Santt ter' Permit dumber (u ;,t .illw Co S _ ST. CROIX COUNTY - -1 f? _~~~{~apuH1TY DEVELOPMENT 6FY, " ` M ` X9213 tct c un)h.r Sanitary Perms Appi>: ~tkOq~ State at) - in accordance ttith SPS 383 21(') It is. Adm. Code, submission of ibis torn to i cn Y~ -al unit I i .jpp to atnr( prior to obtaining a s mt9, . rrrmi<. Note ' licatton lieu s fi?r state ,he Department ol's stet} and Professica al Services Personal nttbrrnauon you prof tde mabe used io, ,econdarv F r°j~ct :-+ddn s t.; Jtltercnt t tatt maihn address) -purposes m accordance (with the Fri acv La s ,--l 04(1)(nt) St.ts I Application Information - Please Print All Inform ttion - ,lyEldarJ/CfGE i'ropcriy :harper ;Nam rw ovnT Q'• I ~ ~~yy ,,rr - mar L 1 +JlQ ~l2o46yTa.~ G~6 /!tCa.t~vlciC LrLR3Slc CaJSrcdcrIoJ C 3ia" op" ~~[c i rn - - - ' crta CJac,t~r s AI p t t Au~ress r!~ syo/~ op $ 13 Ttp : od:. Phone ;Juittber i- SL` section / 7 7 , - I_ /is ~Co-aa~r faircSconel + - II. Type of Building (cireek ail that app[}') ~ o, 1;- 91 or 2 Famih Daael ling - Number ol` Bcdrnonts _ - subdn°isron Name ~k ad I ,.ao~ V j Public;Lone-terciai - Describe Use lQLE---~2~k-~~ i - Slate Owned i-v umber -r ill. Type t t t'ermit: (Cheel: only ne box on fine.%. C-omplete line H ii-appficabie) - 1e % SvgeRt 1 r ❑ f2ep!acetncni System i'reatment/I fulding Tank RePlacemcnt Only - 1 ~ I ~ ❑ Other tilodificatian to }sawn+.; Sv'stem (explain, H. ❑ Permit Rcneacal j ❑ Pcmit Revision ❑ Change of Plumber ❑ (e-nnit Transferto '"~List Previous Permit Number and Date Issued I eu Bet ore Expiration U )er r IV "I'Vpe of POW FS Sysfern%C:nmponrntlDc t ice: ((:heck all that ripply.) - - - - XNon-f'ressuriced in (round ❑ Pressurized In-Ground E-1 .At-Grade F-1 Mound 2' in. o suitable soil ❑ VI(nm(1 _s in. ! suiLshlc sort. - v i Holdin_ t m1}: L C~thcr Disl r .al Component (explain) - i'rc're .,unent Dcaice(t,xplain) V Dispersal~t71c' a Information: oL- (oil rioni cat n [ - hsf, Dis cis^! area Rc I I i Jtstct;t i.,ecation P f i ,S ~~-aul : c~trtlx_ -i_u _ YSa • 7 . ~P~P G y~ ` I ~1. Tank Info ailons 11 Gallons ( 11 Its I - 'stu TCnks ~ f i = I - - £sasunt, tanks l //hhJJ _ J _ f j f V l ~ u v, - ` esponst ilityStatement- t, the undersigned, assume responsibi6t>for installation of flu f ©L1 'I'S shown on flu attached laps lutnhers Name (Print' Plumber's turc - -13~ ' - t us Hess l hone Number _-7~of~.~ ~GkE a~3r3YL 715- G7,7-S,?44 Humher s Address (Street. City, State, Lip Code) _ ~8 fir. wr y a75} uR Aa0 G1` Z ,5-Y7,3 L _ o fII. nt1•/De~rtment Use Only Rp core qpi~, Pem ~ ! Dat t•; ~ rtl isswn•> 5, - - p }te um for DenialS Condi ra cavc~pf I?'s spproi sl - - - 1 - ilia er ,i cell st al, SPIO'lCr S . ma 4nta rec jail Rr, q►@FNeM@ pI TRr ?tdpt 'piwnti~a4 2. II:M ` rgy~ ; g RIDS be1`4nt'ctr,Frf Atf..ch u:, con, ,Ictc plans rur the s-1-1 f _ rt :n the C ,unrv -,nl : n etaper not 11e. 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O w i > ! ~ w 0 ~ L J V I < w C O c 1? y r a N ; N cl: I =t ~ LLJ ° Q w f t s svo I 'e\ F 1' 3~ I .7 cf w U ii u it I 7D :j „Q8 „ 9 I L1 C i Page ~t ''ILE i I,FORWIA ION SYSTEM SPECIFICATIONS I Owner Au1D 0 G6 ;-6 Tank tvianuiacturer, ()/,5-szx Conlce~ErE 0 NA j Per t i t'tSeptlc [I Dose El Holding Vplume: Per (gal) DESIGN PARAMETERS Tank lvianufaliurer. '-5?'NA Number of Bedrooms: ` ,3 ❑ NA 0 Septic C1'Dose 0 Holding Volume: {gaq i Number of Public Facility Units: Vertical Distance T o nk Bottom(s) to Service Pad: /17- r Estimated (average) F low : cairaa lorizontol Distance Tank(s) to Service Pad: } ~d4 t_ y} t /oa Design (weak} ciO;.t = (estimated 5 : i 1 Specitrc otr,AGing mechanics must be provided if vertical is 115 i et or - V11-0 i If n„tizon.ai is ,50 feet. Specific instructions to be provided on bzck. j In Situ Soil Application Rate: . 7 (gal1dav1ft-) fluent Filter Manufacturer: ,d ESr Standard (Domestic) Iniueni`E17uefi Monthly average ; iluent Filter fvlodel: 1114' r=ats, oil & Grease (FOG) <_30 ma/L I Pump lvlarnuacturer. Biochemical Oxygen Demand (BOG;) !5220 mgiL ❑ nl,`: - ~ iy,, tital Suspended Sclids ; SS) g,~ n 'i j ; Pump IVlOde{: high Strength Inrluent/Effluent h,ionthly average Pretreatment Unit (FOG) >30 mo!L Manufacturer. i (SOD>220 mg!L X -A iVA f TSB) >180 mgiL # ❑ Mechanical Aeration ❑ Peat Filter i °retreated Effluent ! I Disinfection , vvetiand Monthly average Sand/Gravel Filter C O.ner. E3 O s30 me%L i Soli Absorption System T SS) s30 m'^/L a NA Fecal oliform (geow etrir mean; <i0` in-Ground (gravity) [j' in-Ground {presspre) N I I t4 I i L At Mound `liaXlCnUm Ci ~ilc"'ni Particle S;Zc i6 in dia. L„ NA l [1 Dr fc-Drie ~ Other: I Other- ] El Other; L NA Nn D iAINTENANCE SCHEDULE Service Event ' SP erAce Frequency Pump out contents of tank(s) i Y%Nhen combined sludge and scum equals one-third (,3) of tank volume 27 When the high water alarm is activated l Inspect condition of tank(s)t t {east once ever;: (PiIa !mum 3 years) _ N.q -3 0 year(s) inspect dispersal cell(s) At least once every: El month(s) (Maximum 3 ears~ ~ t o i 3 RD year(s) y ) I Clean effluent "slier At least once ve e 12, month(s) i rv: [~f , L year(s) i n month(s) %sc'ect pump, pump conlrolS ~ ct2rM 1 At l=ast once every. l~A i;.! year(s) i. Lk, month(s) I--lush r-lush laterals and pressure test _ At least once every--. Other: months) I At least once even,,: ❑ year(,, L N;' i, . jqi Ai NTEhNIANCE IPiSTRUCTIOINIS >7°Cil'J115 O igil'KS and soil aC' is SQrptiQtl Sw leM,; Shad be Made by all individual i07virlg ptlP Of the 01I0`NipS, liGBnsca' or cer i icet c' s. sster Plumber, piaster Plumber Restricted Sever, PORTS Inspector, P0VrrS Maintainer or Septage Servicing Operator (pumper;_ ark inspections must include a visual inspection of the tank(s) tg id<ntit-y any missing or broken hardwara, identi;Ry any cracks or leak=. -_=sure the volume of combined sludge and scum and a check, for any beck up or ponding of effluent on the around sur`ace. The =_csorption system shall be visually inspected to check the effluent levels in the observation pipes and to check for any pondinq of ettiue;~- i e around surface. The ponding of erluent on the ground surface may indicate a fatting condition and requires the immadia, ~-_dflc2tion Oi the local regulatory authority. A, in the combined accumulation of sludge and scum in any treatment tank equals one-third or more of the tank volume, the enti contents of the tank Shall be removed by a Septage Servicing Operator (pumper) and disposed of in accordance with chapter NR "'di cousin Administrative Code. All other services, including but not limited to the servicing of eiilueni fitters, mechanical or pressurized compose is and anv servicing at intervals o, <_12 months, shall be perfom ed by a certified POVTFS Maintainer. ~p r Cc 'fit shall d D.. Dr0 Y8C l iu t,, : x. „~G e vIL ! ah° iJi;al r°gU.2iOr`+ ;uthori., :.'!thin 30 days Of ; :ornclehen a. ary service eve- 'PT UP AND OPERATION J [n Por new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products, solvents or other chemicals or sediment that may impede the treatment process and/or damage: the soil absorption system. If high concentrations are .:elected have the contents of the tank(s),-emoved by a Septage Servicing Operator (pumper) prior to use. Pump tanks may fill above normal highwater levels prior to startup or due to pump failures. Start up or restoration of power under these conditions is not recommended, as the excess wastewater will be;discharged to the soil absorption system in one large dose causing an L'verload that may result in the backup or sur ace discharge of effluent and damage to the system. Tg avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator (pumper) prior to restoring power to-the pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls until normal effluent levels are restored within the pump tank. -c . -m star' p shall not occur when soil conditions are frozen at the inilltrative 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 r ea 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 treatment :arks and soil absorption system: acids, antibiotics, baby wipes, cigarette butts, condoms, cotton swabs, degreasers, dental doss, a^ers, disinfectants, Pais, foundation drain (sump pump,: discharge, fruit and vegetable peelings, gasoline, greases, herbicides; m.ea_ -craps, medications, oils, painting products, pesticides, sanitary napkins, solvents, tampons, and water softener onn; isc^ar ~:drar~tDONTyi1=i~T then the POUFS fails and/or is permanently taken out of service the following steps shall be taken to insure s: -D safely abandoned in compliance with s. -5&383.33, Wisconsin Administrative Code: =d1 piping to arks, pits and other ;oil absorption systems shali 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 (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 inert solid material. -ON i INGENCY PLAN if the POWTS fails and cannot be repaired the following measures have been., or must be ?t i - y ;^,il ^i'. replacement system: 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 neec. ror a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules it effect at the time of their permit issuance. suitabie replacement area is not available due to setback and/or soil limitations. lF the soil absorption system cannot be rehabilitated and barring advances in POWTS technology, a holding tank may be installed as a last resort. The site has not been evaluated to identify a suitable replacement area. Upon failure of the PO%AJTS a soil and site evaluation must be per om?ad to locate a suitable replacement area. if no replacement area is available a holding tank maybe installed as c last resort to replace the failed POWTS. krround and at-grade soil absorption systems may be reconstructed in }place foliovAng removal i":f the Clomat at 'he infiltrative surface. Reconstructions of such systems must comply with the rules in effect at' hat time. 'VW A {=SdIT4G TREATItAENT TAid {S, PUTti>✓ TANKS, AND I'OLDI IC- TANKS MAY CON iPJ-' SO- iOUS GASSCS 0R A 'G SUFFICIENT OX, GEN TO SUSTAIN LIFE. NEVER ENTER ANY TANK UNDER AiNlY CiRCUP01ST1.`NCE. DEATH`fV1A" RESULT, ESCAPE O RESCl E FIR( } ti' , If TERiOR OF -,'-,.NK, 1 r'' 'NIO BE P-SSiSL:E. ,~'_OJITIONAL INSTRUC71ONS: 'OWTS INSTALLER POINTS WIAiNTAINER. E Name Tour J `~Et.eE' - 3 / 3 Y6 Name ~16Na A1.21cE 6~~r eE /Lu~sQiac h7,2 Phone 1 71 G 7 .S.?4G 71S 4 7;-Sa?tG SEPTAGE SERVICING OPERATOR'. (PUMPER) LOCAL REGULATORY AUTHORITY ti name i Name !~r "'/IoiY Zo ,~i rt Dffic E Phone Phone o - uj T u J - C \ y T N LU $$$C ® o J = - r i 1 y uj 0 > p m T h 4-4 a c. - PJ Q. LU M _ pn c J 1 = ~o -4.4 -0 co > ? ~ ~ ~ vim y F Mw 4-1 at Y _ ~ Ti rr ~ G T C J n ~ 6 4 O ~ ~ ~ y .Y y ~au v y ;aax1 . J - v C C 2 p ~ p _ c _ Y ~ ~ L V S J r r k , - O C ^ ~ J- C y Z ~O C -}ae+3 t: 'r ti CJ - N ~ r~ ~ N tC q r w J v y J - ~ 4 r W J O ate.. 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CROIX COUNTY 2L 016 SEPTIC TANK MAINTENANCE AGREEMENT Sj', CROIX COUNTY AND 3OMMUNITY DEVELOPMENT OWNERSHIP CERTIFICATION FORM Owner/Buyer D,+VT-I-) Mailing Address 3q26 'PLA "..,Gel~ lfif f(,/,{,J 5~,r3p3 Property ,Addre & 1 M4- 11 iX-11-v trZ` '.,C CC4,4 (Verification required from Piarttming & Zoning Department for new c true ) City!"State i-A(,O„SCW Parcel Identification Number LEGAL DESCRIPTION Property Location Sec. I T 4'ON R f...-( W, Towsn of(0 _ Subdivision I~VIC~GrOvJ~ 6 r ~(-o Lot # -Z (,.,o 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(3) 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, Iiwe, 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. Uwe certify that all statements on 'form are true to the best of my/our knowledge. l.'we am'arc the owner(s) of the property described above, by virtue of a anty deed recorded in Register of Deeds Office. Number of bedrooms SIGNATU , 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 tlme certified survey map if reference is trade in the warranty deed. 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