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HomeMy WebLinkAbout026-1165-34-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 591 Z / 4og GENERAL INFORMATION State Plan ID No, Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1 m 00 Permit Hold is Name: City Village Tnw n Parcel Tax No: I Hold q~- i_v _ rv~ o 4Z(o - //45'- 3V- CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No- 4•ZS IF,'I Goy - ZZ. 30. g TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic ; P~ Benchmark ( Z . 7 /6~• g Alt BM O Z. '7 Imo- LS 41." 14~1 call, Aeration Bldg. Sewer Xr ~ '74-9 Holding St/Ht Inlet 9.q. St/Ht Outlet 7 TANK SETBACK INFORMATION 73r. TANK TO P/L WELL BLDG. Vent to Air Intake ROAD 19-115 93 -T OILO v w Septic I Dt Bottom ~t Z, - g 7 9 3 S 3e 51 1 ,s Dosing Header/Man. G ' 93 Aeration Dist. Pipe .3 93. (e Holding Bot. System PUMP/SIPHON INFORMATION Final Grade Z S Manufacturer Delm~and St Cover 1 1 O Z ..7 c,Ie~, Zr Model Nu P m TDH Friction Loss System Head TD Ft -orcemain Di ist. to Well SOIL ABSORPTION YSTEM BEDITRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pit$ Inside Dia`® Liquid Depth DIMENSIONS -3 SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR A6 Z' 4 . + UNIT Model Number Type Of System-: • j 1-36 7 OO DISTRIBUTION SYSTEM a( I.S c5 * 9. S ' ION " S Header/Manifold Distribution x Hole Size x Hole Spacing Ve~t~~r Intake Length '4'-°--Dia Spacing Length3~3 Dia_ ip I SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mul hed Bed/Trench Center , Bed/Trench Edges Topsoil Yes No Yes No d COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: ti Inspection rpe Location: 1163 230TH ST ~P n 1.) Alt BM Description = 2.) Bldg sewer length = 5P`i► v' a ~JQ/ r j GGGvvv -amount of cover h srs Plan revision Required? ❑ Yes Kn ' I i5 l 3 S Use other side for additional informati Date VInsepctor's Si ature Cert. No. SBD-6710 (R.3/97) oar q Coua RECEIVED Safety and Buildings D59P --16:7 ivision Sf, ;,t- 201 • p „ , W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.) r K OCT 31 : Madison, Wl 53707-7162 ' P,s, ~ ~9 Z l Co ~ °F slow$ ~ ST. CROIX. CO N Y plica 7GOW26Y3HPK68 SrateTransa umber In accordance with SPS 38321(2), Wis. Adm. Code, submission of this form to the appropnaw govcimuouw, ,..u~ is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to oject Address (if different than mailing address) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary, r purposes in accordance with the Privacy Law, s. 15.04(1) m), Stats. if i q0 N `i I. Application Information - Please Print All Information Property Owner's Name Parcel # -j-0L cd 026- Owner's Mailing Address Property Location )0, 1 3 S, 1C Property ` / k~-- / 2 7 t S~` Govt. Lot City, State Zip Code Phone Number Section Z Z ~elu ~rrCAMo J ~ D 7 3Z4 6 7W dcircle one T N; R d g II. Type of Building (check all that apply) o>bV ~kl`ot# X, or 2 Family Dwelling - Number of Bedrooms r37~> Subdivision Name -7v") Bloe L -4 e~~o ~vs ❑ Public/Commercial - Describe Use ❑ City of CSMNumber ❑ Village of ❑ State Owned - Describe Use n MOW 44 ~ID t~ J W-Town of 2 ~h ~ O M. Type of Permit: (Check only one b ix on line A. Complete line B if applicable) A' ❑ New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B• ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner /0 IV. Type of POWTS System/Component/Device: Check all that apply) 9 Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil / ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dis ersal/Treat ent Area Information: Ar~~ posed V(s5 System Elation Design~l (gpd) Design S~ pl ion ROate(gpf) Dispersal Area Require Dispersal ~L7J J Z- 9 • Jf VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units ° ~ U V U y ti New Tanks Existing Tanks c PL, U iZ VS V) Septic or Holding Tank rf- Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the P01VTS shown on the attached plans. Plumber's Name (Prirl Plumber' Signature MP/MPRS Number Business Phone Number I .1 23/3/x/ 7/5-ZyT--3u~3 ~J/',tun ~a,,,qe// l- Plumber's Address (Street, City, State, Zip Code) 7?S- a w e a m r- w ~y6 z s- VIIour /De artment Use Only Approved Permit Fee Date sue Issuino ent Signature ❑ Owne i en Reason for Denial $ V 2. ' IX CondlgtIReasons for Disapproval ` J t ptirs tank, effluent filter tin d Jl .yvrL O c..) Q~ d*per&i cell must all be spricas ! mr'r~ .'red ' as per management plan profided by plumber. 2 1-Eck"ret3wterlents must be l }aint fired € as per gpplicWt code I ~ rdincince3. Attach to complete plans for the system and submit to t County only on paper not less than 8 in x 11 inches in size ve~4~ MaT SBD-6398 11/11) 0NE&. Name C6 e", C Z PAW 3 of3 Address j ~~S- /2 9 r4 J Brian Pameli .~~w aa~ ~3Z7 /G J1 Benchmark o ou~~,o~ ~L. /~o, o Benchmark 2 Tb4 JI7a-z /fm /e C o Soil Boring Li Suitable Area I" = 40' Scale _ lie 1 t _ 01 y r f CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Owner's Name: Jc- G0 /0 4- gi C- Z Owner's Address: / " ~~r° w iG Ll /Jq o2 ~..Z Legal Description. `jam Township: R G~ /7'10 2 Q County: -S'- , C ---O its Subdivision Name: ~a y `eee Lot Number: ~Y z DTs = 3~~0 Parcel ID Number. Page 1 Index and title Page 2 Plot Plan Page 3 System Sizing Page 4 System Cross-Section Page 5 Filter Specs Page 6 Maintenance & Management Plan Page 7 Septic Tank Maintenance Form Page 8 Warranty Deed Page 9 CSM or Plat r ~ / 2 Lf Designer/Plumber: License Number: Z Date: ~G- Z 7- 6 Phone Number/S- Signature Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01101). Page 1 OWNE& Name Pa9e3 of3 Address S- 2 9 r41,~- Brian Parnell ,-c.v ck m•c CST 231314 Bate 11?- Z 7- I G Benchmark i :Z'2-e,4-o- o uz,~L f, c. Z-~-Z, 1A9. d - 114 Benchmark 2 7o~ ~?a z If-* /e c d ❑ Soil Boring Suitable Area I"=4U' Scals CM) j 1 3 f e ~ ~ f SS~fz %ellf o o~z ~ uSe 6 2 Gy ~~~s~~~c~~ - 76 4/1 -r 6 _ zf 1110- A ep 2 S~2_ ~2 S~_ 2 ~z 2,11 oz ~z f pq SOIL ABSORPTION SYSTEM DETAIL/ GRAVELLESS LEACHING UNIT Page of Project Name- 11h C - ' r ' it No. of Cells v0 0'1Per Cell - ft Cell Width ~,'1.,;~,/add 2-S`" Totat No of~ 203 - /D • it Cell Length sq it EISA Per Get± y z `"e,i S}:acitss 1i Tot a l EI8A 4 j infiltrator Q1203H-Sit 5.0' 25.0 EZ1203H-10ft 10.0' 50.0 Oraveliess Leaching Unit Manufacturer. ~Z- 4 4--/ Gravelless Leachinrf ? irai± lcrdel: ? O 3 - /CS" ~-,S' /jp i ypicai Cross Section i'°inishcd Gw,, ade7 7.P Observation Pipe with ` approved cap or vent --Soil Backfill a Geotextile Fabric ■cri:•a::tc:".•::•i;i:i:tcir:S::fc:.';ctZ:•i.`. -'i - ft Infiltrative Surface 12 in CO F o 0', ft Limiting Factor ~I a Slotted and Anchored Vent[ i, Observation Pipe with Cap r--d-9---_--~«n«~-=ran~a.bn,..,,. Plm,rnbr.r/Dessignor Signature- POWTS O1NMM-S ll MUAC & M MAQOWMT PLAN Page of FRE INFORMATION Owner I& jySTUAWIRM91CATOW Pemft # Septic Tank Capacity /D6G aNA axrfacttuar 4 40L.. 0 NA DESIGN PARAU~TE RS ~ NurrAw of Bedrooms 3 DNA ~~1f ❑ NA Filter Model ❑ NA _ Number of peg*c Fly units O*A Esdffuftd pacity U rilA flow (average! ©O ~ LPWWT::k Design frorav tWM- DNA tad x 1.5j s`Q pkmr(e Manttfar.~ So l Applies hate ❑ NA Purn A Model f3 NA Stadard ink Quality Y Fats, OH & Crease M mgL ~neanrterrt Urpt M*Immica Q S~ Filter Q Peat Fitter " Oxygen, Denmd ( 420 - RNA 13 Mechanical Aeration 13 W TOW Suspended Solids (TSSj 5350 no& ~ pretreated Ott UUw- Y 0 Other tiodeewcal Oxygen Danard 0300 cears) _ NA Q #e-txoun d (gravito ❑ &Wwound (PrawasimeW Tote! Suspended soGs Cif :00 nowL NA oat-Grade ❑ Mound Fecal cc~fant (fieorreeaic mean) 510• cfu/i00nd p Chrip-Lim Mauimurn Effluent Particle ~ 3a O NA ' other oet,ec: 0 NA C7 NA Other: Q NA ;vim tyPkM fbr ~aeW. a ter any! septic ~ efffu6m Icklm 13 NA NlAlN3 MARM fi.E Se:wwe Chrent Serow Ereqwermy Inspect COndition of tanktsj At loan ante everys Pump out swntents of talk(s) ~,i~oremr~j 3 ymmj 17 NA When cong4ned sludge and , equals one-third M of sank vane o Na Inspect dispersal cell{s} At host once evwr layewts) 01111836mm 3 years) D NA Clean- effluent filter At feast once ©moreth{sj evwr 41year(s) . 13 NA -nspect Pump, pump conbrofs & alarm At least once every. © vea*) maeth(sj p NA ws' 'aterats and pressure best At feast.once.e Mr. n month(s) years] f3 NA Comer: At feast once every: DO myearW °r'ti" DNA - MAINTIM ICE RTf1ElCTKM Q NA koPecdons of tarNcs aka 4MK" cede strap be made, by an individual Master ; ir {yl p(undya vfi cartymg are of the fOpovreeg licenses a des: tokSpey'Wr; POWTS Maettaiaer; -SeptW g Operator. Tank netts. tdtde a vtstb ' MPOs)WTgid mane the volane of Sefireer tank(entdy any ff=V or few hardware, identify any cracks or leaks, me cefi(s1 Of be Wwjed sludge and smn and to durst for any bade UP Or pord'ng of effluent an the cracks surface. The dispersal shall VWmfiV inspected Ow effluent to check levels in the ob9enratisi pipes and to check for arty po din effluentan the grotxd surfime- The pwv&V of rmtifixafion of the focal eferet -on 1th0- !mod surface may >rs a9 condition and requires the irnmedlete regtrlatOry autfeority. When tree ca",, antd"m of sludge and mm in any tank equals aid (Y,) or more of the tank volxne, the entire - contents Of the tank shop be aernavaed by a OPWIOor end disposed of in accon*wme va h chapter NR 113, Wisconsin Aftinistgutim Code. Aft outer services, ira*xckg but rot prieitiad'the 9 of efouerrt teats' and any at intervals of 512 .shop be p ~ pressudzW Pr'etreatinent A service rat el" be Pfd to the local ill mdwft Within 10 days of MwWletipn of any service event. START UP AND OPERAM€11 Fagg of For new 00risbuction. Prior to use of the P4DWT$ checlk treetrerent tank(s), for the presence of painting moduicte or other therms that may impede On Vestment process and/or dams the dispersal caft). if # are did have the contents of the tank{s} removed by a septWe servkkV opffaW prior to use. System stet up shall not occw when sob conditions are from at-the anfdtraaive mime. During power outages pump tanks may IN alms, normal 1>ighwater levels. When power a restored the eons wastewater will be dmdmged to the dispersal ce#W in one large dose, overloatft the. cWW and may resutt in the backup or surface discharge of effluernt. To avoid this situation have the commrrts of to pcatrp tank reproved by a Saptage Servicing operator prior to reskemg power to the effluent pump or contact a Pkardm or POWTS M m assist In mater apsratarg the pump controls to restore _rnorrad levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cdt ls.* Do not diivs or- park over, or Otherwise- disturb or ccsnpacr, the area within 15 feet dawn slope of any mound or abgrade sod absorption area. Reduction or ekrrdnation of the fo8owing from the wastewow stream may anPr+onro the performance and prolong the life of the POWTS: anxibiotscs; baby wipes; cigarette butte Cc at aottorn swabs; degrreeaers; dental floss; drams; disinfectants; fat; foh smnp p umpf water, feat and a peelings; 9aso&Wl grease; homes; meat straps; medications; Oil; painting p . Y naepkins; tenwons: and water saftoner brine. A6ANDONMENT When the POWTS fans and/or is Pwmantnn * taken out of service the following stgm shall be taken to Insure -dug the system is Properly and safely abandoned in conqAance with chapter cam a 33. vasconsm. Acktraristrad" Code: • AN piping to. tanks and pits dW be disconnected and the abandoned pipe openings saaw.. • The contents of ail tanks and pits shag be removed and properly disposed of by a Sep to ge Swvipng Operator. • After pumping, all tanks and pits shag be excavated and removed or their covers removed and the void space fmad with sole, gravel or another anent sogd material. CONT04GENCY PLAN 1f the POWTS falls and cannot be repaired the following _Nsres have been, err must be taken. to provide a clods c ern i'uant relhiacarrnthrrt system: . ❑ A sultabis r rent area has been evaluated and may be aft ed for the location of a repiacernmt soil absoptim ..j system. The rspleaw rent area shots be pmftcwd frrom and co~mp~actron andshould not bas Inhinged upon by reed setbacks fra i-e ng-and propotssd structure,, lot bm and wall& 1%&m-W protect the replao trwn area will result in the need for a pe w soil and site svatua on to r a suitable wept area. Replacement -systerna must comply with theMks in effect at that tarns. ❑ A suit". `eplacamint area is net available due to aetlski k and/or and limitations. . Barring advances in. POWTS technology a-hokft tank may be installed as a leaf resat to rem the failed POWTS. ❑ The site has not been evaded to identify a suitable replaoamerrt area. Upon failum of the POWFS a soil aid she evakudar must be performed to locate-a suitable replacement araL If-no rt area is available a-holding tank may be installed as a last resort to replace, the faded POWTS. ❑ Mound and at-9mde soilabsorpfin systems-may-be raoa d is place fo§owing nmwvaa-of She bkmat at the anfitttative surface. Reconstrer r iota of such systems pnust comply vAth the rules In effect at that'tame. < <WALJMM> > SETLC. PUMP AND OTHER TREATII/MIT TANKS MAY CONTAIN LETHAL SUM AND OR ilIISiA~ICtE1M7 OXYQEM. DO NOT - ENTi3t A► SEPTIC. KW OR OTHER TREAWElff TAM UNDW ANY 7'ANCES. DEATH MAY RESULT. RIMCUE OF A i t Lim THE WF8WR OF A TANK MAY SE D1FRt MT-OR SWOSSM.E. ADOLTLONAi. CON11119MTS POWTS INWAtLER POWf'S. NIAaaiIYALlM Nam r 1 a.~ cc r.h e / Name Phone 7/S- ' z y7- 3 2,0 3E SEAM SEM40MM OPERATOR 04 ) LOCAL. i ATORY AUTHORITY Name Name G~ j v Phone Phone This documem urea deafisv c1--c with chapter Corms 83.22IZ Wtt)IeA&M and 83.SMt), (2) & (8). VVisaxid n AdrriWandWe Code_