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042-1079-60-061
Vvis=msin Department o Commerce PRIVATE SEWAGE SYSTEM County Saiery and Buiidinc Division St. Cf OIX INSPECTION REPORT Sanitary Pernik No: 9Z 0 GENERAL INFORMATION (ATTACH TO PERUT) SMt Pian IG No- Personal information, you provide may be used for secondary purposes [Frivaey Law, s.15.D4 (1)(m)l. 7,7 Q3 !9 3 Permit Hoice s Name City ViCage X Township Parce; Tax No, f ~ ri _ ~ _ z<~ y: a,l~cr~ o~L - X79 - GO - 6 ~ S BM Elev. Insp. BM Elev BM Description: Secnonrown Range/Map No 1 5 -'i~ ~ 6-/ z°1• L`( iS i TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACfTY STATION BS HI FS ELEV. 'Septic Z- Benchmarks Dosing a • l • Aft BIV L,0 M~~a t/e~. a F 5: di : 3 .Z S /Q3 5 93 60 2 ` Bida. Sewer , 1 r 10 . ~-7. 7 3 ~Holding SYHt inlet St/H1 OttH=t TANK SETBACK INFORMATION :Z TANK TO P/L WELL BLDG. Vent to A r Intake ROAD Dt inlet Septic Dt,6ottom Dosino Header/Man. . 3. ~I Asa, 0'7 Aeration Dist Pipe Hoidin 13.41 ldo • 6~ 9 Bo t., System `s C/9 C PUMPISIPHON INFORMATION Final Grade I Z /~1 0~ f Itd4anufacturer Demand St Cover GPM Model Number DH ~Lift!'e Friction Less System HeadTDH Fit Forcemain Length Dia Dist to Weil SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Oren 0 h& c PIT DIMENSIONS No. Or Pim Inside Dia. Lioui DDIMENSIONS z SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING ManuMgture': INFORMATION CHAMBER OR TyP°- ystem: UNIT Model Number. DISTRIBUTION SYSTEM of i HeadedManito .I I Distribution x Hoie Siz/ x Hoie Spacing % I Vent to Air Intake ! L Pipe(s) engthDi. Z Length Giz Spazine i SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Dept'n Ove- Depth Over Depth of xx Seegeci/Sodded x(INulched 'Bedrrenm Center / BedTrench Edges Topsoil J K Yes No Yes i7 No COMMENTS: (includs code discrepencies, persons present, etc.) inspection #1: Id / l r inspection #2: F- Location: " w .~ww~ r l yyt GcJ "~i% I EE✓~ ~5✓~Ig1y C~V` Parcel No: NN'' 1.) Aft BM Description = ~ bloc ~Qu✓e.~ ~ ~~~JC' 2.) Bidg sewer iengtr - amount os cover - Plan revision Required? E]j Yes No 1t. 1 Use ofner side for additional information. ~ ~ I i =y._ ~ ~ ~ • Date insepcto. s Signature CerL No. SBD-6710 (R.3,5 ) a ta;-. I Cotmt1 E CE,V Satety and Buildings Division ` t I 201 W_ Washington Ave_, P_O- Box 7162 Sanitary Permit Number (to be ed in by CC-) Madison, VVI 53 70 7-71 62 State Transaction Number COMMUNITY I HILL swWrml A~iplicatl~ IN L~ urdau x. with SPS 38321(2), Wis- Adm_ Code submission of this form. to 3 1 PS1_1'R- _Z 7 ` 3 , ed n:i~r to obtaiwag a sanitary permit Note. P.ppLUrtton. forms for stale owneu . t\ FX2P Projezt Address (if differemthan mailing address) ;'W r k.paim oat of Safety and -Professional Servies. -Personat.information.you provide may be use, ir_~ccordan_cc with-the Privacy ia%, s. 15-04 l)(m)_5tats. _ 7,5ci 16 3 rcX 1. ?kvucatoulnformation -Please Print All Informati n - I r Cwner s Name - Parcel # 04) - Glq - bo per v ~,vn *'s Maiima Address -T Property Location 1 Govt. Lot Cr to 7Zi Code Phone Nwnber 7l5 w. j (circle T R L onore) i.. oe of Building (check all that apply) Lot # - I e l Subdivision Name m1y Dcvelunr -dumber of Bedziwms J ~ek e, .fir ( B1oc1 # - - 1 r _ _ ,urreui t Describe Use - ~ ❑ City of - rz- CSMNumber 4 j ❑ ViLage of - - i _rzbc Use Jb1 $ownofdi. of PermitjCheck onl , one bok on line A. Complete line B if ppLi- /14&(j,a Z ,Nzw System Replacement Svstem ❑ Tteatmentdloldina Taal. Replacement Only i ❑ Other Modification to Existing System (explain; - - - T-- i--- - List Previous Permit Number and Date Issued _j Permit Renewal LJ Permit Revision ❑ Change of Plumber f LJ Permit Transfer to New tsctu-e Expuatlon Owner rye oa.,'OIF'~l'S 5~stem/ComponentDevice:(Check all that apPIN'l Ffcssurized In-(ntauud ❑ Pressurized in-around ❑ At-made fi Ivlourrd >24 in. of suitable soil ❑ Mound <24 in. Of sui le soil i i :anl J Other Dispersal Compuneut(explaru)_.-__ i_- PreueatmentDevice iexplain) ~ X~t~c rsfiL beat ent Area ItAfarmation: - - _ _ i toy, t ydl Design Sot! Application Rate(gpds*_j ntspciaal .Area T2equired (sFj rspersal Area Pzoposed (sf r System Lleratiou p i ;Ark Info Capacity y in j Total # of I Nfanufacmier - _ iailcs- - (Gallon of Li T~ j 3 i'vex Tanis tais7m~ harts i ~ ~ ~ ~ - s - -r _ _ _ r?. punsibiht Statement- 1, be undersigned, assume responsibility for installation of the POINTS shown on the attached plans. a..r ! c s z Plumber's Signature I MP•Rv[PRS Number Business Phone Number I e s (Street, City', State, Zip Code) rovc d r ! ' prove - Permit Fee P~Daze_sue 1ssumg Li-STi at I i0 5 1 tv__~ O h vin Reason for L,emal 44 1_ t ~n~ ••-aSisf c asons for Disapproval 1, )~eptio effluent flfter and tank, 'disp6mal cell must all be seracas r^ ntene~ /tom Cn(1 _ ,]J ~ as:per Management plan pro aided by plumber. t'Ft[~ r v►^-.~ 2 AV Retbadk`.FegWrer lents must be rnaintrir,e;d n as per aKkzbM code 1rdinanm. 6~Ot S '6_ 4-b Attach to complete plans fo: J_,. ;tisfe:a sod suhnzit to the County- onj on paper not less than 8 L^_ ; I1 inches in ssze ~t. G v raj't Ef t,I , DIVISION OF INDUSTRY SERVICES 10541 N RANCH RD r 9m i HAYWARD WI 54843-6462 a ( Contact Through Relay S J~ \ http://dsps.wi.gov/programs/industry-services www.wisconsin.gov Scott Walker, Governor Dave Ross, Secretary September 09, 2016 CUST ID No. 226375 ATTN: POWTS Inspector ROBERT W ULBRICHT ZONING OFFICE ULBRICHT & ASSOCIATES CO ST CROIX COUNTY SPIA 2812 10TH AVE 1101 CARMICHAEL RD SPRING VALLEY WI 54767-9102 HUDSON WI 54016-7708 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 09/09/2018 Identification Numbers Transaction ID No. 2743743 SITE: Site ID No. 826917 _ Donald Anderson Lot 10 Please refer to both identification numbers, 759 103RD St above, in all correspondence with tile a,2ency. Town of Warren St Croix Countv SE 1/4, NW1/4, S:''? R l1~ Lot: 10, FOR: Description: Mound, 3 bedroom residence Object Type: POWTS Component Manual Regulated Object 1D No.: 1614708 Maintenance required; Replacement system; 450 GPD Flow rate; 18 in Soil minimum depth to limiting factor from original grade; System(s): Mound Component Manual - Ver. 2.0, SBD -10691-P (N.01/01, R. 10/12), Pressure Distribution Component Manual - Ver. 2.0, SBD-10706-P (N.01/01, R. 10/12); Effluent Filter The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codescl and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. This system is to be constructed Q' and located in accordance with the enclosed approved plans and with any component manual(s) referenced abov T OF c; The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code ° requirements. P~"~.t~F~SS~Q No person may engage in or work at plumbing in the state unless licensed to do so by the Department perr+s?wwo stats. 'The following conditions shall be met during construction or installation and prior to occupancy or use: Key Item(s) [ • In the event this soil absorption system or any of its component parts malfunctions so as to create a health hazard, the property owner must follow the contingency plan as described in the approved plans. In addition, the owner must insure that the operation, maintenance and monitoring duties as described in section VIII of the mound component manual are complied with. A copy of this information must be given to the owner upon completion of the project. • 'The CST's plot plan suggests that there may be a concave slope here. This system is not designed for and may not be sited on a concave slope. Up to 1% slope end to end of the mound is acceptable. A mound with any portion of the cell crossing a slope of I % or less will require adjustments to the sand fill heights and perimeter dimensions. Reminder • The orientation of the mound system must be such that the longest dimension is oriented along the surface contour per SPS 383.44(6)(a)2. ROBERT W ULBRICHT Page 2 9/9/2016 • Limit activities in the area 15' beyond the down slope edge of the mound per Mound Component Manual. • Surface water drainage shall be diverted away from the system area per Mound Component Manual • Materials shall conform to the requirements of SPS 384. • The existing POWTS must be properly abandoned per s. SPS 383.33 Wis. Adm. Code. A copy of the approved plans, specifications and this letter shall be on-site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of construction/installation/operation. In granting this approval the Division of Industry Services reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101. 12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter and the POWTS management plan to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, Fee Required $ 250.00 Fee Received $ 250.00 Balance Due $ 0.00 Patricia L Shandorf WiSMART code: 7633 POWTS Plan Reviewer, Division of Industry Services (715) 634-7810, Fax: (715) 634-5150, M - F 8:00 a.m. - 4:45 p.m, pat,shandorf@wisconsin.gov cc: Edwin A Taylor, Wastewater Specialist, (715) 634-3484, Monday - Friday 8:00 am To 4:30 pm ROBERT W ULBRICHT Page 2 9/9/2016 • Limit activities in the area 15' beyond the down slope edge of the mound per Mound Component Manual. • Surface water drainage shall be diverted away from the system area per Mound Component Manual. • Materials shall conform to the requirements of SPS 384. • The existing POWTS must be properly abandoned per s. SPS 383.33 Wis. Adm. Code. A copy of the approved plans, specifications and this letter shall be on-site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of construction/installation/operation. In granting this approval the Division of Industry Services reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter and the POWTS management plan to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, Fee Required $ 250.00 Fee Received $ 250.00 Balance Due $ 0.00 Patricia L Shandorf WiSMART code: 7633 POWTS Plan Reviewer, Division of Industry Services (715) 634-7810, Fax: (715) 634-5150, M - F 8:00 a.m. - 4:45 p.m. pat. shandorf@wisconsin. gov cc: Edwin A Taylor, Wastewater Specialist, (715) 634-3484, Monday - Friday 8:00 am To 4:30 pm PLOT ?L)NN LoT I0 GSM (TA rho 4 06 0A 3 a ''1T ° cm. I CLIP r. ! a-- 52-1 lull rug J' f~j 1 q ALL NON-CONFORMING I I ' TREATMENT TANKS SHALL I BE ABANDONED PROPERLY I PER COMM. 83.33. - - - - n q~_° No l~gNs0RE ply` f Rcy-0s C) fa ~15'C O NSl~ uLaRIc~cr f '/`f'' l/l/l/11i11111111111h111`\`` 0 µ 13AGKt~o~ ~ QT'S w C6)OTou R- L-W eS { o BM PER S o c L TE57V-- B oTTa M c otznecZ. of s inl~a~ A'T o~ UL.UHIGHT & ASSOCIATES CO. 2812 1 Oth Ave. - Spring Valley, WI 54767 Rey. Designers or Engineering ,iystUns 715-772-3442 Private Sewage Consultants PROJECT INDEX To L/ 15 2 0((0 Plan I.D. # Date Owner -Po ej o A1jri E'R5®I`3 Phone Address 7 3 6o 1®1 1'-'` 5T: 12 06E1R-T5 , LA) I.~ S tj ®Z3 Legal Description -LOT 10 (,IN -'-PA(Zr 0 c)q2,- 10717-„S~O-,300 y~ ' Pe,AJL)i~jy NW, 52.9, T2q~ R 18 w Town of WA-F, RC N1 County 5 T• G R 0 X C.S.T. THE STEWART- 22.087 Installer NENR~ Local Authority/ uoervi si on i Nl+ e U I 5T. C.R®1y, cry, PROECT DESCRIPTJON ~ LG ' -CIS - 38~ - q G R a 6i-rE APORE5S ' l59 103 R9• ST R0 CAERT5> W1. 5V02_~ REp1.ac~NtE~7- M ®VNP $y-5 TEM F® P., A 3 BEDTZ)~A . M,y . a .51TE 5RLE7 r0 (L PN C®Av VcNTI 0M RL. M OUMu 5 ySTE M - A 51N 1b a MF1z6v ED S AK9p F i l l PR®po5 ~ 7iA3,FoRM c©Njoap, LIA 61EV rl/o0 - Rg0 j - ~~.oPos ~ MOOM0 sys-r. elp-mrro,q w - l0 Till l!G. AlC Ni e ,J1160 THEAT IviL-N 1- I-ANKS SI-I,y"LL OI(~ HUDSON, BE ABANDONED PROPERLY ~ PER CO ~ IN;, 8-.3- _ SIC' Pg.l PLOT PLAN VIEWS Pg.2 SYSTEM CROSS SECTIONS & SYSTEM PLAN VIEWS (REVERSE SIDE DETAILS INSPECTION PIPES & FABRIC/TOP FILL DETAILS) Pg.3 PIPE LATERAL LAYOUT (REVERSE SIDE SHOWS DETAILS OF LATERAL CLEAN OUTS) Pg.4 DOSING CHAMBER CROSS SECTION & SPECS. Pg.5 PUMP PERFORMANCE SPECS (REVERSE SIDE SHOWS PUMP DETAILS)RECEIVED Pg.6.OPERATION, MAINTENANCE REQUIREMENTS (REVERSE SIDE SHOWS SITE & SPECIFIC PROJECT DETAILED INFORMATION,UNIQUE TO LOCALE AND GOVERNMENTAL UNIT AREA) JUL 2 3 2016 INDUSTRY SERVICES The attached plans and specifications are based on the following approved manuals: "Mound Component Manual For Private Onsite Wastewater Treatment Systems " (Version 2.0 SBD-10691-P(N.01/01) and "Pressure Distribution Component Manual For Private Onsite Wastewater Treatment Systems" (version2.0) SBD-10706-P(N01/O1). PLOT ?LAN LOT 10 ~E~Dll,.~ (s- C~SM Y.. 10 PR6,--A5;T T P )X 0 1 r" Y i Co, 1~ II r j ~ I s 00 4 jj -CIO ALL NON-CONFORMING TREATMENT TANKS SHALL RE ABANDONED PROPERLY PER COW £3,33. ~ 6I c OPT u?C F ~SCONS R~ W. C ULSR1CHt ails* SeaL~ , l .,~~G~ ,::aglY,tt,l~Y~ r 0 Yw l3A~ K~oE ~ t`r5 = C6)0 Tou 2 LAN t~s o 5m PER :50 t T'E5r- Yd OTTO M C mzmeC. o~ 5 lnl~ I(T , l OT 5. M~ GoQZN~ K, r- 1~0 100.0 6 t,vA,j V~- M©UAJD GCs i T t` BED 13 1! D 0 F 7~t ST~i(3uTtn,V ~-Y AllerSATE' - G", j'NiGkaESS pip (Pa OF T°p SO i L Gv` TEeP.iet/,fz- S YSrE~M Uui FORK row - ,e - 99.50 l-~",v E sty H 3 U r` G e e t RRTIO MEt~. • • • , ~3) . i ' SA"D w/l Flo ~taPE FORCE" uu+FoRM 1°1A6j ~tMVAT70-3 UuDER BE-P 18-01 FT., S ELE-vAr#©nJ 5 E. S Fr. lmvERr o F ! 4 ,r 1A•rePAk app. D FT- s Fr Top o F R cock /00, 30 # Top OF PLAM ViCw OF MOUJvp wlrvt 13Eo CCOTRRL FURcE: MAiAj A Fr K 12. F T, --t Fr W r - F r ~o a Vv 3 z. fT BE!v ~F Pvc cgppEp To I i'E A~ 4 t E G- T 03SERVh7100 e pip E -s 10e,+r1 ~W-'- ! --Q I- R o m N 17 ®F G G L. . PERMAA., uT MAic KERS <Ta/~S a Gf,E;.e1,ca czc9 j 5" k'Ics: RF C(Qv RED BASAL 4AReA ~'~~'~y whSrE Ffoc.~ q50 svi L t~S Ei ~Ti2hTlt9~" 1 C APACi Yy ~rj `a. Fr. PR,o?o5Eb BAS 4I APeN = B C A tp 1 s J Observation pipe - (-Distribution cell ! ' T` ,,-Cover material Fill material, aggrettateo _ Tilled area 4 <--Slope Force main Figure 6. Cross-section of a Mound System Water tight cal) I Top of - 4"° ntin. dia. leaching ~ Repair couplings charttbe / 6°° min. min. Infiltrative stirface•, Water Closet Collar Bar (113" snit tlia.) r L:. Figure 8 - Observation Pipes 41 e 16 t° 0/3 r i r~ rr 611/ 3 , Observation tripe -24 -Qistribution cell ,-Cover material Fill material-,. -~_1 , ri tie. MOW I'P "-Tilled area Slope Force main Figure 6. Cross-section of a Mound System water tight cal) 4" ruin. dia. - Top of leaching ~fRepair couplings eharnbe ~ / 6.. 6" to l ll. nl lll. Infiltrative 4 un.. surface Water Closet collar Bar(3!6" Init dia.) Figure 8 - Observation Pipes IM, -rom y . I ,f y1 r r p ~ G /`t-~"~~f MAcIQ X I I Ce)6TRAL FORCE ~l Of Cr, cJ 3(O f=7 o D-rAL VOID \10 UUM E OF NE 9 UJORK ' 3 VOU) VDI UMZ 07- FORCE MAN C~ X/2 19.5 ° /00.5 -v I'a kJ.\ L oa ur~~~ 30-rr®Mp r--Va:tjLy ~®0L=5 'PER i A7r-PA L I SIDE FD R -rF-'P-K W P L ,a PER 07x5 ➢ For-P, l sc~PD, a R14TF- To E SPAS. ? r-k ~11INL)TlF Q~ so4 ~aS-rp 1150'r D®~j Po s s'%P~GZ~E Ride 'FOR ~---Atk kr:~P,,A9 7. f2. AA 3~ o .J r Y ~-ZD o 1AVI J 5'1k~ok'47e Fw Nab " /30X ~ . 134-11 114 /e 6F ~~q ill J - '«._..~..d_~..... R , \I a 11 - ! _ _ Ifs 13411 fj~, ef 0 F (e D SEPTIC TANK 6 PUMP CHAMBER CROSS SECTION AND .SPECIFICATIONS 4" CI VENT PIPE 12" MIN. ABOVE GRADE "WEATHER PROOF v~ ?LCD' FROM DOOR, WINDOW OR JUNCTION BOX APPROVED FRESH AIR INTAKE WITH CONDUIT MANHOLE COVER,. i►~~'~ W/ PADLOCK 6 40V ~ _ --(----WARNING LABEL ~~-4" MIN. 5'0 t i o.I:NL,ET ~ I Posy LoLK GAS- ,~E~ ' U _ MO EL TIGHT i $25 A I SEAL APPROVED J,. 4C? F i L,-T ALM JOINT'S W/ 1.) VC 'Pj R B , ON PIPE 3' ONTO 3,10 SOLID (po ' SOLID SOIL SOIL PUMP OFF ELEV. F1'. OFF RISER EXIT PERMITTED ONL R9.50 IF TANK 5()J(® MANUFACTURER HAS APPROVAL 3" APPROVED BEDDING UNDER TANK Lp MOt?EL• CONCRETE PAD (0-0 q~- (0 50ift -SPECIFICATIONS SEPTIC / DOSE W iE5ER PRECAs-r S 'T'ANK MANUFACTURER: C® NUMBER DOSES PER DAY: q0%. TANK SIZES: SEPTIC GAL. DOSE VOLUME INCLUDING DOSE (Q Q GAL. ~(9 FLOWBACK: f 06 GAL. ALARM MANUFACTURER: i E-Yd AIAR11 C® CAPACITIES: A = INCHES = 3 C'0 GAL. MODEL NUMBER: B = 2 INCHES = GAL SWITCH TYPE. F 0 PUMP MANUFACTURER: Z O p-t tp, C = (0' INCHES = D(0 GAL -Y 4 MODEL NUMBER: 7- SWITCH TYPE: P13 ~LK Fj0A-r D = INCHES = 2.36 GAL REQUIRED DISCHARGE RATE 3 2- GPM PUMP & ALARM WIRING AS PER ILHR 16. 23 WA( VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE 41' ` FEET + MINIMUM NETWORK SUPPLY PRESSURE . . . . • 372-5y FEET + 100 _ FEET FORCEMAIN X 2-.5; FT1100 FT. FRICTION FACTOR 175-0- FEET TOTAL DYNAMIC HEAD FEET INTERNAL DIMENSIONS OF PUMP TANK: LENGTH{ ; WIDTH DIAMETER_,--' 5EE' /2EvERSE' 511? LIQUID DEPTH Ll ® SIGNED: LICENSE NUMBER: DATE: PIC SPECS 67,N C1 Q SEPTIC TANK, per Comm.83.44 (2) (c) shall be equipped with an outlet attached approved filter device. Tank shall have an approved above yrouna locking manhole cover for regular (every 12 months or less) inspection & servicing by a F ara-ass/oooldu+ ~3~1~ 9Sb8-SZ~-008 0 09L-V9 IM `3100H N301HN Ol AMH Sn 9LLSM Z -73d-1SOd :31dO 00/00/00 :aLva w A3a 7b nNb W OIld3S w o w •anOd-3i8d „O-,l= t L 31b0S d0M :A9 NM mi 313H0003 1313im NW-059/000IdINI w J.. w U I--I Q z > J ° 000 (r J W U Q~ Ui-. (n W W,. 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