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Home My WebLink About038-1068-50-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) SAN-2017-113 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 LANA MRDUTT DAVID HERZG TOWN OF STAR PRAIRIE 038-1068-50-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: 16.31.18.292G TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing ( Alt. BM Aeration: Bldg. Sew t~l~t ILJ Holding St/Ht Inlet TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic , Dt Bottom 9 P Dosing Header/Man. Aeration Dist. Pipe Holding Bot. System Final Grade PUMP/SIPHON INFORMATION Manufacturer Demand St Cover GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM T BLDG WI=LL LAKE/STREAM LEACHING Manufacturer: INFORMATION Ty f System: CHAMBER OR UNIT Model Number: DISTRIBUTION SYSTEM Header/Manifold a Distribution ix Hole Size ix Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil Yes No Yes ~ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 2104 CTY RD CC 1.) Alt BM Description 2.) Bldg sewer length -r - amount of cove Plan revision Required? ❑ Yes kNo 1 Use other side for additional information. SBD-6710 (R.3/97) Date Insepctor's Signatui Cert. No. sftw -aai-7- R3 rr ty Sanitary Permit Application ST. CROIX COUNTY WISCONSIN ty rd w G 0 21iiln ccoith Chapert 12 St. Croix County Sanitary Ordinance PLANNING & ZONING DEPARTMENT 1mation you provide may be used for secondary purposes ST. CROIX COUNTY GOVERNMENT CENTER Person I.' y ~1 [Privacy Law. S. 15.04(1)(m~ 1101 Carmichael Road 1 v F Hudson, WI 54016-7710 u (715)386-4680 Fax(715)386-4686 ete plans for the by- ~hes in size. ^`QM anitary Permit # ❑ Check if revision to N 1. Application Information - Please Print all Information Location: Property Owner Name ~~yy / 5E 'Sc Property Owner's Mailing Address Lot Number Block Number 2/lam City, State Zip Code Phone Numer t Subdivision Name or CSM Number 11 Type of Building: (check one) ❑ ❑ E. 1 or 2 Family Dwelling - No. of Bedrooms: 6k. c~~`-„~.~ 6 ❑ Public/Commercial (describe use): J~r_ ILL ❑ Neare t Road G II. Type of Permit: (Check only one box on line A. Check box on line B if applicable) A~ew_A Parcel Tax Number(s A) El ❑ ~ 3 _1 B) Permit Number /V- Date Issued ❑ State Sanitary Permit was previously issued IV. Type of POWT System: (Check all that apply) Za #,.A_ El 2: 24 in. suitable soil ❑ Mound 24 in. suitable soil El Mound A++O Non pressurized In-ground X ❑ Sand Filter ❑ Constructed Wetland ❑ Peat Filter DLjILLine ❑ Pressurized In-ground ❑ Holding Tank ❑ Single Pass Other ❑ At-grade ❑ Aerobic Treatment Unit ❑ Recirculating c'? WF V. Dispersal/Treatment Area Information: 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. System Elevation 7. Final Grade Required Proposed (Gals./day/sq.ft.) (Min./inch) Elevation L3 M 0. VI. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic New Existing Gallons Tanks Concrete structed glass Tanks Tanks d.~ , 6Q ❑ ❑ ❑ ❑ EJ El VII. Responsibility Statement I, the undersigned, assume responsibility for repair/reconnenction/rejuvenation/installation of non-plumbing for the POWTS shown on the attached plans. A license is not required for terralift repair or the installation of non-plumbing sanitation system. Plumber's Name (print) Plumber's Signature (no stamps): MP/MPRS No. Business Phone Number Plumber's Address (Street, City, State, Zip Code) / Vlll. Count Use Only Disa Sanitary Permit Fee ed Issuin ent Si at a (No s s) Approved OwnerGiv nitialAdve 677117;-7 ion IX. Conditions of Approval/Reasons for Disapproval: Pe f M : , 5 713 `-0 AAeJ- a ,nom tea. ; 4-a emu; S c- S _6b ~ l5 ✓er A, e 3 r4 b~f o~ Rev: 8/05 PROPERTY AT 2104 CTY RD CC PLOT PLAN NOT TO SCALE SE1/4SE1/4 16 T31R18W 1,000 GALLON SEPTIC TAN WELL. GREAT THAN 50 DRY WELL APPROXIMENT Y FT FTOM SEPTIC SYTEM \l 210TH AVE 1,000 0 DRIVE WAY PROPOSED MOBIL HOME CTY RD CC i CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE'' PAGE Project Name: 1~~ //rf / e~P! yr h/ts 7v~ Owner's Name: ,7 1 Owner's Address: Legal Description: ~y Township: c7 X" a' f 6 ; County: Subdivision Name: Lot Number: Parcel ID Number: .r Page 1 Index and title Page 2 Plot Plan Page 3 System Sizing & Cross-Section Page 4 _Edkcr-acs 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:,f~,/ License Number: Dater Phone Number/S- Signature Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01/01). Page 1 PROPERTY AT 2104 CTY RD CC PLOT PLAN NOT TO SCALE SE1/4SE1/4 16 T31R18W 1,000 GALLON SEPTIC TAN/ WELL .GREAT THAN 50 DRY WELL APPROXIMENT Y FT FTOM SEPTIC SYTEM 210TH AV E 1,000 G-0 ~ DRIVE WAY t PROPOSED MOBIL HOME CTY RD CC Wisconsin Department of Safety and Professional Services Page of Division of Industry Services SOIL EVALUATION REPORT a In accordance with SPS 385, Wis. Adm. Code County Attach complete sit& plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, Parcel I.D. scale or dimensions, north arrow, and location and distance to nearest road. Please print all information. Revie Date Personal information you provide may be used for seconds purposes Privac Law, s. 15.04 1 m we y -5,j/z.//'7 Property Owner Property Location ❑ I1 /-1(., iii rJ i✓!,f Govt. Lot Y< % S N R E (or) Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# City State, Zip Code Phone Number ti ❑ City ❑ Village Town Nearest Road soy,, S ❑ New Construction Use: Residential / Number of bedrooms 2, Code derived design flow rate 16 GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material --So ~ 4 Flood Plan elevation if applicable ft. General comments and recommendations: 5 e Boring # Boring L ; ❑ Pit Ground surface elev. ft. Depth tQ limitin "factor tin. &a *8 el~ CSC 1.)ZE-1 A-00 / Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/Ft2 In. Munsell Qu. Az. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 - Y-4 _ r f ❑ 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 GPD/Ft2 In. Munsell Qu. Az. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BOD, > 30 220 m /L and TSS > 30!5 150 m /L * Effluent #2 = BOD, > 30:5 220 m /L and TSS > 30<_ 150 m /L CST Name (Please Print) Signature CST Number Address Date Evaluation Conducted Telephone Number SBD-8330 (R04/15) ❑ 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 GPD/Ft2 In. Munsell Qu. Az. Cont. Color Gr. Sz. Sh. *Efffl *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 GPD/Ft2 In. Munsell Qu. Az. 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 GPD/Ft2 In. Munsell Qu. Az. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BOD, > 30:5 220 mg/L and TSS > 30!5 150 mg/L * Effluent #2 = BOD, > 305 220 mg/L and TSS > 30:5 150 mg/L POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page / Of FILE INFORMATION SYSTEM SPECIFICATIONS Owner Tank Manufacturer: 4~rNA Permit # ❑ Septic ❑ Dose ❑ Holding Volume: (gal) DESIGN PARAMETERS Tank Manufacturer: ET NA Number of Bedrooms: ❑ NA ❑ Septic ❑ Dose ❑ Holding Volume: (gal) Number of Public Facility Units: ❑ NA Vertical Distance Tank Bottom(s) to Service Pad: (ft) Estimated (average) Flow : g, t (gal/day) Horizontal Distance Tank(s) to Service Pad: (ft) Design (peak) Flow = (estimated x 1.5): - (gal/day) Specific servicing mechanics must be provided if vertical is >15 feet or j a y) if horizontal is >150 feet. Speck instructions to be provided on back. In Situ Soil Application Rate: y/, (gaUday/ft2) Effluent Filter Manufacturer: j~3 NA Standard (Domestic) Influent/Effluent Monthly average Effluent Filter Model: Fats, Oil & Grease (FOG) <30 mg/L Pump Manufacturer: Biochemical Oxygen Demand (BODS) 220 mg/L ❑ NA NA Total Suspended Solids (TSS) <150 mg/L Pump Model: High Strength Influent/Effluent Monthly average Pretreatment Unit (FOG) >30 mg/L Manufacturer: (BODS) >220 mg/L ❑ NA NA (TSS) >150 mg/L ❑ Mechanical Aeration ❑ Peat Filter Pretreated Effluent Monthly average e El Disinfection ❑ wetland Y 9 ❑ Sand/Gravel Filter ❑ Other: (BODS) <30 mg/L Soil Absorption System (TSS) <_30 mg/L ❑ NA Fecal Coliform (geometric mean) s104 ❑ In-Ground (gravity) ❑ In-Ground (pressure) r f I NA Maximum Effluent Particle Size Ya in dia. ❑ NA ❑ At-Grade ❑ Mound ❑ Drip-Line ❑ Other: Other: ❑ NA Other: 'C ~~aNA &e44' f MAINTENANCE SCHEDULE Service Event Service Frequency Pump out contents of tank(s) ❑ When combined sludge and scum equals one-third (33) of tank volume ❑ When the high water alarm is activated Inspect condition of tank(s) At least once every: 3 [I month(s) (Maximum 3 years) ❑ NA ® year(s) Inspect dispersal cell(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA year(s) Clean effluent filter At least once every: ❑ month(s) '~.NA ❑ year(s) Inspect pump, pump controls & alarm At least once every: ❑ month(s) NA ❑ year(s) ❑ Flush laterals and pressure test At least once every: month(s) NA ❑ year(s) Other: At least once every: ❑ month(s) $ NA ❑ year(s) Other: 9NA MAINTENANCE INSTRUCTIONS Inspections of tanks and soil absorption systems shall be made by an individual carrying one of the following licenses or certifications: Master Plumber, Master Plumber Restricted Sewer, POWTS Inspector, POWTS Maintainer or Septage Servicing Operator (pumper). 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 a check for any back up or ponding of effluent on the ground surface. The soil absorption system 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 treatment tank equals one-third (Yg) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator (pumper) 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 30 days of completion of any service event. GMW-005 (02/05) START UP AND OPERATION Page of For 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 detected have the contents of the tank(s) removed 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 overload that may result in the backup or surface discharge of effluent and damage to the system. To 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. System start up shall not occur when soil conditions are frozen at the infiltrative 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 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 treatment tanks and soil absorption system: acids, antibiotics, baby wipes, cigarette butts, condoms, cotton swabs, degreasers, dental floss, diapers, disinfectants, fats, foundation drain (sump pump) discharge, fruit and vegetable peelings, gasoline, greases, herbicides, meat scraps, medications, oils, painting products, pesticides, sanitary napkins, solvents, tampons, and water softener brine discharge. ABANDONMENT 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 s. Comm 83.33, Wisconsin Administrative Code: • All piping to tanks, pits and other soil absorption systems shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and property 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. 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 the time of their permit issuance. ❑ A suitable replacement area is not available due to setback and/or soil limitations. If 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 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 TREATMENT TANKS, PUMP TANKS, AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES OR LACK ' SUFFICIENT OXYGEN TO SUSTAIN LIFE. NEVER ENTER ANY TANK UNDER ANY CIRCUMSTANCE. DEATH MAY RESULT. ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK MAY NOT BE POSSIBLE. ADDITIONAL INSTRUCTIONS: POWTS INSTALLER POWTS MAINTAINER Name Name C Phone Phone SEPTAGE SERVICING OPERATOR PUMPER LOCAL REGULATORY AUTHORITY Name Name C, n. Phone ~rs fit' 6 -'°i Phone This document was drafted by the staffs of the Green Lake, Marquette and Waushara County POWTS regulatory agencies in compliance with sections Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. UV/UIi UU TTnJJ tD.uo ran 1D )00 4000 a1' t:Kd (:U ZUNING 10001 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSVIP CERTIFICATION FORM Owner/Buyer ~ Mailing Address Property Address ~~Grr z" _ (Verification required from Planning & Zoning Department for new construction.) City/State Parcel Identification Number LEGAL DESCRI.N'TON Property Location S71 , J7- , Scc, ,1, .r/ N R Towu of Subdivision. - Lot tt Certified Survey Map # Volume , Page tt Warranty Deed # , Volume , Page # Spec house C) yesRno Lot lines identifiable ('I yes r 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 arc specified in §C.omm. 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 anti/or (2) after inspection a,nd pumping (if necessary), the septic tank is less than 1 /3 full of sludge. I/we;, the uudersiglued have react the above requirement,; and agree to rnai.ntain 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 threiyear expiration date. r' I/we certify that all statements of this form are true to the best of my/our knowledge. I/wc am/are the owner(s) of the property described above, by virtue of a arranty deed recorded in Register of Deeds Office. Number of bedrooms J_ - SIG Z OF AI'1'L I ' NT(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 decd. (REV. 08/05) ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) This is to certify that I have inspected the existing septic and/or dose tank presently serving the following residence: (Street address)-2104 cty rd cc somerset wi located at: se 1/4, se 1/4, Section _16 , Town-31 N, Range 18 W, Town of r ; e( r e-4 II r , , St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of SPS. 384.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service _may 2nd 2017 Did flow back occur from absorption system? Yes No_x_ (if no, skip next line.) Approximate volume or length of time: gallons minutes Tank Capacity: _1000 Construction: Prefab Concrete x Steel Other Manufacturer (if known): _un sure / squaw tank? Age of Tank (if known): n/a Permit number (if known) n/a PAUL R KOEHLER (Licensed Plumber Signature) (Print Name) _MP225410 (Title) (License Number) MP/MPRS r (Date) Form to be completed by licensed plumber (Dept of Safety and Professional Services Chapter 305 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 2/2012 ! I ua T C4 F4 ° to Lu LL w ! Q a ac 'V' U to 0 ui 1 IL1 ~ri Ask I I I s DE) I f ~ I r r1 r'" t`a 1 V TTI ~ fur ! ~j ti m T rn 4 -n C3 tu, r' I E ~zl r E j 99 vr i ~ t } rvi > C- 1 A z to Cx1 oss I E