HomeMy WebLinkAbout020-1123-00-031
County: St. CCOIX
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and Building Division INSPECTION REPORT Sanitary Permit No:
GENERAL INFORMATION (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 Holder's Names City Village Township 1 Parcel Tax No:
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
J65, 0-7 '1 a► v. Go ~t.L 7 A-t
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark s~ , Q iaQ tD
/~7c
Alt. BM J I V -1.6
i"~I ~ ~f tTL 5 ~•~C..L J tJ~.- 7
011
Aeration Bldg. Sewer
Holding St/Ht Inlet
St/Ht Outlet
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic Dt Bottom
Dosing f Header/Man. ® 27
Aeration Dist. Pipe -1.19 C:V ,Z
Holding Bot. System U '=Mr. z
Z ~ `
Final Grade L' g 16
PUMP/SIPHON INFORMATION 7
Manufacturer Demand St Cover 5 ✓aL , O
GPM 7
Model Number
C7
TDH Lift Friction Loss System Head TDH Ft
Forcemain Dia. to Well
t_
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenchees~ PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 3
Z
76
SETBACK SYSTEM TO P/L r BLDG WELL LAKE/STREAM LEACHING Manufacturer: It CHAMBER OR •y
INFORMATION Type Of System: I 1
151, UNIT Model Number: 6:ui it, 4f
DISTRIBUTION SYSTEM a
Header/Manifol`i Distribution x Hole Size x Hole Spacing Vent to Air Int e
Pipe(s) ~ ~0 J
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 ulched Bed Trench Center Bed/Trench Edges Topsoil Yes No Yes ❑ No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location:
1.) Alt BM Description =
2.) Bldg sewer length
- amount of cover = x J J
Plan revision Required? ❑ Yes (No
Use other side for additional information. III -J
41n Insepctor's Sig tore Cert. No.
Date
SBD-6710 (R.3/97)
2 A- -1 1 Sf}rV-av17- 13-3
VE D --SAA Of
„ j
MXMSUY Z017 s n • CMMtY
1400 E Wasl~ Ave
{ Yl > MAY 17 P.O. Box 7162 (to be fiW wby Co-)
MadLw P, WI 5370-7162
ST. CROIX COUNTY 5 " 3 3 .
SuftllansacbmNuniber
IOMM Permit Application
to a=nUnix with SPS 39321(2). Wis. i of tttis ibent to the ft Savounummd txsit
is rulyzed P - - a Nth POWTS a =Amued to Project Addr= (if 0krent dom mmling )
tl- Dq=Uftat of Safty anti FroR=xnal Se v es Personal informutma you providC may be use! for
seumdaq
in ==dm= with ttfiz Privacy t avv, s. P s. t m Sus.
1. Avorkafiaz In fpm- tioa i V ! ~
Qv~~S Nwx I, Q)
PIC
yOwnces Mariling,A&tess qty
~`I Jar Gavt- L
city, Static 7i Cc& Pbane Number -
F A LiJ fy r.,
IL TYPe of B ( - ta[3t T 'i N; R > 'f E WW]
apply)
&eek all that E~~ 2 Famdy Dwell m& - Number of el' Subdivision Name
zol
0 City of
Q Stft Owned _ Deseribe Use CSMNualber Q Vawwof
( r~, t _ : ' l 9, ,may : ~ ~ ; -i- 4 / •':.;,,wx ~ !
M 'P'te of Pmm!t- (Che& oaalyr t box eaxa P A. Complete lilac B if appLicabl e)
A- Q NM Syst= s QT
' ag 3' o* ® Odw rtota to lrxisztag Systr.6c (fir) ;
Pama Q Q at Q Tasustr to MW List Prcvious Pit Number
Bcfi= aviral= Owner -2
IV. T"VW of l'~W B S 'ta - Clesxlt xP1 t
WN-P-=dLq-Gmund Q OAt4kade Q > 2k ic- r e s u3 Q Mnd < 24 ase of . .a
, E, (cTL-sin
9 t Q Devitz V. new Info 'ta dam ,x r.. f . .
Llasign Flow ) Design Sail P (sf) Dispcr~ Arca (SO system Hevauaq
tJ ~;J CIL Ff f' r.
Vt. Task Info, CWacity in Tow ti of r xr
CvAtons tunits
n ° u
t3atia Taa3y Yids 4'% c a m
tm 1. the aIa of t&c the Pk-
fit 's (Prime Tr _
i f
c.
plumber-S Addr- ( City. S Cu zrs1) C )
- C*um , t use Only
-1Z3 l
Ix C"a+v-
tii fai ca must all be sorctcns ! nl nt ~ e .
ner
>wE'p~j r
~ragetnttn! plan pta tiae!i by plu.nbe;.
'1. f,~(!0~'alfll~,~Tjt!!i(,.CIE i.'IaiYt~.:lf".E~
as psr oppOw6b codn / rtfinal on. ,
R I~ r s " fa t 2 w x I I Lmei is s
SPii3-6398 (R 09114)
PAGE 1 OF 4
In-Ground Gravity Plan
Index & Cover Sheet
Component Manua! Design References:
Version 2.0, SBl*3-107 P (N.01/01, R. 10112)
index & Gayer Sheet
of Plot Plat
3 of Dispersal Area Cross-Section & Plan View
of 4 Management Plan
Attachments: Enclosures:
OWTS Application for Review
Sort Evaluation Report Site Map
Project Name eseriti
Owner Name(s) Phone:
r -
zip: Project Address:
God Lot: Iv 114 of ~1 /4, Section ~T Z`f -R ED or V1t',
Township: County
Project Parcel 10 r 2
Designer Information
Designer Name: /V"~ AP,,\/ -dvw~r_(,-_T Phone: -))5 -
t -
Designer Address: _;7' E
E-mail: E' i S a cd St i¢ l €?l t ~~Ul G~'r1 This
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L1cen r 8 - &p
Remarks: k gmm
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PAGE 4 OF
In-ground Gravity Management Plan
IMPORTA N7:
The owner of this in-ground gravity system shall be responsible for its perpetual operatJon and maintenance pursuant to
requirements of SPS 382-384, Wisc. Admin. Code. Pursuant to SPS 383.52 (2), isc. Admin. Cade, this system shall
be considered a human head hazard if not maintained in accordance w h this approved management plan.
f=urthermore-, all inspection and maintenance activities shall be performed by a registered POW TS Maintainer in
accordance with STS 383.82 (3), Wisc. Admin. Code.
Maximum Di ersal Area Operatinq Limits:
Design Flow= gpd; 5 :5 20 rngL,"'; T :5'150 mgL-1; FOGS 30 mgL"
lp,gMction Checklist INSPECT EVERY 3 YES
a type of use
o age of system
o nuisance factors (i.e. Mors, user complaints, etc.)
o mechanical malfunction (i.e., pumps, valves, switches, floats, etc.)
o material fatigue (i.e., leaks, breaks, corrosion, etc_)
o solids volume in anaerobic treatment tank(s) and any distribution appurtenance(s) (i.e., distribution ! drop boxes)
neglect or improper use (i.a., exceeding design capacities, prohibited activities, etc.)
o extent of nding in distribu. on cell prior to dosing
dosing irraguiari ies - if applicable (i_e., pump re-cycling, ficat switch settings, etc.)
o electrical components - if applicable (i,e., wiring, connections, switches, controls, timers, alarms, etc.)
o distribution lateral or lateral orifice plugging (measure lateral distal pressure compare to design specification)
o surface discharge of effluent or savage back-up into structure served
Maintenance Checklist MAINTAIN EVERY 3 YEARS (ter when necessary)
o Septic and dose tankfs) shall be pumped by a certified septage servicing operator licensed under s_ 281.48 Wis.
Stats. when the volume of lids in the tank(s) exceeds one-third (113) the liquid volume of the tame(s) or
as required by local ordinance. Disposal of contents shall be pursuant to NR 113, V isc. Admin. Cade.
o went It s) shall be inspected every years and shall be cleaned when necessary to remove any
accumulated solids according to manufacturer's specifications. A servicing period will always be greater than 12
n?cnths.
Systom imintanance repot shall submitted to the proper local government omit in accordance with
SPS 383.55 Wisc. Admin. Code. Report any component failure or malfunction to:
Name of individual or company A:~ •c> ~i °;t. L~ i.1 i Phone:
Local government unit: ~k Gk" 'x.4 (/Vy f 0, . Phone:
Local government unit address: ZIP: ~ 't 4
Any defective part of this system shall be repaired, replaced, or removed pursuant to SPS 383.51 (1), Wisc. Admin.
Code. Repair or replacement of failed or malfunctioning components shall comply with SPS 383, Wisc. Admin. Code.
No product for chemical or physical restoration of the POWTS may be used unless approved by the department in
accordance with SPS 384,114lisc. Admin. Code.
Continency dart
in the event that any failed treatment component of this POWTS cannot be repairers, it shall be replaced pursuant to
a plan submitted to the appropriate agency for review and approval. A failed in-ground dispersal component may be
abandoned and replaced by a code-Complying dispersal component in a pre-determiners area of suitable soils.
System Abandonment
If use of this Pt3WTS is discontinued, it shall abandoned in accordant with SPS 383.33, Wisc. Admin. Code.
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The,QuU4 Standard Cir arr ber fits ir, a 36" wide trench
and is ideal for curved or straight stysterns. It features the
patent-pending Contour Swivel Connection°.. which permits
trans up to 15", right or left. The MultiPort,'-, endcap alloys
,r
multiple piping options and eliminates pipe fittings. The
chamber's four-foot length provides optimal installation
lexibility.
Advanced contOU. in,] connections svvivel up to
right or left
L ding mechanism aiiows for quick; installation *1 09
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