HomeMy WebLinkAbout038-1034-80-000 (2)
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
(ATTACH TO PERMIT) 597343
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:
Edward J Tichenor Revocable Trust TOWN OF STAR PRAIRIE 038-1034-80-000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
08.31.18.154C-1
TANK INFORMATION EL ATI DATA
TYPE MANUFACTURER IV C7 3 CAPACITY STATION BS HI FS ELEV.
02 1 Ain A
Benchmark IHAL 41 152`
Septic 0VO
C44 J
Dosing Alt. BM
ow
F S t Inlet
~
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO P/L WELL LDG. Vent to Air Intake ROAD Dt Inlet
v
Septic Dt Bottom
Dosing Header/Man.
Aer tion Dist. Pipe
Holding Bot. System
Final Grade
PUMP/SIPHON INFORMATION
P
Manufact Demand St Cove
del Number
DH Lift Friction Loss System Ft
Forc Dia. ~D,t. to Well
SOIL AB ORPTION SYSTEM
BED/TRE H Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits nside Dia. Liquid Depth
DIMENSI NS
SETBA K SYSTEM TO P/L BLDG WELL LAKE/ M LEACHING Manufacturer:
INFORMA ION HAMBER OR
Type Of System: T [11.del Numbe
DISTRIB TION SYSTEM
Header/Manifold Distribution x Hole Size x Spacing ent to Air Intake
Pipe(s)
Length Dia Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Moun t-Grade Systems Only
Depth Over Depth Over epth of 1xx seeded/Sodded T Mulched
Bed/Trench Center des Topsoil
Yes F] No E] Yes ] No
COMMENTS: (Include code discrrepencies, persons present, etc.) Inspection #1: / Inspection #2:
Location: 2236 100TH ST ~
1.) Alt BM Description OA y ~j~,~(,.ns lv~f--U
2.) Bldg sewer length V/V~ ~~IJ / V / b
- amount of cover - lul f
~iSilN(~ 1x ~n~ WSignat Plan revision Required? ❑ Yes ~ No Use other side for additional information. ICert. No.
SBD-6710 (R.3/97) 1tA I -V ^ no"
SAN -a0
County
~ Y Safety and Buildings Division
C
S 1/ 201 W. Washington Ave., P.O. BOX 7162 Sanitary Permit Number (to be filled in by Co.)
PS rl Madison, WI 53707-7162
IVA A)'
ST. CROM& State Transaction Number
t~~ rv$ermit At
LL
In accor ce wi SPS 383.21(2), Wis. Adm. Code, submission or u_ le govZ'rntntnta] unit 1 /
is required prior to obtaining a sanitary permit. Note: Application forms foi submitted to Project Address (if different than mailing address)
the Department of Safety and Professional Servies. Personal information you prove. -ndary
purposes in accordance with the Privacy Law, s. 15.04 1 m , Stats.
1. Application Information - Please Print All Information
Property Owner's Name Parcel #
i
Property Owner's Mailing Address Property Location0~ V$ I S'4 G- I
7 Govt. Lot
City, State Zip Code Phone Number
4 -j E Section
(circle one
~Zk
11. Type of Building (check all that apply) Lot # T 7 N; R L E o
Subdivision Name
1 or 2 Family Dwelling -Number of Bedrgtfns
. o
Block # ,r
❑ Public/Commercial - Describe Use ❑ City of
CSM Number ❑ Village of
❑ State Owned -Describe Use
Town of
III. Type of Permit: (Check only one box on line A. Complete line B if applicable)
F
A.
❑ New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain)
❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued
B• ❑ Permit Renewal ❑ Permit Revision
Before Expiration Owner
IV. Type of POWTS System/Component/Device: Check all that apply)
❑ Non-PressurizecTIrr-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. Dispersal/Treatment Area Information:
Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation
VI. Tank Info Capacity in Total # of Manufacturer
Gallons Gallons Units o v
New Tanks Existing Tanks o d 2
aU m wC7 a
Septic or Holding Tank
Dasmg-Ehwnber q
VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS showu on the attached plans.
Plumber's,Name ((P tint),-7 Plumber' Signgture: MP/MPRS Number Business Phone Number
Plumbers Address (Street City, State, ip Code)
VIII. Coun epartment Use Only
,Ai iiroved El Disapprove 4 - Permit Fee Date Issued Issuing Agent Signat~e ,
❑ Owner Given Reason for Denial
IX. Conditions of Approval/Reasons for Disapproval M VU n V
SYSTEM OWNER: L-5), ~ ~
1. Septic tank, effluent filter and (~a;r~~'e `d 7n~" ad feM Ned hl~l ~l
dispersal cell must 0-591viced /_maintained
as per management plan provided by plumber.
2. All se t ans for a system and submit to the Cou ty onl on paper t less than 8 in x 11 inches in ize
as per applicable code/op rngnces. r~ J r~
f 11 7~a
SBD-6398 (R. 11/11)
~
f Plau AtA #11 P6V* sJ1411 b~e PbOd Ufe el
Coop . ~ l.. - _ r ,
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATLAIENT
FOR UTILIZATION OF EXISTI' 6SEPTIC TANK(S)
This is to certify that I have inspected the existing septic and/or dose tank
presently serving the following residence:
(Street address)_ j>7'1 J1 located
at: /~4, Section 3 Town N. Range 1,e W.
Town of 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 Comm. 84.25, and it (they)
appear(s) to be functioning properly.
Most recent date of inspection or service
Did flow back occur from absorption system? Yeses No
(if no, skip next line.)
Approximate volume or length of time: gallons minutes
Tank Capacity:
Construction: Prefab Concrete Steel Other
Manufacturer if known):
r
Age of Tank (if known): ,
Permit nuz bey (if kno'~~,n) X71
l
-
(Licensed P umber Signature) (Print Name)
h9'~
(Title) (License Number) MP/MPRS
~
711
(Date)
Form to be completed by licensed plumber (Dept of Commerce Chapter 5
and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin
Administrative Code)
Rev. 9/2008
CONCRETE HOLDING TANK DESIGN
Single Combo Tank Option
INDEX AND TITLE SHEET
Project Edward J Tichenor
Owner Edward J Tichnor
Address 2236 100th ST
Somerset WI 54025
Legal Description NE-SE-sec8-T31 N-R18W
Township Star Prairie County St Croix
Subdivision Name Lot No. 1
Parcel ID Number 038-1034-80-000
Plan Transaction ID Number
Index and title sheet Page 1
Holding tank specifications Page 2
Site plan Page 3
Maintenance and contingency plan Page 4
Holding tank Agreement Page 5
Holding tank servicing contract Page 6
Designer Kim A Oconnell.)
Signature Phone No. 715-381-7917
License Number 224263 Date 05/16/17
Designed pursuant to:
Holding Tank Component Manual For POWTS (Version 2.0)
SBD-10855-P (N. 03/07, R. 01/12)
Version 7.0 (11/12) Pagel of 6
HOLDING TANK SPECIFICATIONS
t_3 Number of bedrooms
Non-residential estimated flow (gpd)
2000.0 Minimum holding tank volume required (gal)
Side A Side B Total
1000.0 600.0 1600.0 Proposed tank capacity (gal) Proposed tank size is too small.
Wieser Tank manufacturer 4:
WLP1000/600-MR Tank model number '
Rhoumbs Alarm manufacturer
101 HW Alarm model number
Tank Dimensions and Data Tank Anchor Calculations
X for round tank 14970 Ibs Weight of tank and cover
36.0 Liquid depth below inlet invert (in) 1.00 Safety factor
8.0 Maximum depth of soil cover (ft) 10510 Ibs Weight of anchor required
56.0 Height (in) Outside 14.4 in Soil cover req. for anchor or
150.0 Length (in) Dimensions 2.6 yd' Concrete counterweight
84.0 Width (in) Only
HOLDING TANK CROSS SECTION
Electrical complies with NEC 300 and SPS 316
optional vent pipe
vent pipe manhole cover with finished
location locking device and grade
junction warning label
box
4" min. 4" min.
F- 23 in. „
conduit
18" min.
thether -
/ weight Note: All tank joints, and joints -
IG between tank openings and building sewer
alarm I on piping are sealed watertight. All inlet
blind plug
to seal pipe and vent materials comply
outlet with SPS 384. Manholes with
90% Full 30.2 in locking device are typical for each
manhole opening .
Side A 1000.0 gal _ 600.0 gal
3 in. bedding under tank. Tank is anchored as necessary to negate buoyancy.
Project: Edward J Tichenor
Transaction Number: Page 2 of 6
HOLDING TANK SITE PLAN
Project: Edward J Tichenor
N Legal Description: NE-SE-sec8-T31 N-R18W
Subdivision Name:
Scale: 1" = 40 ft ; Parcel ID: 038-1034-80-000 Lot No.: 1
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Transaction I.D.: Page 3 of 6
HOLDING TANK MANAGEMENT PLAN
This Private Onsite Wastewater Treatment System (POWTS) has been designed, and is to be installed and
maintained according to SP 383, Wis. Admin. Code, the Holding Tank Component Manual (SBD-10855-P
N. 03/07, R. 01/12), and the St Croix County Sanitary Ordinance.
1. This POWTS is designed to accommodate a wastewater flow of 60 to 320.0 gpd.
2. The owner of this POWTS is responsible for system operation and maintenance, including all provisions in
the attached Holding Tank Servicing Contract and Maintenance Agreements.
3. Each time the wastewater in the tank reaches 90% of the tank(s) capacity or a level of 12" below the inlet
(at which time the alarm will activate), the pumper listed in the current Servicing Contract must be called to
empty the tank's contents and dispose of them in accordance with NR 113, Wis. Adm. Code.
4. At each service event, the service provider should visually inspect the condition of the tank, risers and
manhole cover(s) and verify that the alarm system functions and manhole locking devices are present.
Discrepancies are reported to the owner in a timely manner for corrective action. All corrective actions
shall comply with the county sanitary ordinance and SPS 383 and 384 Wis. Adm. Code.
5. All service events or inspections of this POWTS shall be reported to the county within 30 days.
6. The owner may not remove any of the wastes from the holding tank(s), or cause such wastes to be
removed by any person not authorized to do so under Ch. 281, Wis. Statutes. The discharge of wastes
tank to the ground surface, including intentional discharges and discharges caused by neglect, constitutes
a failing POWTS and may result in issuance of correction orders or a citation by the county or state.
7. No one should enter a holding tank for any reason without being in full compliance with OSHA standards
for entering a confined space. The atmosphere within these tanks may contain lethal gases, and rescue
of a person from the interior of the tank may be difficult or impossible.
8. In the event that this POWTS fails and cannot be repaired, a code compliant replacement holding tank
may be installed in the same location (a new sanitary permit is required for such a replacement). Con-
nection to municipal services would also be considered at this time if they are deemed available to the
property.
9. If this POWTS is replaced, or its use discontinued, components no longer in use it shall be abandoned in
accordance with SPS 383.33 Wis. Adm. Code.
10. If there is a problem with, or question about this installation, the following persons maybe contacted:
a. Installer...... Kim A Oconnell Phone: 715-381-7917
b. Service Provider Phone:
c. Co. Zoning or Health Dept. St Croix CTY Zoning Phone: 715-386-4680
11.
Project: Edward J Tichenor
Transaction Number: Page 4 of 6
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SEPTIC or HOLDING TANK SERVICING CONTRACT
Contract Date
This contract is made between the
Tank Owner(s) Name(s) and Pumpe's Name
We acknowledge the installation of (a) septic/holding tank(s) on the following property:
(Provide legal description):_
i
1. The owner agrees to file a copy of this contract with the local governmental unit (St. Croix County
Planning & Zoning Department) to document maintenance by a certified septage servicing operator as
required in Comm 83.52(1)(c)2. Wis. Adm. Code and the approved Component Manual.
I
2. The owner agrees to have the septic/holding tank(s) serviced by the undersigned pumper and guarantees to
permit the pumper to have.access and to-enter,apon the property for the purpose of servicing the
septic;/holding tank(s). The owner agrees to maintain the access road or drive so that the pumper can
service the septic/holding tank(s) with the pumping equipment. The owner further agrees to pay the
pumper for all charges incurred in servicing the septic holding tank(s) as mutually agreed upon by the
owner and pumper.
3. The pumper agrees to submit to the local governmental unit (St. Croix County) a report for the servicing of
the septic/holding tank(s) on a monthly basis. The pumper further agrees to include the following in the
monthly report:
a. The name and address of the person. responsible for servicing the septic/holding tank;
b. The name of the owner of the septic/holdmg tank;
c. The location of the property on which the septic/holding tank is installed;
d. The sanitary permit number issued for the septic/holding tank (if Imown);
e. The dates on which the septic/holding tank was serviced;
f. The volume in gallons of the contents pumped from the septic/holding tank for each servicing;
g. The disposal sites to which the contents from the septic/holding tank were delivered.
I
4. This agreement will remain in effect until the owner or pumper terminates this contract. In the event ofa
change in this contract, the owner agrees to file a copy of any changes to this service .contract or a copy of a
new service contract with the local govermnental unit named above within ten (10) business days from the
date of change to this service contract.
Owner(s) Name(s) (Print) Owner's Signature(s) Subscribed and sworn to me on this date:
/ Today's Date
Pum, pper's Name (Print) Pumper's cSignature Notary Public Signature '
! C``
Pumper's ,Registration Number Commission Expiration
Document Number Document Title
St. Croix County
Holding Tank Agreement
J Permit Number -
t2
Name - (Owner) Typed or prim e
being duly sworn, states, under oath, that:
1. He/she is the owner/part owner of the following parcel of land
located in St. Croix County, Wisconsin, recorded in Volume
Page Document Number St. Croix County Register
of Deeds Office: Recwdln area
A parcel of land located in the of the t/, of Section Name and Returrr Address
,T~N-R fc W, Town of
St. Croix County, Wisconsin, being
duly described as follows (include lot no, and subdivision/CSM or
detailed legal description):
/ 7 Parcel Identification Number (PIN)
Agreement Date: L V
We acknowledge that application is being made for the Installation of (a) holding tank(s) on the above described property or that continued use of
the existing. premises requires that a nodding tank be Installed on the property for the purpose of proper containment of sewage. Aiso, the property
cannot now be served by a municipal sewer, or any other type of private onside wastewater treatment system as permitted under Ch. SAS 383, Wis.
Adm. Code, ar Ch. 14-5, Wis, Stats.
As an Inducement to the county to Issue a sanitary permit for the above-described property, we agree to do the following:
1 . Owner agrees to conform to all applicable requirements of Ch. SPS 383, Wis. Adm. Code relating to holding tanks. If the owner fails to have
the holding tank properly serviced In response to orders issued by the governments[ unit or the Department of Commerce to prevent or abate
a human health hazard as described In s. 254.59, Stals., the governmental unit (Town) may enter upon the property and service the tank or
cause to have the tank to be serviced and charge the owner by placing the charges on the tax bill' as a special assessment for current
services rendered. The charges will be assessed as prescribed by s, 66.0703, Stale.
2. The owner agrees, pursuant to s. SPS 383.54 (2), and SPS 382,40(3)(e), Wis. Adm. Code, to have a water meter Installed In the structure.
The water meter shall be installed by a plumber authorized by the Department to make such installatlons, with said Installation complying
with State regulations and manufacturers specifications. The owner agrees to be financially responsible for the purchase, Installation,
maintenance, and repair of the water meter, and agrees to Dow the governmental unit or the Department of Commerce to enter the above- '
described property on a regular basis to read andlor inspect the water meter.
3. Owner agrees to pay all charges and costs incurred by the governmental unit or county for Inspection, pumping, hauling, or otherwise
servicing and maintaining the holding tank In such a manner as to prevent or abate any human health hazard caused by the holding tank.
The governmental unit shall notify the owner of any costs which shall be paid by the owner within thirty (30) days from the date of notice. In
the event the owner does not pay the costs within thirty (30) days, the owner specifically agrees that all the costs and charges may be placed
on the tax roll as a special assessment for the abatement of a human health hazard, and the tax shall be collected as provided by law.
4. The owner egress to contract with a person who is licensed under Ch. NR 113, Wis. Adm. Code, to have the holding tank serviced and to file
a copy of the contract with the governmental unit The owner further agrees to file a copy of any changes to the service contract, or a copy of
a new service contract, with the governmental unit within ten (10) business days from the date of change to the service contracL
5. The owner agrees to contract with a person licensed under Ch. NR 113, Wis. Adm. Code, who shall submit to the county on a semiannual
;basis a report datatitng the servicing; of the holding tank. The govemmertal unit or county may enter upon the ,property to indestigaEa Rte
condition of the holding tank when pumping reports and meter readings may indicate that the holding tank is not being properly maintained.
6. This agreement will remain In effect only until the county office responsible for the regulation of private onsite wastewater treatment system.
certifies that the property Is served by either a municipal sewer or a private onsite wastewater treatment system that complies with Ch. Comm
83, Wis. Adm. Code. In addition, this agreement may be cancelled by executing and recording said certification with reference to this
agreement to such manner which will permit the existence of the certification to be determined by reference to the property.
7. This agreement shall be binding upon the owner, the heirs of the owner, and assignees of the owner. The owner shall submit this agreement
to the register of deeds, and the agreement shall be recorded by the register of deeds in a manner which will permit the existence of the
agreement to be determined by reference to the property where the holding tank is Installed.
Owner(s) Name(s) - Please Print, Subscribed aadswom to before ms on this date:
Not4ad Own Signature(s) Notary Public
Governmental Unit Official Name, Title - Please Print My Commission Expires
Governmental Unit Official Signature Drafted by:
Personal information you provide may be used for secondary purposes [Privacy Law s. 15.04(1)(m)]
"THIS PAGE IS PART OF THIS LEGAL DOCUMENT - DO NOT REMOVE"
This information must be completed by submitier document title name 6, return address, and PtN (if required). Other Information such as the
granting clauses, leagal description, etc, may be placed on this first page of the document or may be placed on additional pages of the
document. Nola. Use of this cover-page adds one page to your document and 22.00 to the rec.4rd1na fst,. Wisconsin Statutes. 59.43.
S 1 111 I ~ l j
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"It FILED
JUL 22 1977 'Q o w X
p+ JAMES O' CONNELL _
o°
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