HomeMy WebLinkAbout032-2156-80-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit NC:
(ATTACH TO PERMIT) 597394
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:
KIMBERLY WEE TOWN OF SOMERSET 032-2156-80-000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
I 3i`, f, , # 12.30.19.1350
TANK INFORMATION ELEVATION 16A
TYPE MANUFACT R CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
'.Y r~ ~~j i.'j~"~ ~ 6~ ~ 1 (/{d .J V ~J
per- Alt. BM
A&,9 i Bldg. Sewer
St/ t Inlet' 12
TANK SETBACK INFORMATION ~,tAf it ) toutlet {p / S
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet C}
Dt Bottom
Septic e J
Dosing H n. 0 ,
Aeration Dist. Pipe -a
T
Holding Bot. System 9~ 1 C ~Cra
Final Grade
PUMP/SIPHON INFORMATION 3 q
Manufacturer Demped, St Cover Q
Model Number J o~J
TDH Lift Friction Loss System Head TDH Ft
Forcemain Length IDia. Dist. to Well
SOIL ABSORPTION SYSTEM '
BED/TRENCH Width ? Len~~: No. Of Trenches i PIT DIMENSIONS No. Ot.P s Inside Dja- Liquid Depth,,.
DIMENSIONS t ; 1 ti "
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacture
INFORMATION CHAMBER OR
Typ
e Of System ¢ y r UNIT Model N erg
'Lid i
DISTRIBUTION SYSTEM
Header/Manifold s, Distribution x Hole Size Ix Hole Spacing Vent to~Air Intake 1
L4 Pipe(s) 1-11
Length ~~-Dia I LeAlJfF-" Dia Spacing c I 1! t
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 Cente Bed Trench Edges To epiL _
i p Yes No Yes I` NO
t
COMME TS: nclude code discrepencies.. persons present, etc.) Inspection #1: Inspection #2:
Location: 879 167TH AVE`
1.) Alt BM Description =~,v y~ o* w C
2.) Bldg sewer length = IVh
- amount of cover
Plan revision Required? Yes No " "i. I
Use other side for additional informatig'
L~L Date Insepctor's Signature Cert. No.
SBD-6710 (R.3/97)
T-- County ~ i
RAG9R38MOC1 JY 5 _
2 Sanitary Permit Number (to be filled in by Co.)
ps CU Nlac ~oti. W -37u7--7162
CoU
ST 5173 9 Z
. RO )VELOPME
State I7ansacti(m,Numher
Sanitary Permit Application NN~/+~~'
In accordance with SPS 383.21(2). Wis- Adm. Code Submission o: this form to the appropriate oyernmentat unit
o-ins for suite-owned PONY, are submitted to Project Address (if different than mailing address)
s required prior to obtaining a sanitary permit Note: Application
he Department of Safety and Professional Seryies. Personal info anon you nroaide may be used for secondar)
purposes in accordance with The Pi n ac} L in s. I ? 44(1 }(m), S tats.
j L Application Information Please Print All Informatio 79 Ito
Property Owner's Nam, Parcel 4
00
Property ONyneC s Mailing Add,- , - - - --~9-- proms tc Location Id 2Q q 5L~
Govt Lot✓
e~
Cri}'. State Zip Cidc ~Fhorn Number J fr^_
Section
YN_ iz~ieli.(-~
11. Type of Building (check all that apply) ' / (-)t P - -
`~u'tfd on Na:n
or 2 Family Dwelling - Number of Bedrao;r~s _ _
i
Block #
6kN:
Public/Commercial - Describe Use City of
C _
ta- C.R Nriintx r iof s(c c w_
L~ State Owned - Describe Use
,
1II. Type of Permit: (Check only on box online A. Complete line B if applicable)
A kNew Systcm L Replacement System 1 ❑ l ceatmentlrlolding Tank Replacement Only ❑ Other Modification to Existing System (explain)
List Precious Permit Number and Date Issued
13. Permit Ienewal ❑ Permit Revision Change of Plumber ❑ Permit Transtter to New
Before Expiration Ow~t,r
J V. T e of PON TS SvstemlCom nent/Decice: (Check all, that apply)
r I
table soil
XNon-Pressurized InAirowrd - P,t,t. ized Its Grsund ~ At-Grady Mound'> 24 in of suitable soil ❑ Mound <24 i (sui
loldmg fink J Oil 'r Dap rsaf ConFxf .eat (c1p1 - - l iti n i De i, e (explain)) _ -
V Dispersalffreat nt Area Information:
Design flow (gpd) Design Soil Application Rate.( st) Dispeis,al Area Reqwred (st Dipersal Ai -aPioposcd (s S% c i El yatq~n
,~r! ~ ~ / VVV
AT Tank Info 4 Capacit} in Total of Manufacturer
I
\n T,I-nK CidiioI s1sitin_ 7ar:1., _ C7ai1011 Unit"
/ /r//~ 1,6k ' r s L
pea
Septic or Helc[i
F
Dosing Chamber
~ I
II Responsibility Statement 1, the undersigned v,.,un e responsibility for installation of the PONNTS shoran on the attached plans.
r
Plurt ; r Nam„ [Prat l ?n r"x r rnatur y !MFRS Number Business Phone Number
KA
Plum r s addre ( i °t Cih, State. LiI) Code) /
N'Ill. ntv/De artmentUse Only
Perriit}c, Date l sa i _ Issuing not Signature
pprorcd s.appro ed.
Condit asgnt tarj)asapprovat
r it' eztlt.w,; tl a rId
3) a a.w.e (rQG~i
t3isper...+i cell lust all be rcns! r? rota{ec J
sS per Management plan r u hued by plu+nbe:. 366
Z. Aq ttE.k rlGt+lrBt'tlttlrS mtl'at be t"tatnt 11 E [ rd~ 1 J
is psr *W*m i rt d I t.rdinaanon. r ~1 ` f {V•~
ry41
r¢aci+ to complete pions for the system and submit to the County nly a nL of less than 8 riz X11 inches iI si~e
XM,JOX
- 40
~Isl)_(,95Ii.. ~.1t1 5 ~ per- 5 S
~r
a~raJ ,
13 ~1-36
7y
3c
DL,
fi ~ \
~P
t
t"j $4 t'
Resicientiat Application
INDEX AND TITLE PAGE
..-.xjr7er's Name:
A
f
Number
;fie ~x -m • _
age L ?,r" P'a.n
g=age 3 System S, ;ra & Cross-secticll
ce 4 °er cue;
5 or
^ 0. • ^
age ? St Crcix Cy Seat c Ta^K %la ntena
age 6 '-'Varna ty Deed _
Q g CSI'v" p a"
i~e^se Number.-
--P (N.02;0+)
j - y 36
c
J ,,J
(A
4
y ~
t.
Soil Absorption System Cross Section
Final Grade
4' SC-s:;.. e 40
e
{ PVC,.'=--- pip ft
V~1:: Cap
reaching
Chamber ft
ystem Elevation
f ft
Soil Absorption System Plan View
~v
ft ~ Vent Or Observation Pipe ~ C~amtbe~ ~ Trench 1
4„ Dia.
Trenr- 2 Header
Leaching Chamber S ecifications
L
Manufacturer And Model 1n
L
EISA Rating so ft per chamber Soil Apc'caion Rate 9pdlsa ft
i
L gpd Design Floor x Soil Application Rate D~ EISA Chambers
2 ro~Ys of Lq 9, chambers ear-^
C-)
Page of
(EFFECTIVE LENGTH!
I ncill
2-
F X31 {
~ r
1
Q
B" INVERT 5 3 INVERT
8' IN\ ERT ! , t I f
R 2' -
- _
2J' INVERT g U vvvvv\'~~v~w -
,d PIUS Standard Cn tats°~~~ ° specifications
t
';.221.4436
J `S
f- r
~ X7"1 'j`' --(~.®rr.,✓°`' ~ ~ ~~~~-C7-i
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co Ja
G
37- J cn
s m
fl""
m ~
FTI
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Y
START UP AND OPERATION
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of Painti Page er of
that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detect
of the tank(s) removed by a septage servicing operator prior to use. ng products or other chemicals
detected have the contents
System start up shall not occur when soil conditions are frozen at the infiltrative surface.
During power outages Pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be
discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or s
effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator
power to the effluent P surface discharge of
restore normal levels within the prior to restoring
pump or contact a Plumber or POWTS Maintainer to assist in manually operating the
Pump tank. Pump controls to
Do not drive or park vehicles over tanks and dispersal cells. Do not drive
within 15 feet down slope of any mound or at-grade soil absorption area.
or park over, or otherwise disturb or
compact, the area
Reduction or elimination of the following from the wastewater stream may improve the performance and
POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; dis
foundation drain (sump pump) water; fruit and vegetable peeling gs prolong the life of the
painting products; pesticides; sanitary napkins; tampons; and waterssoftenler brine ase; herbicides; meat scraps; med c taons; fo I;
ABANDONMENT
~ Ihen the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure
property and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code:
that the system is
• All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed.
• The contents of all tanks and pits shall be removed and properly disposed of by a Se to
• After in P ge Servicing Operator.
pump g, all tanks and pits shall . excavated and removed or their covers removed and the void space filled with
soft, grave} in another inert solid material.
CONTINGENCY PLAN
( the POINTS fails and cannot be repaired the following measures have been, or must be taken, to provide a
rcpiace;men* system:
code compliant
suitable replacement area has been evaluated and may be utilized for the location of a replacementsoil
system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by
absorption
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 mu
comply with the rules in effect at that time.
must
A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS
technology a holding tank may be installed as a last resort to replace the tailed POWTS.
T aluati
r be
e ase
rq){ 4(3 TTet" h/~,J a o ing ~a ,
duie 11
x_! Ir0ound and at-grade soil absorption systems may be reconstructed in place following removal of ShUC~1
infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that Lime.
WARNING> > biomat at the
EPTiC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND!OR INSUFFICIENT OXYGEN.
I=NTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT.
PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. DO NOT
RESCUE OF A
i DITIONAL COMMENTS
:)WTS INSTALLER
Name ! =9::iZE POWTS MAINTAINER
Name Name
Phone
Phone
PTAGE SERVICING OPERATOR (PUMPER}
Name LOCAL REGULATORY AUTHORITY
Phone Name 5 <
y
Phone / 1C~~~
> document was drafted in ^ 7i. 9 4
ompfinnce with c:hnPt0, ::;nrnm 83 2 t2) b)~1 id)8,If) and
5 411 A?) s. Z7") ...ICY i.,_rntwF, I"r;il
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNS SHIP CERTIFICATION FORM
Ownet°/i3uver _
Mailing Address ~+_!Q
Property Address
(Verification required from Planning & Zoning Department for new construction.)
City/State Parcel Identification Number
LEGAL DESCRIPTION
Property Location ' 1 1
-5/-- % ,See. '1- 3 ~ R Il own of zsc7't'~~
Subdivision Plat: _ Lot #
Certified Survey Map # Volume , Page,
Warranty Lleed f.
-6_/__ (before 2007)Volume . Page
spec house 4-11ti Lot 1;1":
SYSTEM MAINTLNANCE AND OWNER CERTIFICATION
Improper use and maintenance of your septic s}stem could result in its i~ -
maintenance consists of pumping out the septic tank every three years or sooner, itrleeded, by a ficcn,ed 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 are specified in t)SPS. 383.52(1) and in Chapter 12 - St. Croix: County Sanitary Ordinance.
he property, owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the
ouncr anti by a master plumber. journeyman plumber. restricted plumber or a licensed pumper verit} ing that (1) the on-site
wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary-), the septic tank is
less than 1/3 full of sludge.
I/we, the undersigned have read the aboi e requirements and agree to maintain the pri-ate sewage disposal system with the
Standards set forth, herein, as set by the Department of Safety And Professional Services 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 three year expiration date.
I %%o certify that all statements on this form are rue to the best o, rm, our knowledge. I ~t c <tm 'are the owner(s) of the
zicscribed above, by virtue ofa warranty- dee -ccorc:ed in iZ~ ~.ster i~. Deet;ti Of:icc.
Number of bedrooms _a_^
S iNATLJRE OF APPL1CA1VT(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 liom the Register of Deeds Office and a copy of the certified survey map i t
reference is jn,i(!C ;'le
(RLN'.04/12)
-
5 _ R W.L - sus %
v 10
3.OOF1 ACM _ - 12
1306M 90 Fr i 3jM ACS i 3km90Fr 2,0 1
;
E 3.000 ASS
t a 4 130 60 80 Fr ;
- -
FFE W7.5
HAL - 92&S 121.W
a
WaLWOWMA
i ~fem.
C~fT$I~p'TYfQIL~ / , r-/ R 1
7t~IlORAIft~~ 1 V
eMMlR Tfl AR 3.000 ACM
IIO EXrE OK M KW.L 924A tm)m SQ F
FFE - 9&0,p o r ±
8 ,
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130OZ 90 FT j' - 3.M6 AC HM
MOn 90 Fr
3.003 ACFES
! 130,9 90 Fr ;
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k rr i
MW ; .'!242.324237 ~
kNSass~~•e ~azo.~ar
ALL44M M COUNTY OMMMN ~ T - O.H.W.AA OROR*W"am WOK Ma IMAM
ax*a 1 MDNL AMNT FOk M3 r EgrABLM HW BY Sr. CAM COUNTY
_ ZO1rt~0 OMI'IC! ON 1 QId0yD1.
I? i MUM 11Ou C1mAETM W4N we r r~+ 1~
1, a STOW 1t WAIM FKtBNnM AREA
Y O at<r 2 3WUUTNN C 6VAKM X IV LONG
PM VA O *NQ S'ft Los, PER LtWAR FOOT ~ . - _
3Q ltt1.T11' lA TT
000000M PRRVIOUL4Y 1tOCOIWGp
EX FENCE
NOM. ALL COM LOT OOmmow MONL*Awaw StM 10
VAT" I* OLnjW9 OWMRM We IV LOO /ION PROPCOM DFVW
PMT W11K*04Q I.is Lai. PM L11~ rom
H.W.L. HIM WATM LM B EVATION
ALL dM"1F LJ.~l i. A rKAM POVEMM
7w Ol IQ" - 1017 RDAOWAY SETBACK
O 1 06 ~p 9c ~ ~ ,ioirTr oFM FAeE3MErTr
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
County s } 0 1
Attach complete site 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 Parcel I D.
percent slope, scale or dimensions, north arrow, and location and distance to nearest road.
Please print all information. by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). S t7 3
Property Owner Property Location
,C~a Govt. Lot SG 1141,)E114 S T ZC-) N R E (or~
Property Owner's Mailing Address Lot # Block # Subd. Name or CSM#
1353 A `fee 7r. - i hl s
City State Zip Code Phone Number ❑ City ❑ Village [JI TovifO Nearest Road
44 U8 ---6n I W t 3 Ito I (Iii )64q- ~4-731
Same l-1~~
[2]-New Construction Use: Residential / Number of bedrooms -6 Code derived design flow rate 5 Ce 0 GPD
Replacement Public or commercial - Describe:
Parent material CCU l~-~~5~ Flood Plain elevation if applicable AJ /4 ft.
General comments g . (O
and reco mendations:3~!s4rn -e,ev, ~b ~UvveY
~X oL 4~ . eleV. GO
Sy s~ak~
F11 ❑ Boring ~Vl2S5 ff~✓Yt(cry a- n C' 111
Boring # ~OfG~yr as,;k
Pit Ground surface elev. q"[ •36 ft. Depth to limiting factor J1 3
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Bound' Roots . ,GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `-*Eff#1 *Eff#2
i b-~ Ip r31 Z k rn r C 5 l v~ S
2 `i4 1b Sic Zm5bk v,-)4- c.S - (e
3 V 113 ib 9 m5 O S m y -7 ; l• 2
d0~~ ~r 6
1
F -2-1 Boring # ❑ Boring Q/
® Pit Ground surface elev. 1C9.1(~ ft. Depth to limiting factor 126 in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
Z /,)-q/ 13 / - Sid 2 rn5 rr1 C - ~ ~
3 1-I2p 16 rn b s rn
71
* Effluent #1 = BOD5 > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L
CST Name (Please Print) Signatur CST Number
Ado h Zs
Address Date Evaluation Conducted Telephone Number
2113 801151. Som,erSe ~ LJ1 3qbZj" /0- 38 - U 1 7,,5) Zy7-L/aa8'
SDD-8330 (R07/00)
Property Owner py~ Parcel ID # Page of 3
Boring
❑ Boring #
® Pit Ground surface elev. q(0-[6 ft. Depth to limiting factor 11^7 in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
6-12 10 1 5 i C. 5 I V f S 8
Z I -3 (p -1 Ig
S i c l Zrn:s 6k mCr c 5 - L .6
1_ Z
3 7 ID 1
10
Boring # Boring
F-1 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. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
Boring
F-1 Boring # Ground surface elev. ft. Depth to limiting factor in.
pit Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
* Effluent #1 = BOD, > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD5 < 30 mg/L and TSS < 30 mg/L
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777.
SBD-8330 (R.07/00)
Property Owner Parcel ID # Page of 3
Boring # ❑ Boring
531 ® Pit Ground surface elev. q(D ft. Depth to limiting factor 11-7 in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
t 6-12 lb 1 Si Z ; VI 5 8
Z I2-3 I 4114 S i c l Z rn~'r c. -5
3 39-117 ID - m5 O 1 ~7 I - Z
It
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/ftz
in. Munsell Qu. Sz. 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/ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
* Effluent #1 = BOD5 > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777.
SBD-8330 (R.07/00)
.1
PAGE OPa
NAME 5 c,-4-- LOT# LEGAL DESCRIPTION 56- X/o r i4 ,S /Z T 36JN,R, If Elorg
SCALE: 1"= y0 - - - - -
BM 1 ELEVATION (00• U
BM 1 DESCRIPTION
BM 2 ELEVATION ~O
BM 2 DESCRIPTION 3
SYSTEM ELEVATION oUq4e,er o cJ
ALTERNATE ELEVATION_ ~O. D U
CONTOUR ELEVATION jy po q(, . a v
w r.
1 ~
Y V
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SIGNATURE DATE /2 - 2 y-C~~
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