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Home My WebLink About042-1066-30-000 (2) Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No (ATTACH TO PERMIT) 597433 GENERAL INFORMATION State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. \j Permit Holder's Name: City Village Township Parcel Tax No: Donald & Bernadine Greenfield TOWN OF WARREN 042-1066-30-000 CST BM Elev: Ins p. BM Elev: BM Descri do Section/Town/Range/Map No: ~„1 24.29.18.368B t"- TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER ~.7 CAPACITY STATION BS HI FS ELEV. Septic Benchmark Alt. BM Dosing • _ 1 J ~e l~ Aeration Bldg. Sewer ! ; 1 r Holding - St/.t Inlet +~r_ l~ 11 1 St/Ht Outlet rt TANK SETBACK INFORMATION r t y, J TANK TO P/L, WELL BLDG.` Vent to Air Intake ROAD Dt Inlet r; 'IT Septic y ; { Dt Bottom Dosing ICU' Header/Man. Aeration Dist. Pipe ' f V N{olding Bot. System i Final Grade PUMP/SIPHON INFORMATION Manufacturer Dem.. d St Cover GPM C b` a f ~W Model Number r TDH Lift Friction Loss System Head` TDH Ft t Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM pth BED/TRENCH Width Length No. Of TregPIT DIMENSIONS No. Of Pits Inside Dia. Liquid De DIMENSIONS !1 SETBA CK SYSTE Oa . / BLD ELL- LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of Sys em: _ UNIT Model Number: i DISTRIBUTION SYSTEM Header/Manifold 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 F ] Yes ❑ No S-Yes ❑ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: r ~ J'(111 Location: 1472 HWY 12 E C 1.) Alt BM Description I~J~JA, 2.) Bldg sewer length t~ - amount of cover = LJ`" ` ~~JJ Plan revision Required? F] Yes [ No /A ~A, 311 Use other side for additional information. DateYnsepct Sign ture y Cert. No SBD-6710 (R.3/97) u ST r c~.ui~fj~ld pp~ Gr-cc a~%~ G~~ py, 40 5~9N-x017,9H or-on County RE Safety and Buildings Division St. Croix 1,. 201 W. Washington Ave., P„ 0. P- '2 Sanitary Permit Number (to be filled in by Co.) p $ ~ 1 P = S ~G ~7 4 Madison Wl 5071` Fg6 5*!. ~Y A 0 COON pM QNSG ° I ~pMMu Itary Permit A,,~ StateTransactio Number ntpro:- ~G In accordance with SPS 383.21(2), Wis. Adm. Code, submission o_ ms governmental unit / V is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to Project Address (if different than mailing address) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary Iq purposes in accordance with the Privacy Law, a 15.04(1)(m), Stats. lqi K~ I 1. A lication Information - Please Piijnt All Information ` Property Own s Name Parcel # Donald042-1066-30-000 Property Owner's Mailing Address Property Location 2 tJ ag . 1 g. 3Gfi 1155 Co. Rd. E Govt. Lot l City, State Zip Code Phone Number NW y, NE 'A, Section }24 o OF New Richmond Wi. 54017 T 29 N, R 18 (eirelE o r W H. Type of Building (check all that apply) Lot # ❑ I or 2 Family Dwelling - Number of Bedrooms Subdivision Name Block # Public/Commercial -Describe Use Ag Tractor Repair ❑ City of ❑ ❑ State Owned -Describe Use CSM Number Village of /r Town of _ Warren III. Type of Permit: (Check only one box on line A. Coftiplete lme B if applicable) A. ❑ New System ❑ Replacement System LJ Treatment/Holding Tank Replacement~nly ❑ Other Modification to Existing System ( plai ) lu Il B. El Permit Renewal ❑ Permit Revision ❑ Change of Plumber ist Previous Permit Num er and Date Issu . ❑ Permit Transfer to New ~ A Before Expiration Owner 18855 IV. Type of POWTS S ent/Device: Check all that a 1 Non-Pressurized In-G1, y I!f Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil _ ❑ Pretreatment Device (explatn) ❑ Holding Tank -",D -Other Dispersal Component (explain) V. Dis rsaVrreatment 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 r -o U a Poly-lok 525.. New Tanks Existing Tanks w _ 0 A.` U in h on w C7 A. Septic or Holding Tank 1000 1000 -1-- Wieser X Dosing Chamber r VII. Responsibility Statement- I, the undersigned, assum esponsi lity fo in tallation of the WTs shown on the attached plans. oo, MP/MPRS Number Business Phone Number Plumber's Name (Print) Plumbe gnaturq. 648443 651-470-1737 Keith Knudtson Plumbers Address (Street, City, State, Zip Code) 927 150th St. Roberts VW 54023 VIII. oun ent Use Only Permite~e1 Date Issued Issuing Age nature p ved ❑ Disapprove~$^ $~~j'"l~ ❑ Owner Given Reason'f6c Qcmal IX. Conditions of Approval/Reasons for Disapproval SYSTEM! OWNER: 1. Septic tank, effluent filter and dispersal cell must to serviced I mainttoe-d aspermanagement plan provided by ptumebar. - t 2 x 11 inches in size Attach to complete plans for the system and submit JNlJtR6MAWJWbA'FA 'A as per applicable codelorar~ SBD-6398 (R. 11/11) CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Greenfield tank replacement Owner's Name: Doald Greenfield Owner's Address: 1155 Co. Rd. E New Richmond Wi. Legal Description: NW 1/4 NE1/4 S 24 T 29 R 18 W Township: Warren County: St. Croix Subdivision Name: Lot Number: 1 Parcel ID Number: 042-1066-30-000 Page 1 Index and title Page 2 Plot Plan Page 3 System Sizing & Cross-Section Page 4 Filter Specs 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: Keith Knudtson License Number: 648443 Date: 08/07/2017 Phone Number (651) 470-1737 Signature i Designed pursuant to the In-Ground Soil Absorption Component Manual for POWT'S Version 2.0 SBD-10705-P (N.01/01). Page 1 il! i e ~ e ~ ST ~ s d L w~ u ~oaa .5-4.e- d I f ~ i ~ ~ . 1~ ti~ ~ 1. / / . _ . ...j POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page , ~f 2 FILE INFORMATION SYSTEM SPECIFICATIONS Ov ner - Septic Tank Capacity ~QQa gal ❑ NA Permit Septic Tank Manufacturer ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer L o ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model ~Z ❑ NA Number of Public Facility Units I :A Pump Tank Capacity gal *-NA Estimated flow (average) gal/day Pump Tank Manufacturer ffikKA Design flow (peak), (Estimated x 1.5) gal/day Pump Manufacturer )<-N"A Soil Application Rate gal/day/ft2 Pump Mode( A Standard Influent/Effluent Quality Monthly average; Pretreatment Unit A Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter ❑ Peat Fitter Biochemical Oxygen Demand (BODF,) <220 mg/L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg/L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Vlno-G- sal Cell(s) ❑ NA Biochemical Oxygen Demand (BODS) <30 mg/L rou nd (gravity) ❑ In-Ground (pressurized) Total Suspended Solids (TSS) 530 mg/L ❑ NA ❑ At-Grade ❑ Mound Fecal Coliform (geometric mean) <_10' cfu/100ml ❑ Drip-Line ❑ Other: Maximum Effluent Particle Size Y$ in dia. ❑ NA Other. ❑ NA Other: ❑ NA Other: ❑ NA `Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: 25 ❑ month(s) (Maximum 3 years) ❑ NA Ally-ear(s) Pump out contents of tank(s) When combined sludge and scum equals one-third (Y3) of tank volume ❑ NA Inspect dispersal cell(s) At least once every: ❑ onth(s) (Maximum 3 years) ❑ NA 3 year(s) Clean effluent fitter At least once every: 0 onth(s) ❑ NA I~ year(s) Inspect pump, pump controls & alarm At least once every: ❑ month (s) A ❑ year(s) Rush laterals and pressure test At least once every: ❑ month(s) NA ❑ year(s) Other: At least once every: ❑ month(s) ❑ NA ❑ year(s) Other: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber: Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. 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 to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the gro ind surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notificatior of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third (Y3) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator 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 :02 months, shall be performed by a certified POWTS Maintainer. A service report shalt be provided to the local regulatory authority within 10 days of completion of any service event. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND WNERSHIP CERTIFICATION FORM OwnerBuyer Donal Greenfield 1155 Co.Rd. E New Richmond Wi. Maili dd ss~ US Highway 12 ~,..;Y Prop A ens . (Verification required from Planning & oning Department for new construction.) City/State Roberts Wi. Parcel Identification Number 042-1066-30-000 LEGAL DESCRIPTION Property Location &-'40 '/4 , ,Al '/4 , Sec.., T g?N RZW, Town of Warren Subdivision Plat: , Lot # 1 Certified Survey Map # , Volume 4 , Page # 1 127 Warranty Deed # ! l~ 7 -1/ (before 2007)Volume YId (o , Page # 3&_5 Spec house llyesElno Lot lines identifiable ❑ yes❑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 are specified in §SPS. 383.52(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 and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1 /3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private 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/we certify that all statements on this form are true to the best of my/our knowledge. I/we am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms e- V l71 SIGNATURE F APPLICANT(S) DAT ***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 deed. (REV. 04/12) _ 0O JV ~r :~2$' EFFLUENT FILTER -525 Filter is rated for 0,000 GPD (gallons per day) 1116? Filtration Slots - -g it one of the largest filters- AWrm :.;ass. It has 525 linear feet filtration slots. Like the „PVC k _ ok PL--122, the Polylok ^"a^ has an automatic shut ' Pail installed with every filter. the filter is removed for Ong, the ball will float up and s ' 11 Jill ;Dorarily shut off the system so effluent won't leave the tank.~~of1j1W 't*.:: other filter on the market can FNration Sots _ e that claim. Rateato.over AM GM t~! tf st :z^ a SCND. 40 Pipe -~-e PL-525 Effluent Filter should zYerate efficiently for several years - der normal conditions before -equiring cleaning. It is recom- --ended that the filter be cleaned eVery time the tank is pumped or „ - flows between least every three years. If the to 400 - 1,500 GPD, While this filter stalled filter contains an optional alarm, the owner will be notified can handle • o an alarm wf1cws and can be hen the filter needs servicing. Servicing should be applicati6nsit is tone by a certified septic tank NSFcertiffedfor i pumper or installer. Autornatk Shut-Off U.S. Patent No# 6 Oi 5488 "-[s 8aN when Flter is 1. Locate the outlet of the 5,871 640 Remand a- septic tank. 2. Remove tank cover and pump tank if necessary. 3. Glue the filter housing to o ~ s- i - o 3. Do not use plumbing when the 4" or 6" outlet pipe. If filter is removed. Ideal for residential and com- the filter is not centered 4. Pull PL-525 out of the housing. mercial waste flows up to under the access opening 10,000 Gallons Per Day (GPD). use a Polylok Extend & 5. Hose off filter over the septic Lok or piece of pipe to tank. Make sure all solids fall 1_ Locate the outlet of the center filter. See page back into septic tank. septic tank. 19-21 for Extend &Lok 6. Insert the filter information. cartridge . Remove the tank cover and into the housing making sure pump tank if necessary. 4. Insert the PL-525 filter the filter is properly aligned into its housing. and completely inserted. 5. Replace and secure the 7. Replace septic tank cover. septic tank cover. l