HomeMy WebLinkAbout032-2156-30-000 (2)
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
(ATTACH TO PERMIT) 597472
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:
Richard Stout TOWN OF SOMERSET 032-2156-30-000
CST BM Elev: Insp. BM Elev BM Description: Q Section/Town/Range/Map No:
14/ IJo{~edvr ,j :L 12.30.19.1345
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Benchmark
Septic o ;
t4t P !j
w Alt. BM (J"~ y
fri Za1 l/ 6 w Z
Aeration Bldg. Sewer
Holding St/Ht Inlet
47-
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO A ill L WELL BLDG. ent Air Intake ROAD Dt IN t $
111 J# CUA /S -+c, Dt Bottom
Septic 7/4* 3(o
i
Dosing Header/Man. ty,') g 47, y
Aeration Dist. Pipe
7-
Holding Bot. System 'S • 4~
4_ 1 "7 .'Cgigs (ys
PUMP/SIPHON INFORMATION Final Grade 0 ~Z. We
91.1
Manufacturer Demand St Cover (62. 11:
GPM tl-/ a hi ~d &t,_/4F_
Model Number
TDH Lift Friction Loss System Head TDH Ft
t4
Forcemain Leng Dist. to Well
SOIL ABSORPTION SYSTEM
BEDITRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 43 76 7- `1_
SETBACK SYSTEM TO P/L / BLDG WELL LAKE/STREAM LEACHING Manufacr: rl~
INFORMATION CHAMBER OR =i•J~ a
Type Of System: ? / UNIT Mo Nu~b
~cti✓uA'I~tr. ~Q✓ 3g ~x-
56-
DISTRIBUTION SYSTEM Joy +-17 =34 " vS
Header/Manild / Distribution 7ze Ix Hole Spacing Vent to Air Intake
4 Pipe(s)
1Length Dia Length Dia Spacing-' GV
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Gam- S
Depth Over Depth Over xx Depth of xx Seeded/S ded xx Mulc ed
Bed/Trench Center , Bed/Trench Edges Topsoil No es No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location: 1683 89TH ST l~ 615 locjoii~j A ~Oc~- 40,4jV-,, IkA
1.) Alt BM Description
2.) Bldg sewer length = a'"' P.t > G
- amount of cover
Plan revision Required? ❑ Yes No 4 ✓ v .00 Use other side for additional informati n.
SBD-6710 (R.3/97) Date Insepctor's Sig ture Cert. No.
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) f 3 y ~r f,~ located
at:1/4, Aim 1/4, Section 12 Town_2z) N, Range/4W,
Town of ~V 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 2 aL 7
Did flow back occur from absorption system? Yes Nom; "
(if no, skip next line.)
Approximate volume or length of time: gallons minutes
Tank Capacity: /poy
Construction: Prefab Concrete Steel Other
Manufacturer (if known):
Age of Tank (if known):
Permit number (if known)
(Licensed Plumber Si ature) (Print Name)
(Title) (License Number) MP/MPRS
-L,)~ Z2
(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
ore Industry Services Division County
7 1400 E Washington Ave
I'_(}. Box 71
Sanitary P-lit Number (to be filled in by Co.)
370 7
V ~9 7-el 7Z OUWY
ST. J %wo?"'p,
CI e rrf it APPIica Tut Transaction Number
In accordance ~ S1383.21(2), Wis. Adm_ Code, submission of this form to the a roate ovcYnmental unit
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 Sr rrviees Personal information you provide may be used for secondary
u ses in accordance with the privacy Law, s. 15,04 I fm), Stats. /
1. R lication Infortnazttioo - Please Print Ul InfOrMation z7 ✓
Property tAtvncr's Name
Parcel # E7T
Property Owner s Mailing Address _ cr' R✓-'~ E✓~~
. mil`-AT/ I i r P L Property Location
City, State gg Zip Code Phone Number Govt. Lot AA~-
`ld ~s C ~(G NE ~ 'i., section 1
El (circle one
H- Tylre of Building (check all that apply) Lot # f - N, R-j ~ E a X)
1 or 2 Family Dwelling - Number of Bedmo_._
Subdivision Name
❑ PublicfCormnet+eiai -Describe Use Block k
❑ City of _
❑StateOwned-Describe Use CS Number ❑ Village of 1 Tf7 Town of_ W ~.~~at =
Ill. "Type of Permit. (Check only on box on
lute A. Complete line B if applicable)
A.
New System Replacement System ❑ Treatment/Holding Tank Replacement only
❑ Other Modification to Existing System (explain)
B. El Perrttit Renewal ❑ Permit Revision :01 Change ofPEumber [ Pcrmst Transfer 7NNmv List Previous Permit Number and Date Issued
Before Expiration
owner
IV.Te ofPDL~°Is Sys '-/09, 7-1l -0,4
1 y teta/Com onent(I)evice: Check all that apply)
rttlNon-Pressurized In-Ground ❑ Pressurized In-Ground ® At-Grade ❑ Mound> 24 in. ofsuitable soil
Q Mound < 24 in. of itable so
Ho '
lding Tank other Dispersal Cam onent(ex
P plaid) ❑ Pretreatment Device (explain) 3 ~
V. Dis ersaLrFreat ut Area Information:
Design Flow (gpd) Design Soil Application Rate ~
(glids Dispersal Area Required s
{ Dispersal Area Proposed (sf) System Elevation
r
VI. Tank Info Capacity in Total p # of `7 t q_ I)o p
Gallons Manufacturer
Gallons Units L
New Tonics Existing Tanks
Septic ank
I tx U U ui ci tJ it
Dosing chamber X i
'i II. Responsibility Statement- I, the undersigned, assume r ousitt' ty for instatlatio of the POWTS shown on the attached plans.
Plumber's Name (Print) P u is Si to
f Num7 Business Phone Number
Plumber's Address (StrceE, City, State, T_ip Code)'t~ / S_ ~]~'j
/65- El CAIDOTT _5LJ 7 2- "7
VIII oun Me artment Use Only
Approved S LZ Fee Date ssued Issuing t Signature
Reason 9 L easan fo 7
r aial
/7
TX C onintfit lsa roval
z 'w•~Ar~tlrrl~.t~t~al.ar,xir,~► ~~a f e
a/Iri~iolilir.aodeE~ropl, ~
Attach to complete plans for the system nod subwlt to [rte Loan a en
ty oly paper not Tess than 8 arz x lr Caches to size
SBD-6398 (R. 08/I4)
CHECK BOX AS APPLICABLE
CHECK BOX AS APPLICABLE
❑ SOIL EVALUATION Scale: 1°=40' K SYSTEM PAGE 2 OF=-(
SITE MAP 40 6f3 ~
PROJECT NAIME:
_ (10Itgrid) PLOT PLAN
102 DESIGN FLOW: e-t'S GPD
Attach design flow calculations for commercial plans-
PROJECT ADDRESS-
. I V,~~5 Pipe Material i ASTM Standard (Tables 384.30-3 & 384.34-5)
BM Symbol: BM Elevation: Cpl. f FT Sanitary Sewer. J
L
&M Description: ryf" Gf~ FQ EzRif->A'7 ! G Force Main:-
Slope Gradient(!) Indicate north by IMPORTANT:
of Tested Area: Well Symbol (if applicable): Q drawing an arrow Show ground elevafion contours at suitable intervals.
on the approprite line
I
1
l
d ° ~1c -af4'~C~ E/.s 1 DL. 1
b ' 9~ vGfi~(} F FG
} L _
f
- d2E
35N iT1 rte, - 5' yj , /I ~ L . 1c~o 9S, 5 LoL&~~ .62- .
{I~ D
If
`I
i
PAGE 1 OF 4
Gravity In-Ground Index & Cover Sheet
Component Manual sign References:
Version 2.0, SBD-10705-P (N.01101, R. 10112)
of Index & Cover Sheet
2 o 4 Plot Plan
3 of 4 Dispersal Area Gross-Section & Plan View
Pg 4 of 4 Management Plan
Attachments: Enclosures:
POT'S application for Review
tq ` Soil Evaluation Report & Site ap
Project Name I Description
r r Name 4s3. K 4 ki A RN 0. ; rk-y V _n'h)t(-T Phone:
Owner Address: k 3'%5 I IA-r-i ; i :'TRAIL +6 t Q Qot zip: f t
Project Address: ~ ~ .
Go Lot: A a 1 /4 of A~ 114, tiara_ C) N-R E 9 .
r~olp YYa
Township: L.> 0 l s -f County: 7: tA
Project Parcel ID t) 32 - tS(~sn 3 v G?OO
Designer Information
Designer Marne: f- ~cPt' rzT Phone: ?)5
Designee" Address: 2~Li4'l K~tU~~>~+t~urzs ~f_ ~~4NKLft1.. W_T Zip: 5y8~C
E -Mail. tzol( i rclest ri j$~ o0<b a rn,
sP4C6 '4"- g p '4W stamp,
License Number: ! 8s~ - on '7 r
Remarks: gij %
uzu e
iA1 L
}
Signature. °~r~✓ ~ I Date.
t3ng~nal na#ure required ov epim stied copy,
CHECK BOX AS APPLICABLE.
CHECK BOX AS APPLICABLE
SOIL EVALUATION Scale: 140' ~ SYSTEM PAGE 2 OPy
SITE MAP 40 60 80
PROJECT NAME: PLOT PLAN
(1Q ft grid) 102 DESIGN FLOW: q t GPD
Z~)-k 611,T Attach design flow calculations for commercial plans.
PROJECT ADDRESS: p Pipe Sanitary Material / Sewer.ASTM Standard (Cables 384.30.3 & 384.30-5)
BM Symbol: BM ElevatFon ' FT
n Force Main: J
BM Descripticn: -Tick, F?}, /0D AT I
Slope Gradient Indicate north by IMPORTANT:
of Tested Area: Well Symbol (if applicable): drawing an arrav Show ground elevation contours at suitable intervals.
on Ne appropdie Fine.
I
~E
ee e,
VU-tl-- T m q~ :5.
"N 1)~Vtf3f6f, VALVE,
°
)a
ztitZ~ - 5 l~Z 'd~ ~L._. Ivy? 9d,
i
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PAGE 4 OF 4
In-ground Gravity Management Plan
IMPORTANT:
The owner of this in-ground gravity system shall be responsible for its perpetual operation and maintenance pursuant to
requirements of SPS 382-384, Wisc. Admin. Code. Pursuant to SPS 383.52 (2), Wisc. Admin. Code, this system shall
be considered a human health hazard if not maintained in accordance with this approved management plan.
Furthermore, all inspection and maintenance activities shall be performed by a registered $ Maintainer in
accordance with SPS 383.52 (3), Wisc. Admin_ Code.
Maximum gjgj!2rsa I Area Operating Limits:
Design Flow = ~-L
~ gPd; EODs < 220 mgL"'; TSS < 150 mgt."'; FOG :5 30 m9C
lnsRgction Checklist INSPECT EVERY 3 YEARS
o type of use
o age of system
o nuisance factors (i.e. odors, 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 !strop boxes)
o neglect or improper use (i.e., exceeding design capacities, prohibited activities, etc_)
o extent of ponding in distribution cell prior to dosing
o dosing irregularities - if applicable (i.e., pump re-cycling, float 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 sewage back-up into structure served
Maintenance Checklist MAINTAIN EVERY 3 YEARS (or when necessary)
o Septic and dose tank(sl shall be pumped by a certified septage servicing operator licensed under s. 281.48 Wis.
Stats. when the volume of solids in the tank(s) exceeds one-third (113) the liquid volume of the tank(s) or
as required by local ordinance. Disposal of contents shall be pursuant to NR 113, Wisc_ Admin. Code-
o, gjgM t jrlterdsl shall be inspected every 3 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
months.
System maintenance reports shall be submitted to the proper local government unit in accordance with
SPS 383.55 Wisc. Admin. Code. Report any component failure or malfunction to:
Name of individual or company: A~>V.A -kk & IiiPTW Tyro} S f ~Q j Phone: `7
Local government unit: KQ~j 'Tj - tyyq (F 1f C Phone: -7 f-s 3&b _q
Local government unit address: 4 - i~Sty; Lk-a' ZIP:
Any defective part of this system shall be repaired, replaced, or removed pursuant to SPS
383.51 1 sc.
Code. Repair or Wisc.
replacement of failed or malfunctioning components shall comply with No product for chemical or t SPS 383, Wisc. Admin. Code. ~
physical restoration of the POMS may be used unless approved by the department in
accordance with SPS 384, Wisc. Admin. Code.
Cormtiingft Plan
In the event that any failed treatment component of this PO S cannot be repaired, 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 i s
dispersal component in
p apre-determined area of suitable soils. ~
System Abandonment
If use of this POWTS is discontinued, it shall be abandoned in accordance with SPS 383.33, Wisc. Admin. Code_
J
-lei gg q
S KA+ 4Ry~ L 5
r ~
! t Y" t r8_
f£'
g t
4m 9 AVY '.b
V'T
s
The Quick4 Standard Chamber fits in a 36" wide trench
and is ideal for curved or straight systems. It features the
, t
patent-pending Contour Swivel Connection-, which permits
turns up to 15', right or left. The MultiPort- endcap allows
multiple piping options and eliminates pipe fittings. The, ,
chamber's four-foot length provides optimal installation
flexibility. " 1(I°
• Advanced contouring connections swivel up to 15°,
. ° 'y`
right or left
r r
• Latching mechanism allows for quick installation
• Four-foot chambers are easy to handle and install
• The Quick4 Standard Chamber supports wheel loads of
m'
16,000 Ibslaxle with only 12" of cover
i -
• Certified by the International Association 1AM
of Plumbing and Mechanical Officials (IAPMO)
• Tear-out seals on inlet ports provide a tight -
fit to the pipe _
• Eight molded-in inlets /outlets allow
for maximum w ' -
i fn flexibility ~
• Eliminates pipe fittings
• Fits on either end of the Quick4 Standard Chamber
APPROVED in
I
i
Qui - `
12`
v u
34° - v -'48" y
(EFFECTIVE LENGTH)
ltiF E Cap
FRONT VIEW SIDE VIEW TOP VIEW
Typical Tm-wh View 14MW ATM WATER TSCHKMOSMS SFAF
(4 The structiwd wftity, of each der. endeap eaW der atx r retncnifactured by
khtiator Cl s-k when insteRed and opw4ed in a bwd*eW of at ore septic system in
t+aATIVE Bk tiL TOPSM acccrdwcee vAh hfilrator 's ` urbuc6om is uerin riled to M ash piachaser (-Hatderl against
defective and rzxlottardigr far cm year tam ft date that the septic permit is issued for
the septic system cmiUdnang tta Untis provided , tcd if a sepal permit is rot requved by
applicab* tavr_ the -r-Ay period vad hem upw the date, that irmteflation of He septic system
COVER
commences. To etc its vvanardy, hjo--. H otdier roust nobly K-d& ;tor in writing at its Corporate
Heaftmders in Old Saybt~ Con m=att v' *M Wmw J151 days of ft armed tided. hlMra"
I f %A supply mpWaniat lkWs for 1ka15 deternwed try WftWW be Wvered by this Umited
22 72 g' MERT Wamrtty. k6tratws bimbo spedficafy awkic rs the cost of ranovat wor esterion
of the units
M THE AND PBKUIES IN SUBPARAGRAPH (a) ARE E)CCLtSIVE.
sh r-^-+-t°-St?WCFCet6PER air THERE APE NO OTHER WARRANTEES WfMRESPECT i0THELOOM MCLUDINGNO
lAMIUM WARRANMS OF ktETTiCHANTAMMY OR Ff WSS FOR A PARTTT AXM PUi2POSE
_ h) This t.knftd Waranty shad be Witt' any part of tie cfrwober system is r turel by
amaycrm otter than kditZtDr The Umded Warranty does oar extend to ir>i . cons a
specd or unekect derrages. Infiltrator shd root be Fable for penalties; or fi"daled derrm9es.
Size 34"W x 53"L x 12"H inialix" boss of Production a d profas. b bur and rringagkr, eavstimal costs, or off= b or
(864 ITITTT x 1W IT" x 305 rMn) expenses incurred by ltre Holdw or arty Ytdrd party. Specific* exckidad hum Lirrided Warrarity
Orvieerage we die W U* tkds die to, ardir ty waw ate tear. alteration, accident avww-
EffixfM Length (1213 mm) abm of neglect of the Unite the Units brag MkOxIed W Wade WW orWw condiltiom Mich
use not P&MMed by the ` trStdafim inskctions: tArle to maatein the rrararnamt ground eov-ers
8" (203 Tram) sel ftrth in the the pdaceniveht of impropeir rtawrials into tme system
GuiltairwiV Me U 6aure of Be tkuls or the sepfhc system; dw to wwroper sTnq or anpmopes
sbxage Capacity 43 9M (163 Q SoMa. eXces- -t- -ge- -prop- T- &M-L - -T-P- q-al-- - " on-
event ;rot cmrW by kMr-Or. This Lusted Warruq shy be valid it go Hotk:r f to comply
hwert lht 8" (203 imm) Witht 21 of ft teim set tofttt is His LiffftMd Mbwsrft- Forte in no e d stull kaNtrator be
neSPGraA Ur any IDW or damzge, to Be Hok*r, to Units. or aty teed pasty rest" from
or shiOnvent. or horn any phi figay, ofairts of tinlder or arry ttaod party. For #4
LMIAW W W aP* fhe Lk tt ink" is a corchm a1 h at site o
by a Wad ktcad h al dher appkatie tam and truer s " knaacfinm
(cdp ~ - ~ tear rie aa#aee[y Ao daaage a est0eetd Neu ►iraxiTed Wam►atety.
No vvwa* appbes to airy party other um the migind Haider-
The allure tt thL' SM0ft d LxhW Waaranty offered by khfbatrw A limed manber of
a Buskmess Prrc fdoaf states and ox xM- t-- dibf~d tvartady, rey3eaaem ft Any part~r of Lk-As shDtW cons ad
Pja OW BOX h1mr-dcr`s Corpaaae R ^ in Old Saybrook- C~a~ i ut. Pnor to S#r pero3ase. to
Saytraoa~ C
- - - , _ . - IXio - Fax a 86 a6U-s7r-7~7 app&zwe w.araray. Wand shmaukf
SGO-s77-7 obtmn a copy of t e e~a0y ;earl that wwranty poor to the
1-600-M-4436 puschase orUnds.
come
iLS b 4.Ma,S68; s 077_oat: S t 5336-017. A IG S.iot. 5 Sti. 5.7 ra lax 5.S TM &nx& a Csnair~ihs fk t 329 :2A0t.s6s 00wpt&ft p~+
and ~ aF T ism trdmmaa n Frame t~aorwakr Ysa r~s! aa~ersax in ea®o
awiLam a
~Y►aRt , txo~.r>cac. r cxcsr. ohm am uaaienmus as kobaoar w=er T
of W•
isa oq tncTt.w-TnE;sa ot'RJi lUE.t alla dwwk
a 2oas hAka- W- T tiC.rm-Y%3 inU„SEA. 732bt t3