HomeMy WebLinkAbout032-2174-27-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
597477
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)j
Permit Holder's Name: City Village Township Parcel Tax No:
CARRIE ROGNEY 7 TOWN OF SOMERSET 032-2174-27-000
CST BM Elev: Insp. BM Elev: BM Description, Section/Town/Range/Map No:
V i~ } 27.31.19.1482
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
3
Septic Benchmark
Dnsirag Alt. BM
Aeration' Bldg. Sewer f 1
Holding SVHt Inlet
SUHt Outlet
TANK SETBACK INFORMATION v~•~~
TANK TO , P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic t 1 I _ F Dt Bottom
u,
Dosing Header/Man. ~Q•~
Aeration Dist. Pipe ( J
Holding Bot. System t T~
5,.
P.C
Final Grade -
PUMP/SIPHON INFORMATION
Manufacturer De and St Cover ~j
41
j- .
GPM
Model Number
TDH Lift Friction Loss System Head TDH Ft
Forcemain Length Dia. Dist. to Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width LengthyNo. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS } Gam"
r
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR f
Type Of System t' q i UNIT Model Number.
DISTRIBUTION SYSTEM L
SOIL Hole Size x Hole Spacing Vent to Air Intake
Header/Manifold Distribution ix-
Pipe(s)~i
Length Dia Length Dia _ Spacing f
COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over j 1 xx Depth of xx Seeded/Sodded xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil ❑ Yes ❑ No Yes J No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: -l-nnsspection #2:
`~%S1 VN b0'1~Um at S ~ y
Location: 1997 57TH ST Q
1.) Alt BM Description = 1 ~T1~ L ,_~p1e
2.) Bldg sewer length
~CIS'TyNI~ UN0
- amount of cover = ~ a~o,`~ t
Plan revision Required? J Yes [J-No 1~
Use other side for additional information._ -
Date nsepctor'~Siggaiure Cert. No.
SBD-6710 (R.3/97)
COUNY
RECEI
2Q1 W. W&Ova pion Ave., P .O. Box 7162 Sunkay Pena Number (to be tflfed in by Co.)
s 4 :EP' 05 2017 Nom, Wl 5370T-7162
5171/77
COUNTY
,ornM r eTE t App] 9 r Stwnweactip2hualber
in aoceudwcc wrm SPS 38327(2), Ws. Adm. colic, submimon of diu EG807 7.•, unit A
is mq *W prim to obtakiing a sanitary permit. Note: Applies ion forms for smw 44 to Project Aft w (if different then mailing addle:
ttu Deparunw of Safety and Prof viand Swvx& Personal udormaaion you provide may SSG
ptaposae in acoorr>aarx with the Prwacr Law, s. ls.oa(ixm), Slats. ~ l t -7 7
1 A &sties .Reformation - Please P Ii Infamation
ProMty Owner's Name Parcai N
- c
CARRI- ut~ ~ 032-,Z J'-I'q - Z-7
Prop1e fty Owner's MaWaS Ad ) Property loeasso®
1 ,
1 ~6 txft
t ort
City. Soft Zap code PlneNumber swum z-z
G'T Iri/`~ lj LI V (edrde ~
IL Type of BKBdfag (cbo& all that apply) T-'•+f B I
5 'onNmne
M-or 2.Family Dwelling - Number of B
D PuWWComsueroiel - Desmbv Use D City of
D Stan Owned - Describe Use CSM Number rD~ViU~e of U
2- C&19~ G Vu own of ~..~.1 ~ -
IIR. Type of Pwalt: (Check only tame an line A+ Cosaplebe flat B N appi&awwe} a r`a-
A. D New Sygm Peep w9M' m System D Ttetdsnatt/tiolditsg Tank RepW man Oaty D Other Moaficatian to Bws* System (atpis
B- ❑ Ptmait Rawwaf D Permit Revision D C7seage of Plumber D Perstit Transfer to New List Rr"ious Permit Numbs and Doc ~
BafnwEvir"on owner P' &gA,,
XV. TYPe of POYM S mfCom nontMovies: Check all that apply)
&4ou-?m=r red in-around D Pressurized in-Grouna o At-Grade o Mcamd > 24 its. of subeble soil n Mound <2a is of writable sod
D Holding Tank Other Dispersal Compt>sM (=pplaio) ❑ Pretreatment Device (explain)
V. Dis IIT Area Information: F
Design Ft~ s Design SW A limsion Dispersal Areg.#te*d Dispersal Araa System Elev
J V pis ? f, 73 n~#j
VL Task Info Ct:paaty in Tomb # of M
Galles GaBoas UFAM
New Taste ftivia Taunt r
w Po Zs U aft ts. Q
Septic or Hallding Tot i ( E
DosiftChiusbur
V3I. R onsfbitf Statement- 1, the sad cd, amuse respoeWbility f int Wiation of the POpVTS attsew era.
Plumber's Name (Print) Piambar's S' Nff" RR
8fival her 73uaiaess Phase Number
<T:L- t 4 Z;?,3ZL/e-
Plumber's Addrt:ss (Street, City, State, Tap Code)
F0, ~?b p~CS50K per 54069
VW-ConaMp2partlisent Use fDrtl
Pftwk F= rye s
ags.~ ' g /7
r Detaiad
M for ziwm1 Dkapprowal 3
be- muo
4r.44- 4
r!k, Erfltxnt 4iltend 1/~
V .~tw ct',W) nusi all be ~ . ac /
as per,t)(gr~ement plan pr_ , Jv plumber.
2. 'iliQ-lqt 'tligt ,ens rnv.5t o nt<ir;e.l
it pw vVpA ttbir, cods: / tifdi P1:1;:
Attach to eeaapiata plow for the iqa vW submilt to the C.nty oaty sa paper net iaaa tta.n 8 vt 111 WA m is ale.
SBD-6398 ('R. I1111)
Nrl
137,
v
4
E
_ f
77
i~
CONVENTIONAL COMPONENT DESIGN
Residential Application
INDEX AND TITLE PAGE
Project Name:
Owner's Name:
Owner's Address: 11T7 ' 7 X14
.GAJ f N75
Legal Description: V~ IA/
Township: County: G~ RQJ
Subdivision Name: Pow( Rt p C.F_:
Lot Number:
Parcel ID Number: 2-7 ()VV
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: Hex License Number: V1
p~♦~
~ - <
Date 1Phone Number
~►51~~
Signatur
s 1
Designed pursuant to the in-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01/01).
Page 1
i
T
r
~L
Al,
r~
Cj
z
r, J
T
J
p°~----"`Firms Gn de
4m Kk& ~Q
PVC Vent Pipe S~
' °5
Vfh Pant Gap
t_eaWing ...p,
Chamber -4-- Etatton
ft ft
rf~~ i$
Iffiflil HIM till
UM"M ft
Trench i
Vent Or Obser4stion F" chembem
4° Dtea.
°fench 2 deader
i ee~ G11 ~ S ifl gin
Man rer And Model 1 tJi=1lT ~~4 t~ ~ t K /
EISA Rating C) aq ft per ember Solt Application Rata , . 9ld/sq ft
46 0 gpd Design Flow + Sc n Rats _ 2-0 EISA ° o Chambers
2 rr of ( chambers each.
Page of
JUSTRUIMO
INSTALLATION
PL-5251PL -625 FILTER
s setR~1~•
- _ i
FATUM&
F r"
a RaWd for iO,OW GPD
f _ of 1118° Ffta*m
P1.-52 =
Fee 'tt3 '
FhalOn
PL-625 - 625 Lit F.c
a.CM
P
aAccepts e and fr
deady ® Suit in Gas Deftectof
averel yam under nOTM21 conditions before a AntalWc Vnd-)ff i FEW ~ Romoved
&W*IW it is mmmwded that t Mar be
ied OvM Ume, the tac is pufiy*ed or at teest evarY Alarm AccessWW
# yeam if the his[ oonWns an oponai spccspts PVC Extension
3, #0 owner WIN be roffied by an atm when the
raedr. serAdngm Sew should be done by a
fed esift tank pumper or Ender
M Ell
;GI# PRO
y}r PVC FftK
Hantft
f 4_ Y 9
ld:
sbdng YOff is SM ED UN tM hMMOV bye" vMMM tvM
tG tW* t ' lD sObtWlvdGWWftW and tub fOWQ aeon t ? and =I*& s tM "a or ~ s~ a* ter and tMFdc
yoursweader t *M sew 8 s -
W *4 tM* F'fts T and'rP4W-
rance
vlOt our web she e'
Powrs ® +S KAFi[1Aia AND T"NAMWT
sysrmu CA' IODWS COVAC4
L NA
TO&
Owner
Mr
of Tuk
11 NA
60 MOW
C3 Put
flow Ptuestinost Solt 1.tmit Pift (NAt3) qty ave~~°° 0 SIMIC99 l F*K 0
Pa. OR A (POO) ~ 30 n~ ~ d O Dkhdcdm $ Tor1~&Iqmdw ~ soh } ~ 220 ~lL Mbd*
238 Dupeml Cell(s)
WWO 8 i~1y- w ;Cbva~nd (gmft) MOUad
S 30 mg/L ® At
'faol ('rW s 30 MWL d inar
Fecal Co ) <_10 Cu'l0tin+l
Ila ' AM
Ra4•
wV and CAkubdam v$ MAPS i -
( ) of nsan
~ ~ aa~Y ~t ~P't AAA.
'Vsta~ types hoc doaa~tic ( and bo ftWWjW PW
aepd~c talc afflwnt. and 1
***V for
x3.1"0)
Snit c mcv~ 3.C and -
15,22 f. Septic Tank-SOU Sysms" -
aad
Tmmbea and Bed:". RJ Otis -ASAE PublksbOm 5-77
• Convoubma ` EPA 6251140-012 Wahna' 1980
b4snnal L3ajqg Prmm Disu*utaa"
143W-.P (1.6") -in Va sim 2.0
-10705•-P (H 41101) -In Sd
C3 SOD _ 1 (NNAW) Sazad Fiiaor S
• IW Ftler Systun
®
, SBD ..1072-F (R-6 3) Sftmd CO
T3 SOD _ 10691_p (N.01101) Saud Psi Vasiom 2.0
n
C3 SOD m 1 (,l~ CmWOUM Manor
SW - 106.57-P (R- 6W)
C3 SBD ®1QS73-P } 2.0
t f,OIoCl1) f'" mvw, ° W
AN
RV(G 3
° of gs a grad ► maw 1!3 of t~olc v*m- 3
11111
a
s At !asst a L Umd'', lime
® s
At ~ a NA
aim=
At lei Oum a W
Flo* At ame rl NA
!u1. 13. 2017 1:35PM St Croix Cie Govt Center No. 4490 P. 11
START UP AND OPMTM' psye °t =
For new construction, prior to use of the POWTS check treatment tonkss) for the pretanoe of painting products or oflter chi►ntea
that may impede the treatment process and/or damage the dispersal csillal, If high eonoentrations are deteotad have the eontsm
of then tankls) removed by a eeptage senrloing operator prior to use.
System ,star! up shall hot omur when soli conditions are frozen at the ktfiftrative surface,
during power outages pump tanks may till above normal highweter levels, When power is restored the oxease wastewater will b
discharged to the dispersal cefifs) In one large doss, overloading the oellis) and may result Wthe backup or surfaee'+dieoherge (
effluent. To avoid, this sianat)on have ft ,contents of the pump tank removed by a Wil gs Ssrv100 Operator WW to two&
power to the effluent pump or contact a Plumber or POWTS Msintolner to ssalst M manually operaldng rho pump controls
restore normal fevelt within the pump tank,
bo not drive or park vehicles ova tanks and dispersal osile. Do not drive or park over, or•otherwiss,,disturb or compoot, rho arc
within 15 fast down slope of any mound or. 0-grade soil absorption area,
Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the Ilfe of the
POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; dsgressers; dental floss; diapers; disinfectants; fat
foundation drain Isump pump) water; fruit and vegetable peelings; gasoline; grease; herblold",,,lutist-scrop pMedications; oil
painting products; pastic(des; esnitary napkins; tampons; and water softener brine. -
%BANDONMENT
when the -POWTS fall endfor is permanently taken out of service the following steps shall be taken to Insure that the system is
Properly and safely abandoned In compliance with chapter Comm 83.33. Wisconsin Administrative Codes
• All piping to tanks and pits shall be disconnected and the abandoned pipe openings 880,W.-
• The contents of oU tanks and pits shall be removed and properly disposed of by a Septsoe $ervioing Operator,
• After pumping,' all tanks and pits shall be excavated and removed or their covers removed and the Vold space tilled with
$oil, grovel or another inert solid materiel,
,ONTiNGENCY PLAN
If the POWTS fails and cannot be repaired the following measures have been, of must be taken, to provide a code compliant
eplaoement systems ,
J6 -A suitable replacement arse has been evaluated and may be utilized for the location of a replacement soil absorption
system. The replacement area should be protected from disturbance and compaction and should not be lnftr aW.ttpon by
required setbacks from existing and proposed structure, lot Ones and wells. Failw* to protect the replacement area wiff
result in the need for a new soil and site evaluation to establish s suitable replacement area. Replacement systems must
comply with the rules in effect at that time.
C3 A suitable replacement Bros' is not available due to setback and/or soil limitations. Boning advances In POWYS
t chnology a holding tank may be, Installed as a Igst resort to replace the failed POWYS. -
Bit nor~~eeen evelotod to,109ndfy a ell ltsblo repiaoaMi4it lit~a~ Upon failto of the S :Ill od and to
a at ups beiperforrho to loc e e suitabl legles~s~n ~rd}e• It ncepjjmgt»nt.:allaei Le anal . h k
a be ad as is rase ` o re Cho fall POYJTS:
p
/d Mound and at-grads-so# absorption systems may be reconstructed in piece following removel of the biomat at the
infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time,
<WARNING> > .
3ePTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INGUFFICiiliNT OXYGEN. DO NOT
ENTER A SIPTIC, PUMP OR OT49R TREATMENT TANK UNDER ANY CIRCUMSTANCES, DEATH MAY NMLY. RESCUE OF A
PERSON FROM THE INTERIOR OF A TANK MAY 88 DIFFICULT OR IMPOSSIBLE.
DDITIONAL OMMBHTa
eRtt
•:)WTS INIiT
POWT$ MAINTAIN
Nam Nams
Phon Phone
3y
S
:PTAGE E MING OPPATOR pUMM ) LOCAL. RE UL.ATORY AUTHONU
Name Name
Ph*"* Photo r1f'
is document was drsfW M oorrtpasnc* with Chapter Comm 83,2212i1blkiildAl" and 83.64111, 121 &13). WwooAsln A+Arrtk4Ws0v* Coda.
ana the bouttICBSC (,jtlarW or Um NorMe"t 44UUUr Ot tlOfj ;
as 11% /W%flM
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RECEIVED C_ST -a c C7 - ~
Wis.*Dept. of Safety and Professions R ,Q 7 I / SOIL EVALUATIO Page of
Division of Safety and Buildings
ST. CROkXZQVN a with SPS 3#WiE
m.
"
NT Cou Y ?
DEV~LOPME ~
~ MItNITY
Attach complete site plarYaper not less than 8 1/2 x 11 inches in slzP QQ
include, but not limited to: vertical and horizontal reference point (BMA GV Parcel I.D.
i
percent slope, scale or dimensions, north arrow, and location and c. 9 nearest road. ~ c- 2-1 ~ 2 0
Please print all information. Revie d by DateQ
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). G V-1\~7
Property Owner Property Location
1.. A f)f-) `c. L Govt. Lot N V,) 1/4 1/4 S ~ N R )'f E (orkW)
Property Owner's Mailing Address Lot # Block # Subd. Name or CS #
t 1,, F?-) ! ~t CJCa~
1997
City State Zip Code Phone Number ❑ City ❑ Village ®Town Nearest Road ,
❑ New Construction Use: Residential / Number of bedrooms Code derived design flow rate GPD
® Replacement ❑ Public or commercial - Describe:
Parent material Flood Plain elevation if applicable ft.
General comments
and recommendations:
F1 ® Boring
Boring #
` ~ -
❑ Pit Ground surface elev. T c. , r!) ft. Depth to limiting factor L; in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 ff#2
f '7, - 1 F ( C w 2 r. f
3 2G-11 i la.,~ r ::4 V-) wr r~A
4
~p IL
a Boring # Boring
❑ Pit Ground surface elev. 3 LD ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 *Ifff#2
0-! 0 ?-5V -L S Ps K o\ t /13 2 n 2 7.5, w s b K
i C~ • J Sys / ~ S MLC4- SW
3 Lo '5AAA~~ L--,1 41,, CIO
5 /l0 7,5y,"ts
Effluent #1 = BOD s > 30 < 220 mg/L and T W>30 11150 mg/L ` Effluent #2 = BOD 5 < 30 mg/L and TSS < 30 mg/L
CST Name (Please Print) Signature CST Number
[ J 2, L q C
Address Date Evaluation Conducted Telephone Number
i L.5 tt,c ~c S C,` Ott t 17 ~7t5 yy(-:
SBD-8330 (F
ll(<~a;~ 1~ ?e~ >9 ri, t 3-. ` 174- G ►v Page
of
Boring Property Owner el ID # J I Boring # E] ® pit Ground surface elevq?' 6.5 ft. Depth to limiting fact 7in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft z
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 ff#2
f s l'
0-7 ~U
Y~(o S s h t~ y r crc.► o
7 -3 6 psya
1 SI IFsbk rnU~r W
q 7 -52 -7
LO wA\~( Fk N `Q i T ►4 lJ ?a c~
6 66 -117 176v? 67/L S t, ,nA 1 r, ~
❑ Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 ff#2
Boring
Boring # Ground surface elev. ft. Depth to limiting factor in.
F-I ❑ Pit
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 ' ff#2
" Effluent #1 = BOD 5 > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD 5 < 30 mg/L and TSS < 30 mg/L
The Dept. of Safety and Professional Services is an equal opportunity service provider and employer. If you need assistance to
access services or need material in an alternate format, contact the department at 608-266-3151 or TTY through Relay.
SB D-8330 (RI 1/11)
Property Owner C-A (het e Oconn c E t Parcel ID # 3 7 Ll! 07 -006 Page ~ of .J
Boring # A Boring ~^J C
1-31 ❑ pit Ground surface elev.G t 2, J ft. Depth to limiting factp2 L F7 in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 , ff#2
cw 7
7-36 Y~6 S ZF~bK vfr u.l . (a ,D
3 3 L/ x SI Ifs 6K mjFr w 7
v v\,-/ Gu i r ~4 C 13
r,
b 46-1/7 7 5 a S t--v. V s ca , A t -7
Boring # ❑ Boring 4q
❑ ❑ pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 ff#2
F-1 Boring # Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 ff#2
* Effluent #1 = BOD 5 > 30 < 220 mg/- and TSS >30 < 150 mg/L ' Effluent #2 = BOD 5 < 30 mg/L and TSS < 30 mg/L
The Dept. of Safety and Professional Services is an equal opportunity service provider and employer. If you need assistance to
access services or need material in an alternate format, contact the department at 608-266-3151 or TTY through Relay.
SBD-8330 (RI 1/11)
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