HomeMy WebLinkAbout036-1078-90-000 (2)
County: St. CfOIX
i Department of Commerce PRIVATE SEWAGE SYSTEM
and Building Division Sanitary Permit No:
INSPECTION REPORT 597442
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)]
Permit Holder's Name: City Village Township Parcel Tax Na
RIVERSIDE TRAILER PARK TOWN OF STANTON 036-1078-90-000
CST BM Elev: Insp. BM Elev: BM escription. __t _ I _ L ~ (3 Section/Town/Range/Map No:
WwC 6 31.31.17.487F
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic `~iZ.•1 Benchmark tog
Dosing it. BM -
Aeration ID. 3 R 1
(3• vim. ~e~l
Hold in ~ 3f~ IVAI
Qett6
TANK SETBACK INFORMATION '6w►v- Qee St/Ht aGwlt~k- J. I(R.
TANK TO P/L WELL BLDG. Vent t Air Inta RG6D Dt I let
Dt Bottom
1 g
Septic ,1 0 131
JYIA Dosing J~-, `l OO Header/~-
Trc. wak Aeration Dist. Pipe
-
Holdin Bot. System
PUMP/SIPHON INFORMATION j MA
Manufacturer Qt'-IlI and St Cover
tips
Model N-um-ber - - - l Ya~~t~ O d
TDH L&----- Tiction Loss System fiead TPH Ft
Forcemain Length Dia. Dist. to well r
I ~f /C
- - is - ! T
- - -
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. O enches PIT DIMENSIONS No. Of Pits is i epth
DIMENSIONS
SETBACK SYSTE O P BL WELL LAKE/STR EACHING Manufacturer.
INFORMATION CHA OR
tuber: -
Type Sys m: UNIT V-IaL
DISTRIBUTION SYSTEM
Header/Manifold Distribution / x Hole Siz ix Hole Spacin Vent to Air Int e
' - Pipe(s)
Length Dia Length / Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over (I Depth Over xx Depth of xx Seeded/Sodded xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil Yes No Yes 71 No
f
COMMENTS: (Include code pencies, persons present. etc.) Inspection #1: Inspection #2:
Location: 1442 CTY RD K 11
1.) Alt BM Description = 1
2.) Bldg sewer length = 0A cz tGn,
- amount of cover = 010 c$(~t
PI revision Required? F Yes F No `L
r--~_ 1 444
Use er side for additional information. Cert. No.
Date Insepctor's Signat
SBD-671 (R.3/97)
RECEIVED SAN-ao1-7 -aS8'
County
Safety and Buildings Division St. Croix
i > o AUG 10 2017
201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.)
S P t'1 Madis WI X3707-7162
fis S r.' ST. CROIX COUNTY J, 7. t
'~t-~,.='OMMUNITY DEVELOPME 1.
B 8 B DA 5 H YZt"„J YJ State Transaction N her
Sanitary Permit
In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental 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 Servies. Personal information you provide may be used for secondary
u ses in accordance with the Privacy Law, s. 15.04(1)(m), Stats. / ~W~
1. Application Information - Please All Information ! n
Property Owner's Name / Parcel #
Riverside Trailer Park 036-1078-90-000
Property Owner's Mailing Address Property Location ,
369 E. Kellogg Blvd. Govt. Lot
City, State Zip Code Phone Number SE 31
$W /4, Section
St. Paul Mn. 55101 T 31 N; R 17(cirelEoor
H. Type of Building (check all that apply) Lot #
Subdivision Name
❑ 1 or 2 Family Dwelling Number of Bedrooms 5 (01.6
5 (Y/O 4---6 Block #
❑ Public/Commercial - Describe Use
❑ City of _
El State Owned Describe Use CSM Number El Village of
Town of_ Stanton
I~
III. Type of Permit: (Check only one box on li A. Complete line B if applicable) O1~
A. ~~cc,,
❑ New System ❑ Replacement System i~J Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain)
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber El Permit Transfer to New List Previous Permit Number and Date Issued
Before Expiration Owner
IV. Type of POWTS System/Component/Device: Check all that app]
❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil
X1 Holding Tank her Dispersal Component (explain) ❑ Pretreatment Device (explain)
1s ersa reatment Area Information:
Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation
750
VI. Tank Info Capacity in Total # of Manufacturer
Gallons Gallons Units o v
~d v U"
New Tanks Existing Tanks y ° e a n# ~y
n. U v~ v~ w C7 ci
a o ti
Septic or Holding Tank 3000 3000 1 Wieser X
Dosing Chamber
VII. Responsibility Statement- I, the undersigned, assume respo ibility for ' stalla6o of the POWTS shown on the attached plans.
Plumber's Name (Print) Plumber' S}gna MP/MPRS Number Business Phone Number
Keith Knudtson 648443 651-470-1737
Plumber's Address (Street, City, State, Zip Code)
927 150th Street Roberts Wi. 54023
oun /De artment Use Only
Permit Fee Date sued Issuing t Signature
PProced $ , V161J-7
Given Reason for Denial (od -
Condi
r Disapproval I
44 so r i-A.N tions of Approval/Reasons foL 60
2-1 6 4:f4%JtA_ 1J.kfJ 6 .0
Attach to complete plans forth ystem and submit to the County only on paper not less th 8 112 x 11 inches in size
SBD-6398 (R. 11/11)
l
CONCRETE HOLDING TANK DESIGN
sinyk; ",Dption
INDEX AND TITLE SHEET
Project Riverside Trailer Park
Owner Bill Block
Address 369 E. Kellogg Blvd
St. Paul Mn. 55101
Legal Description SE 1 /4 SW 1 /4 S 31 T 31 N R 17W
Township Stanton County St. Croix
Subdivision Name Lot No.
Parcel ID Number 036-1078-90-000
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
Designer Keith Knudtson
Signature Phone No. 651-470-1737
License Number 648443 Date 08/06/17
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 4
HOLDING TANK SPECIFICATIONS
5 Number of bedrooms
Non-residential estimated flow (gpd)
2500.0 Minimum holding tank volume required (gal)
3000.0 Proposed holding tank capacity (gal)
Wieser Tank Manufacturer
W3000 MR Tank model number
SJE Rhombus Alarm manufacturer
Tank Alert 1 Alarm model number
Tank Dimensions and Data Tank Anchor Calculations
X for round tank 25485 Ibs Weight of tank and cover
51.0 Liquid depth below inlet invert (in) na Safety factor
8.0 Maximum depth of soil cover (ft) #VALUE! Ibs Weight of anchor required
71.0 Height (in) Outside 3 #VALUE! in Soil cover req. for anchor or
S #VALUE! yds Concrete counter weight
185.0 Length (in) Dimensions ZU.
93.0 Width (in) Only #VALUE!
VALUE!
HOLDING TANK CROSS SECTION
manhole cover with
locking device and finished vent cap
junction warning label grade
box
4" min. 12" min.
23 in.
Manhole and vent locations
conduit vent pipe
18" min.
tether weight -
building sewer
service 12.0 in. inlet
blind plug alarm on Note: All tank joints, and
to seal joints between tank
outlet openings and piping are
Electrical as per 39.0 in. sealed watertight. All
NEC 300 pipe and vent materials
and SPS 316 comply with SPS 384.
3 in. bedding under tank. Tank is anchored as necessary to negate buoyancy.
Project:
Transaction Number: Page 2 of 4
HOLDING TANK MANAGEMENT PLAN
This Private Onsite Wastewater Treatment System (POWTS) has been designed, and is to be installed and
maintained according to SPS 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 100.0 to 600.0 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 Service 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 may be contacted:
a. Installer Keith Knudtson Phone: 651-470-1737
b. Service Provider Powers Liquid Waste Phone: 715-246-5738
c. Co. Zoning or Health Dept. St. Croix County Phone: 715-386-4680
11.
Project: Riverside Trailer Park
Transaction Number: Page 4 of 4
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KNUDT5,IN PLUMBING & Ile
927150TH ST. 648447MPRS
CELL 6 7 I
ROBERTS, WI 54023-8526
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AUG 10 2017
ST. CROIX COUNTY
COMMUNITY Sllffr HOLDING TANK SERVICING CONTRACT
Contract DaGte
J " This contract is made between the
Tan Owner(s) Name(s) and Pu er's Name
L:
We acknowledge the installation of (a) septic/holding tank(s) on the following pr erty:
(Provide legal description):
W------------
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.
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 upon 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/holding tank;
c. The location of the property on which the septic/holding tank is installed;
d. The sanitary per-nut number issued for the septic/holding tank (if known);
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.
4. This affreement will remain in effect until the owner or pumper terminates this contract. In the event of a
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 governmental unit named above within ten (10) business days from the
date of change to this service contract.
Owner(s) Name(s) (Print) Owner's Signatur Subscribed and sworn to me on this date:
121 o fn I-A-vt LL-f Today's Date
I
Pum er's Name Print Pumper's atu Notary Public Signature
Plymper's Regis ration Number Commission Expiration
II IIIIlIIIIlilillllll 111
8462574
A Cl'1 Document Number Tx :4389957
I t(.~, Document Title
U~+
C~puC OUNV St. Croix County 1052260
1' N~TY D IPMF-RT Holding Tank Agreement BETH PABST
~~AMV REGISTER OF DEEDS
ST. CROIX CO., WI
Permit Number -
RECEIVED FOR RECORD
~~V 2~c S1C~~. IA L- 08/10/2017 12:31 PM
Name - (Owner) Typed or printed EXEMPT
being duly sworn, states, under oath, that: REC FEE: 30.01
1. He/she is the owner/part owner of the following parcel of 1 d COPY FEE: 3.0
located in St. Croix County, Wisconsin, recorded in Volume PAGES: 2
Page qa6 Document Numbe{ St. Croix County Register
of Deeds Office: Recording Area
A parcel of land located in theSE % of the-:W r/4 of Section Name and Return Address
T 3L N - R W, Town of
lam! St. Croix County, Wisconsin, being ~Z (i /Q c/ GJ 1,1,64
duly described as O lows (include lot no. and subdivision/CSM or
detailed legal description): See- ~ 6\9d 6 3 12 - 16 l 0-660 7 d Parcel Identification Number (PIN)
Agreement Date: I~ 17
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 holding tank be Installed on the property for the purpose of proper containment of sewage. Also, the property
cannot now be served by a municipal sewer, or any other type of private onsite wastewater treatment system as permitted under Ch. SPS 383, Wis.
Adm. Code, or Ch. 145, 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 falls to have
the holding tank property serviced in response to orders issued by the governmental unit or the Department of Commerce to prevent or abate
e human health hazard as described In s. 26459, State., 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 presedbed by s. 66.0703, Slats.
2. The owner agrees, pursuant to a. 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 authorked by the Department to make such Installations, 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 allow the governmental unit or the Department of Commerce to enter the above-
described property on a regular basis to read and/or 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
servlcing 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 dale 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 9a provided by law.
4. The owner agrees to contract with a person who is licensed under Ch. NR 113, Wis. Adm. Code, to have the holding tank serviced and to file
e 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 contract
5. The owner agrees to contract with a person licensed under Ch. NR 113, Wis. Adm. Code, who shalt submit to the county on a semiannual
basis a report detailing the servicing of the holding tank. The governmental unit or county may enter upon the property to Investigate the
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 systems
cer8fies that the property Is served by elther a municipal sewer or a private onsite wastewater treatment system that complies with Ch. Comm
B3, Wis. Adm. Code. In addition, this agreement may be cancelled by executing and recording said certification with reference to ihls
agreement In 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 and'swom to before me on this date:
d 0-0
Notarized Owner's SI atu Notary Pubi
Uv`~
Governmental Unit Official Na e, Title - Ple Print My Commission
MARY J. BL K
N
Governmental Unit Official Signature Drafted by: j)p~~ ~M~
r
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 submittec document title. name & Tatum address and PI (if required). Other information such as the
granting clauses, laegal description, etc. maybe placed on this first page of the document or may be placed on additional pages of the
document.Note. Use of this cover page adds one page to your document and SZ QQ_tQlhk r.QcQrding fae_ Wisconsin Statutes, 5943.
St. Croix County 1052260 Page 1 of 2