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HomeMy WebLinkAbout012-1012-50-000 (2) Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division ~ INSPECTION REPORT anitry Permit No: 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 No Tyson & Jennifer Lybeck TOWN OF ERIN PRAIRIE 012-1012-50-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: YVii I GST 04.30.17.54 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic wt, 0- Z:, p -'s ' Benchmark Desrtg n Alt. BM V V 4::, l x..14( /60. Aeration Bldg. Sewer 2 .9 - f , 7 Holding St/Ht Inlet 3.7Z q-7, z TANK SETBACK INFORMATION St/Ht Outlet 3• cK* 7. 7 __1 I TANK TO xP/I, WELL BLDG. ent Air Intake ROAD Dt Inlet ~ ` ftA 1 .0 l Septic 7 Sat Dt Bottom Dosing Header/Man. I. .'S Aeration Dist. Pipe S • t 9L • S $ .vs Holding Bot. System p b2. ~ OLJ PUMP/SIPHON INFORMATION Final Grade m, d ~5 L Manufacturer GPMand St Cover ~ AA A . JAA- Model Number ~ W5 95.53 TDH Lift Friction Loss Syste ad Ft ~.Z'S Qom/ `~L. Forcemain Leng ia. Dist. to Well (::~*I g O 5.35 C 6 SOIL ABSORPTION SYSTEM BED/TRENCH Width Length / No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 1136 /1341 •Z `1rf_ c SETBACK SYSTEM TO P/L BLDG WELL t LAKE/STREAM LEACHING Manufacturer: INFORMATION TypC.O Sys CHAMBER OR 1 0.+ C~lL / AV~`rJ a 3 tv T I -7(o UNIT Model t n1V, 1 _ 7f 4 ~IlY DISTRIBUTION SYSTEM 3Z 333X. awe, S Header/Manifild Distribution x Hole Size x Hole Spacing Vent to it Int ke Pipe(s) Length v Dia -4 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 Q 5 Bed/Trench Edges N__.1 Topsoil `es ~L -1 No No COMMENTS: (Include code disccr~ep~encies, persons present, etc.) Inspection #1: Inspection #2: Location: 1747170TH ST f ~r~r"' ~u/{J~. G~1;/`~j d-- ~.•aG~ d~ 1.) Alt BM Description = ll r - - 2.) Bldg sewer length= /3 - amount of cover = PT a"~/~..~ 0+~ Plan revision Required. ~ Yes No 1 ~ ` I Use other side for additional informs on Date Insepct Signatur Cert. No. SBD-671 0 (R.3/97) . I'~'(f~Lf(1 Sri Z`r7 ZSl County TAID Saf* and Bulldits DtVrlon p~f L t i X- 249 W. Washington Ave., P.O. Box 7162 Madison, W 53747-712 52uitffiy Permit Number (to be filed in by Ca.) y ~y ~M Nay H1 ~-C Sanitary Permit App loo Star Traus1c caber in accordance with SPS 3832I{2)~ his. Adm. Code, submission of this form s~i govetnmerttal unit _ De red laiar to abtainiag a soQitary permit. Now Application forms for 4r . rr*0"k=d, t o Projax Address (if dif orA the mailing addrm te Departoment of ety and Pafesaiat Berries. Personal information you Y 7y~ is accordance with the EtIMIAN, a 15.041 ml, scats. I Application deformation - P10M Print All Information„ M Property OwnWs Name i M r WF- Parcel # C1-z_ - I C1) - COO .10 Property Cluvoer`s Mailing Address µ Property l.o~atiori y 30. / -7. S7 -7 `I r ~ f Gds. ~ City. State zip code Phcme Number ~14 SYtf V,, Section vet t C I~1 ' 000 Dl. TYPC ofBuildiin (check all that apply) Lot # T 13C) N> R E or n-t,or2Family Dwcllong-Number ofBedrooins Subdivision Name QnQlI S_ b Block I-' ❑ Public~otomerciel - Descn~e U. V~(Jn ~ D City of 0 3tame th~vned - Describe Uc `u'' w i csM Nmrrber ❑ Village of 3 D►s"r~l TI~U C~2cd' + l k 1 Town of r el r i Z►l R C EHL Tygu of Permit (C6 ire A. Complete live $ if applicable) A System 5ysresat Treatmeat/Halding Tani Reptacezrtent Only ❑ od= Modification to adsfirtg System (expll B• Q Permit Renewal ❑ Permit Revision D Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Dssued Owner . Type of POWTS Svata oai nrattd?evice Check all that a } 73oa Pressurized ]n-Ground © essnrizea in-Ground © A"GG`raade l~ Mound 2:24 in of suitable soil ❑ Mound < 24 in. of sritablc nog liokling T ispeasal Cwwonent (explain) ^ ertt Device (explain} V. d>is rea#ment Area Information: ~ / Design Flow (gpd) Design Sail Application Dispersal Area Required ( Dispersal Area Proposed (sf) Systean Elevation 00 IR~v Z 8 7 oo c'- L~ ce ~t Vb Tank info Capacity in Tout # Of Msmwr cr i ` j C, f C t3alialss Gallons Units 'Z.eDUQ Newry Septic or HoMiag T 2 VU r ij' Doug C hwnber '^A>' VII. Responsibility Statement. I, the undersigned, assume re8p0osibil91y for install " n of the P0 WT5 yhorro on the attached pleas Flu{ abed-s Name {Print) l, i f NPR N 7 -Buusiness Phone, Number iaa' Address (Street, City, State, zip Code) t_. 0- 56,5 TW 7 f Coca artment ume onl Permit Fee Bate lasucd Issteiag Rgaatt Signature (3wtrer Given Reason for Denial S r" a l /a` dX. Conditions of Approv ns for disapproval 2 n n ^ ~n- SYSTEM OWNER: rjOt I~I ~Un f I! / t UX wi :7-- aq~ (M t .r 1. Septic tank, effluent filter and 7r s /m~/ ~~s~~ C, I L~~IJ/l~~ dispersal cell must be Serviced / maintained A as per rianagement plan pi,-) :~ted )y plumber. left"C, hoII p ~Iaqae~ a per 'W pii Ca b , 1 1 Dar the I sad sabrsih to the C 0ty only an paper tat CW. than 8 lqo ie~ ~fnW f~5~vl yv ba SBD-6398 (R. 11111 CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: ~,l k3(~ J< Owner's Name: 44 Owner's Address: -7 -1,10 3 r 0 _ Dr f Legal Description: Township: 11~ County' . n (Y ) t Subdivision Name: Lot Number: Parcel ID Number: C; / Z.m° ) (1)1fz- ~ ~;0C..) 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. I" Fu)( License Number: ~ Date 7 Phone Number 7 i cj - J `i 'Ifia 1i'7 Signature- Designed pursuant to the in-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01101). Page 1 gglo n Grote NqOon ft Final Grade 4° Sdiedute 40 PVC Vent Pipe ft With vent cap Leaching ft Chamber System Sevation G v yi ft ft §o61 AMgUZ on Vf ft IiiIIIIHIIIIIIN Leachkv Trench Vent Or Observation Pipe Ch nbem Trench Header ++r` Lughing _ L Manufacturer And Model i~~' EISA Rating Sq it per chamber Soil Application Rate ? gpd/sq ft 1_~ \ C gpd Design Flow + Soil Application Rate = EISA = i hambeM 2 robes of x ~ chambers each. Page of to 1r in, a tr f a 1 obxrsof#S I L IT ML-06 FEATURES & 804EMS b RaWd for j0,00() GPD Fed+fIlifrFes' - _ 4 FAU PL -6L5 = unew Fes Of'113r 4' and a Ste- 4d p# PI 425 in C-,m DdeCIDr Oluot L- F before S~ 8M au n FW jsRet~rmved avow YOM under nOnn'►tded ttd fftrbe Ity , - L ft two tee evefy a tbl ad evsfY t ins an op al PVC Exw~ e to owner wil be nofifted gnga ServICI9 should be dons by S roe& fled 96Pft tw* r or inst r "C FOW PRODU can ryas - r•J^_ '~~r.;-c;~ .`S ; ~ ~X.[ -y ~~`~~~5 18-4ec Am bm GOD" EOWA SOW &Laklm P ip tri 0.0 Von" P WO apon to Use ~ t.P a e bSF dkvi- a mm- l0*Wte* Fhs rsndCpOOM NAM at edMok roduM Fey. ~ ful IM of MANAOMIMT rA I\, t, Task t# NA ~A Tak Tok T ftow XL soy RM r frsW C3A & t O4DGj s 30 =WL c odw- tbcy~en s 220 ® l6oder T ® 1► ate' odor. Total So13& (Tw s 30 =sIL Fwd oJifto vwm) MADAM p 118 ha 33nnaciror Area ~4• ( of F% AlownWolift. • ~''a' FW7M-jMjW&b MW .M t ~ ~ Corr M s = s pdftoWn 1522 for Sep* TatOc- g 4.5 1 TMCW amd R.T. O* -.AW tkaticw5-97 nod "4WP ooftwamwdK ad DispoW EPA 52511480-Q12 OCOObOr 1980 69,'AlO.& C.V..o Mama UD3sb%un gOD-1O 1 SOD- M;'*M'G,,,d A MWa r 9z 111625-~ } Re t3tak ~ ® W S C.a~p . D - (NAW ® WD -10656•-!P fN6"' " sw Remmbft gmd vow Bym= c.,,,w Omar 130D • 10572-F (L60) X 20 t3 5W -106gk-r ~.0111f1) 1Ot' 0 1 MOD a 10.473-P (VL } tP 2.D s 107064 t 1 W C3 for EmmstDkw=dctuqxmstmAwd t3 A ~p1r~ESs g,~~ 3 air" too= I"omofm 2 At ::::r-l ~mm s~3 s. --am all eet oueloob o[~ ; At a ffi 1 & ml At LMt ON" s 3~3A n a varrc(s~ i~enb ® At IPSO gww 0 Ow" 49.9... ._...r r.._...... ,ifl.13. 2411 1:35PM St Croix Co Govt Center No.44`1U r. It ,TMT UP AM 0MRAMIl ` For mw coftetttrtrdo, pft w itM of tlN pOWTS cheoat tfnsatnterft tonktal for the WSW" of produota at oMter alaitnloo that may WOW* the Veamom praora proton damtgd the dispersal coNA). If high aaeoenMitiOns. ON deteOad have the oontan, of the WWII removed by a nptspu rtafvWq operator prkr to use. Systearl staft up shag teat oadttr peen soli conditions am ftczen at the fnftftrm*o surfade. During power outapaa pump looks Rosy fill above normal highwwar levels. WW power is rerltVW the *%M# wauta+xr&r WIN b dlsoherged to the eMeoaraat oellsi M eAe large does, overloW4 the *00 and may result kt•the backup of a 0we't#eoh" c of tklent. To eveid• thh ethoftft taw tho•oontants of the pump tank nmovad by a Smogs lwvW4 Own w odor to irfiehafkn pgww to the Of w R Bump or wteot a Plumber or PO WTS MoIntsinsr to assist In manually opwK4 the pump o0fttfois f , , . restore ttgnnaf seveil whidn the pump tank. I Do not drive or park vehicles, over.tonks and diaParsal•oeNs. Do not drive or park over, or•oth tw ownpact, the ire within 76 fast down d0pa of soy mound at atVads soli obsorption was, RaduaSott at af#itdrtsdat of In f+olilowing from the westewsw straOm rnW improve the partorMwm and prolong to lint of 05. i POWT& at>tN 0,0 baby wtpee;. cearette butte., condoms; coffon swabs; degreasers; dwW frog; dlapew, dWeotanta; fat ga; tarbl o";, 001t eertfw meflaallons; o9 fo s; gosoMfte; asa futdrraoft disirt (OM pampt peter, frtdt arrd vapatable paelitg painting ucts; psetialose; sanitary napkins; tampons; . and worst saftener brlne..- i %B ANQONMDfT When *4 'Powre fi and/or to per-nanentty taken out of service the following steps shag tie talon to Insure that the system k property and set* a)endo wd in compliance with chapter Comm 83.33, Wisconsin Administradve Cadet 0 All p,pktp to taztit# MM Pita "be diaronnected end the abondonsd pips opanMps aedso-'- • The contente of eo teaks and pate shall be removed and properly disposed of by a fleptage sw*hv operator. e After pumpktd,' -ad Wks and pits shall be excavated atnd removed or their oovers rompvod and the void space Mad with sail, travel or erfotMr Inert saW malarial. `rONTII Y PLAN If the POWTS fees, NW cannot be repaired the following meamea harm been, of must be takaft, th fvovkU a code torniiAalt eaplaaentartt ay,>itift►r 36-A suitable tt►plao6ment area has bean evaluated and may be utilized for the location of a reptewftteM "M absorption syst m. The Mplaa nW4 arse MWId be protected ffom disturbance end comps t, VA "N titOt bill (ttfftflped.tf N by reoutred estboake from existing and proposed struotum, lot teas and woik. Faftow to praftoc the rout was will rasutt an the now for s new soil arnd site evaluation to "IsbNsh a suitable replacement was. AspleceffwK systsme must comply with the tube in efteot at that time. E3 A suitable mtacement arts' la not available due to setback and/or soil limitations. Barring advan4es in POWYS t hnology a hoWAV tank may bs, Metalled ass st resort to replace tin failed POWTG.-. sic f•svak*od toldentlfy a s Rablo;Abodrl*t NW Upon talk" of titan e rfamttadl ttf °c s a suitabl 4~.atr. it nok e f2d'PO , D Mound eftlf ::Ita- xN ebaorptiort systame may bs reconstructed M plift followkq rerfwvat of the WOW at the 'atfitttedve wNfe aet, Noartattuctions of ouch systama ntuat comply with the rufas M effOSt at that tons. ' <WARMtN4> a . 30PTIC, PUMP AM o'f'W MAYMENT TANK/ MAY CONTAIN t.E'TM GASS95 ANOM T OXYf3INI, DO NOT ENM A , f'tlW ON OTMLlt TIMATWW TAW MN ANY CBlCt11110TAf11M, V4ATW MAY JOKY, RUM Of A PEWN fltofilf TM NTWOR OK A TANK MAY as fD mcuLr oR wrossiou. ufJfTlObl 3WT8 MNif'T ANft- N N Name Phont - tnl►ana ~r LOCAL MIJ T -PTA ME offtaY CM) flame . N+rt+e ~a dosttrsertt /was ereftMi to ootripNetro+ with clsapta Comm (q.Z3i+tiibil41tt8aih end e3.9~Nth i1i b teh WlsgrfeMl /igrtiWaVaOra Coda• an-ooa~ ~~~u 9518-SZ~-008 0 \ r- :anod-isod :31va 00/00/00 :ova osLas w 'Aoua N3oivw 0l lMH En 9LLCM z ivnNVW 3I1d3S :an0d-38d „0-,l=„t t :3 'AM 1vos d0M N7v7v 31313UUU BOOM z N,,,OOZM V) \ W J LLI U) 0 ~ H Q m a o m p af C) O W O• J z U 0 Jw 0 o w IL N ? N Z m U) CL m li C/-) o o 0 o 0 ° in w UI Q a Z U wF J J J 3u Y w o Q Q I- UZ W0 ~'-Oh U O^~ U o o z mkt Z w to Q H Qt w H d Q ~ o ~o oa aac=i Q a oz Q}lam > C } o 4- a O U) Uj m fl! J W W (-5 N Q N U tY " a p FT M p - m m J ,Q E 0 U) N x w Y d "sZ. _ Pry (0 J Q m J F (n 0 U N 0~ 0~~00 (A~ MW~j N O t1. ~ Q ~ -4k Q a N e O F- J CC) M F- I q l- Q 00 J a- O J Z N rµ OCL ~vwis L'i ~ ~~~~,>U) ~a1vOZM z OU N= v o-izo (n h c~ _ LLJ CVO OF- Z w JH V) w fn a OQwUOW Q ZFQ wU O~ 0 ..t+ (%J FO- CWK " S' O_U Y W Q WJ m F X 0U = O .w1- O ~J~ Z W X N Z JF- >ZUZ ~ ZUQ z - 4 0 0 L'i ~ Q a Ca z U U F= U < V) ~ll Z3m M = w~mJ o Z Z0< U WW 00 J W U W W Q Y > Z M J J Z a O o O Q OQ 0 Z U U w ~ „OS 0 z w ~ i Li w \ 5v0 .,.v ilf Q Q I N F- m I U U Q I lI „9ti w 0 n d w J Cl_ Q U a O X vwi I- (n w „9 ( °9' 0 I o c~n ~ w w U ~ r „f5 do 0 \ Of CY U Q (711 N O ~~^y Z 4'd d - w aa3a „£s Q „99 ` Sv „99 C. .3 z ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM f Owner/Buyer 0 h L~-/ L~ Mailing Address Property Addr S : C o (Verification required from Planning & Zoning Department for J w const ction.) City/State kJiyV1b-kJ (,t) r Parcel Identification Number LEGAL DESCRIPTION Property Location '/4 , '/4 , Sec. _LL, T ()N R W, Town of Subdivision Plat: , Lot # Certified Survey Map # , Volume Page # Warranty Deed (before 2007)Volume , Page # Spec house ❑yes no Lot lines identifiable [ yesE]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. I/we, 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. 1/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 warra deed recorded in Register of Deeds Office. .Umber b rowns SIGNATURE OF APPLICANT(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 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) RECEIVED wc.. Dept of Safety and Professional Services SOIL EVA T N Page E T of 7 F Division of Safety and Buildings 2 017 AUn aacc~or an with SPS 385, ws- -__,,QFN1v G Attach complete site plan on G4oM.~st ' include, but not limited to: t _.,ection and Parcel t.D, percent slope, scale or dimensions. north arrow, and location ano distance to nearest road, - ' - - .'uPlease print all information. Revviiiee'ed by Duatee personal information you provide may be used for secondary purposes (Privacy Law, s. 95.04 (1) (m)). G Property Owner Property Location Govt. Lot 1%rt 114 1/4 S✓ T N R/ i E (or6o Property Owner's Maifetg Address Lot # Block # Subd. Name or CSM# City/ State Zip Code Phone Number ❑ City ❑ Vin~ge ❑a Town Nearest Road ❑ New Construction Use. Residential / Number of bedrooms Code derived design flow rate GPD ❑ Replacement ❑ Public or commercial - Describe: _ F: ft. Parent material Flood Plain elevation if applicable AL General comments 7 and recommendations: %alpw ~n,° use 50' vrh wM ~~E . Bori Mng # Q PB~Whg it Ground surface elev. 14z, Depth to limiting factor ~.S in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure nsistence oundary Roots GPD/ft 2 in. Munsell Qu. Sz- Cont. Color Gr. Sz. Sh. ff#1 *102 J1 A T-- I "O~ Boring # ❑ Boring ® pit Ground surface elev. /fe r ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure sistence Boundary Roots GPD/ft 2 in. Munselt Qu. Sz. Cont. Color Gr. Sz. Sh. ' ff#1 ff#2 3 3 Eftiuen 1 - BOD > 30 < 220 mg/- and TSS >30 < 150 mg/1- ' Effluen =130D < 30 mglL and TSS < 30 mg/L CST Name ( Pri Signature ~j CST Number / Address ate Evaluation ondu ed Telephone Number SBD-8330 fRl I/11) Property Owner ' Parcel ID # Page of Boring Bonn # L t g ~ Pit Ground surface elev. ft. Depth to limiting factof in. Soil Appri Rats Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft : in. Munselt Qu. Sz. Cont. Color Gr. Sz. Sh. * ff#1 ' ff#2 r / Boring # ❑ Boring 46 ❑ pit Ground surface elev. . ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure nsistence Boundary Roots GPDift Z in. Munsell Qu. Sz. Cont. Color Gr. SZ Sh. * tt# t ` ff#2 r-~ LJ ❑ Boring # Boring Ground surface elev. R Depth to limiting factor in. ❑ Pit Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence undary Roots GPD/ft 2 in. Munseli Qu. Sz Cont. Color Gn Sz. Sh. ` 01 ff#2 ` Effluent #1 = BOD b > 30 1220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD s < 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. SffiY8330 (RI I!I II 1