HomeMy WebLinkAbout040-1261-20-000 (3) I
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
(ATTACH TO PERMIT) 600269
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:
Daniel & Celeste Siedler TOWN OF TROY 040-1261-20-000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
W.?1, ~j OJ~~"" 18.28.19.1401
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark 5.7-5 .7L
Alt. BM 7 315 All /9 7
Aeration t Bldg. Sewer P"
St/Ht Inlet
SUHtOutlet
TANK SETBACK INFORMATION S - 74, ~ l• 72
TANK TO Al' 1 WELL BLDG, ent Air Intake ROAD Dt Inlet `
Septic Dt Bottom
'94 X4
Dosing Header/Man. r 94~ 3
Aeration Dist. Pipe tZ.1
.1 Z.. I I
Holding Bot. System
PUMP/SIPHON INFORMATION Final Grade 4 •Z 97- 7
Manufacturer Demand SLCover 4
GPM teGf~, 3.5
Model Number
a 1Z•1 93.3
TDH ift Friction Loss System Head TDH Ft
T r3. I 1Z .3
Forcemain ist. to Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 3 1-76 J" Z --jr,"Cam`' I ~ 7~!~
SETBACK SYSTEM TO P/L BLDG WELL LAKE/ T EAM LEACHING Manufacturer..
INFORMATION CHAMBER OR J r 4
Type f System
UNIT Mo O Nufnb
b
c..J
hg en, a 7Z f °13 ✓~~c 4/ ~g
DISTRIBUTION SYSTEM dryv~ r 2
Header/Manifoti Distribution X Hole Size X Hole Spacing J V~to Air ntake
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 S~ Bed/Trench Edges Topsoil n
✓ No Yes No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection 1: Inspectio 2:
Location: 381 WHITETAIL LN Oki CaUf4
1.) Alt BM Description VC. k J~ ,
2.) Bldg sewer length = (
-amount of cover
Plan revision Required? Yes El No / tl _1 ~4 3 _ - L - SBDUse-6710 other (Rside.3/97) for additional information. I7 , /
Date Insep is Si re Cert. No.
RECEIVED oN~14%_e,
NOV a I industry Services Divisiv❑
Coutyty
14001 Washington Ave
P.C} Box 7162 ~ f"G (
$T. CROIX COUNTY Sanitary. Permit itiutnber t
r : UNITY DEVELOPMENT ~ Mach ~r7 5 07-7J2 { be filled is by Co.)
66 Z IAc
anitary PerrI}.it AppljCatiot 0 1 ,tiac "Ira tc:tion Number
la acccrdarx,e With SPa 3$3.21(2), Wis. Adm Cade, submission ofihis form to Ine a
is required poor to obtaursn a sanytary pprtgrnate governrnexttal antic Fffener tt than mailing address)
patxnit Note: Application "mss for state Daunted P{}Vr'TS are submitted to
Project Address (if d
the Deparitnent of Safety and Professional Sen iCes. Personal inionnation you provide may be used for secondary
u rs in accordance Mot the Privacy Law, s. 15,040 XP Stats.
1. A lieation Information _ Please Print %It Information ftrV1
P' =z a J
YfkrCCl 4
°v l L.. K
Pmperty Claaner's Mailing Address
Property
Locz~rion
>
j City, State Zf Cvtie Govt. Lot
)
}P Phan ?tiutn xr
-Aj~E V,, Section
(circle r nvl j
II, Type of Building `ng (clseelc all that apply) _ Lot P T - `5 N; 12 1I` j
1 ( or 2 Fatuity Dwelling -Number of Bedroa 17 ~ Subdivision Name
0 PubiictCatmnereial - Besen7e Use ~
City of
CSMNLMber Villnzeof s
G
;Q Town of 71>;(}y
IIl.'Iype of Permit, (Check only one bras an line A. Complete line B ifaltpli€able) -
New S}_tem tcplacemcat S tem ❑ Treatment,,Hoidinb Tani: Replacement On; y Q Luther M
odtfieFUian to Pyusting System (explain)
~ PetrrtitR n
e n,rfl
Permit Revisi t
o t Ch ne of Pltuzrta r j Permit Transf.~r ,o u u List Previous Permit Number and l3at Issued
Before Fxpiratiar ~
! thener J_
1 cv
l~• T oi'Pf31:'TS 9v1 te:yu'+Co rtentJ?3elldce: CljecE: all drat apaslt~ -
varF Pre zed In-Ground D Pressurmod br-Ground ❑ At-Caade Q Mound > 24 in ofsuitable soil 0 Nlozmd < 24 in. ofsaitabie soil Q l
d Hoi Sittg Tank iher D Spzrs.ai Component {exp(ain)?~~1/t c} { f L 7~ 4~ ❑ Pretre-afinent I}e(explain) .jviCe ~ Ot. l?as ° rs 6~# t ea eat ~krea informal
h
a€r: ~ v` r ot M41
D,;. uuii nuvi swat i -iiuwi i + ?ri;.l tr.:+kti n7L'2i +i.ulUFrt~:i F,St) + iti,~;r,K;rg-}t Ar?'~ t" gCQ +
_ ?o t= 3 asst m 1 e axon
L , T anus to 'rapacity in Total t # of li manufaLtarer
~ 'L
Gallons Gallons Units 60 , n
New Tanks x st T=6
L J ° 1
F~ L, -
septi
~I- ~Ces~orsaitsi2tty 9aytonssnt- a, ltee ans&ersFgarct, tdsSU~Ue rrsl2quxtb3lfCynor dustoEtat§an or Me t't"7WF55#c7Wri on the astraCiaed plans.
Piur.tbLr's Name (Print) Ylu.nt ar s signature
PRS Number Business Phone Number
! r s s - - 5 rte/ -•~~Y-
€'iumbei `s Addre& (4„ cx t, C } , 5tat:, Zip Code) i `
,1J ~i
i^
_..~j
VII' ~ountvJ3ej!artnaent L se Ottiv -
(J F I?atcIssued
Apirovrd isa, r Pcrtnit
t P Issuing gent Signature
. cocoa for I7enrai /
1X. Cotadit ¢rs„g a.oasfnw Disapproval ~ i
cinj:er "ai cell must d++ E, #sPer~Tlatrayemena plan iar w Nw+n4er 3
2 'A~~c i>~,ir~en,s tntl,,t 4t, ~.~ant,.ue,i p
M PM Wfulift co& / udiJ ax".
Attach to cDmptel-e fAurz for tU zy0ew and submit to the ouaty only ou ,
pap>r not trst 2 ~ rf2 z t it~tzts in aizr
SBD.6343 ((f" 03/11)
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iiii-Ground 3AiSEI OF
Index & Cover Sheet
"..rC7fIP~:l41I1~S'fdd l+~i~ltaieai jtrr rSCSt~CxicriRt;c,S:
Version 2.0, SBO-10 P (N.01/01, R. 10112)
index Cover Sheet
P of . Plat Plan
-
Dispersal Area Crass-Section & Plan flier
of 4 Management Plan
Attachments; ' Eni; ipsures:
ppl.ication for Review
O
Sail Evaluation Report & Site a
Project e 1 Description
Owner ar e(s); A :
Owner Address: t Zip:
Project Address: Cr~l -
Govt. Lot: Xe_ 1/4 of ~ J ~ 114, Secton T 21/ N-R~EE]or Vif
Township: TryCC ount :
Project Parcel 1 : Cu~0 0- 61700
Designer Information
;
f
Deli n r a e _U'_ Phone: :tZ&' I 7_5-
Designer Address: 2~' I a7 ~6,Vf-: AKTHRR C AVv.RW4 W-r Zip: -61 13--:X
E-mail: l1 o 1 i s~ cVc t c' - ; t~O '!~(wvk This SPc rvet3 stamp.
pL4g9 S <
License Number
Remarks:
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PAGE 4 OF 4
In-ground Gravity Management Plan
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. Cade. 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 register Pd S Maintainer in
accordance with SPS 383.52 (3), Wisc. Admin. Code.
Max!
avtlsl€~ ~l real A a at l~irni:
Design Plow
gpcl; BODj 5 220 mgL'i T ~ 150 mgL j~ F013:5 30 mgL*' j
s
1M,- ctson Chec Ifst INSPECT EVERY 3 YEARS
type of use
co age of system
o nuisance factors (i.e. odors, user complaints, etc.)
c mechanical malfunction (i.e., pumps, valves, switches, floats, etc.)
o material fatigue (i.e., leaks, breaks, corrosion, etc.)
solids volume in anaerobic treatment tank(s) and any distribution appurtenance(s) (i.e., distribution / drop boxes) r
c neglect or improper use (i.e., exceeding design capacities, prohibited activities, etc.)
extent of ponding in distribution cell prior to dosing
o dosing irregularities - if applicable (i.e., pump re-cycling, float switch settings, etc.)
c electrical components - if applicable (i.e., wiring, connections, switches, controls, timers, alarms, etc.)
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
eu:tenancc Chec:cl t r1VOWNTAI EVERY 3 YEARS (of, vv; ; aet,4 ~4 arIv)
o Septic and dose tan fs) shall be pumped by a certified septage servicing operator licensed underss. 281.48 VVis.
Mats. when the volume of lids in the tank(s) exceeds one-third (113) the liquid voluma of the tank(s) or i
as required by local ordinance. Disposal of contents shall be pursuant to NR 113, Wisc. Admin. Code.
c iu t ~Iterfsl 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.
f
System maintenance reports shall submitted to the proper local government unit in accordance with SPS 383.55 Wisc. Admin, Cade. Report any component failure or malfunction to:
a,rze of individual or txxnpany: b V A,'C p S~e 1 ( _t y j,-A r? L-A- I CAI Phone: 71 S. -7 5 - J
Local government unit: _ 5-1 o, i _LL- V-iE:Lphone: 7I = 3~ i - 4~
Local government unit address: +(t(D c=n1 , k s ,SIP: -/o J i
Any defective part of this system shall be repaired, replaced, or removed pursuant to SPS 383.51 (1), Wisc. Admin.
C e. Repair or repiacement of faiied or madunctioning components shall comply with SPS 383,1Jilisc, Admin. Cole.
No product for chemical or physical restoration of the POSITS may be used unless approved by the department in
accordance with SPS 384, disc. Admin. Code.
Conflrtenc~° Irolar~
In the event that any failed treatment component of this POWTS 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 dispersal component in a pre-determined area of suitable soils.
SYtent Abandt~nent
If use of this f OWtS is disciantir:+Jeif, if shit-.al! abandoned in accordance ojith SPS 38133, Afiisc. Admin. C-le.
The Orilt Septic Tanl,d, "iItei' i'o'till Evc !KcI d
I auC 1 U1bd+-
1
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1 he li etime ~ ili tel
11 i 'u. go t C1
The lifetime filter is the most efficient, low maintenance effluent filter on the mat,het, rated 3500 GPD. With nea
~ftarirg capacity of other filters, lifetime filter is the west value for your dollar. The unique plate design eliminat
su CS inside the cartridge virtually e iminating maintenance. Cleaning is made easy through the elirnination of s
!P-N,,1ePn nia~ P~ m,*ing thn lime to clean and replace ninimal. Our unique, durabie crnstru,.tion and patented ~
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(,.i!l(ki•e pro e:- 71 1 Lr, 4 1}t .i iE t! 1/64." 7 i( ?iu d. 71E flYl t I~L( C.'~~r (j lI?n and fi l{taP ioni s
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rec-sonahle pi ice ~ it, cut -ompFon-,ising qual ty.
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11-) le-Flece Alter Lase
1=~~~ ct high quality materials, this sngle-piece
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p. ace. The additional side hub provides even not
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(EFFECTIVE LENGTH)
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34'.
INVERT 10.4"i INVERT 9
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INVERT 3 ,
9".- t
JI_ L'. L, j-' PQ 34" x 53~, 403 035 an x ES✓ cm) lat 8rt eight
:~l cis cm,
/a 3 TU R
i r? ,,,brick, CT 067475
Y r 4 tt ! i ~ ~C:i s,yj 111 ~~`^~w3ti.,3e m~ty(`^,
on 117 in x Olt vy,
.1 X37'
22 0
Cover policy for Infiltrator chambers in
conventional applications. INFILTRATOR'
systems Inc.
t] ill ? t 11` t`:1 po:[cy is tc1 ?Sir I+SII CaV<" G ! i'10 j1;?1 C i UI,L?T`i3t'tS T,n;' v8f; ac✓ordhQ 10 Stale and
for rnalntainit;g &fruCtuMl integnt`l• ioca1 rojulations. If unsure of instaiiatian requirements,
contact your -?ate ar Iocal rogutators.
El Durinq system design it is important to n,-ote that any
sc!ptic r;y810rr: desirined and imstnlied d€epcr than ri feet 0 Questions roc)arding tho installation of Infiltrator clamber
n, y experience perf<3rnlttt,cc p?obler7,s as a result of limit- systerns`f Gall the Technical Service Department at
u,J cx, az,n tr n, fe l ihw th ;o'. S0 for current instal .rtior insE!r~cticns-
t
Fable 1: Burial depth in feel (exclusive of chamber height) I
Products
Configuration
LS Q ickQtiick4 High Capacity Qu M Quick4l
tandard High Capacity H-20 Equalizer 24 Equalizer 36
minitnurn cover in fleet I
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P~-tc n tali' n:111* -15 r'r fi./1I 0 5/1
Tf] ncilez` ` 0.511 ` 0.511 ` i. 0.511 " 0.511
maximum cover in feet
Beds 4 4 8 4 4
Preaches" - 8 8 $ 8
0.5 ,eet burial depth for no t-Iraffic applications only. 1.0 feet burial depth for H-10 toad rating.
honchos refers to a I4cot minhm,nt soil separafiorr behveen chamber rv4.s.
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Distributed By:
INFILTRATOW
systems inc.
Cox 76a ^ "3usirrevs Pam Rozd , Old S!iybront<, CT 06,175
6r G77 7QU ~r e PAX Ei£,0-577-7011 I
°J'JVV*1V.lrE!ti?~~:GfS~~S~rI!`..,i.d;VSE~
1-600-221-4436
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c 14i i h3 11 U::.~ I t Pia X't Y 1.7 g fr. 1 l i. l rf iS 9 cJ ni r n 2Y 9 i _ _I krat6?.n .i~ a
! JL i 10, F '-/It:T ll' 6 < (3 ~2. ti h i v s_ c c7 „t,~kF:2Jr .ua l..i.'S71. Y{~ ~f (t)k1wwy SYS:=, 1,;.
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ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF EXISTING SEPTIC TALK(S)
This is to certify that I have inspected the existing septic and/or dose tank
presently serving the following residence:
(Street address) j Y r located
at: i/~, '14,
-L! C7 >
Section Town N Range W
Town of j 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 /(')1 ! ~4' _7
Did flow back occur from absorption system? Yes No
(if no, skip next line.)
Approximate volume or length of time: gallons minutes
Tank Capacity:
Construction: Prefab Concrete_ Steel Other
Manufacturer (if known):
Age of Tank (if known):
Permit number (if known)
(Licensed lumber iinature) (Print Name)
p t ~ f
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(Title) (License Number) MP/MFRS
1
/ i /7
(Date)
Form to be completed by licensed plumber (Dept of Safety and Professional
Services Chapter 305 and s. 145.06 Wisconsin Statutes
s ) or licensed disposer
T
(NR I 1 - Wisconsin Administrative Code)
Rev. 21/ 2012
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer /4 i E r,~ f / k .
Mailing Address
Property Address
(Verification required from Planning & Zoning Department for new construction.)
r
CityiState
Parcel Identification Number
LEGAL DESCgIPTIONT
Property Location Sec. v , TN R W, Town of
Subdivision Plat; Lot #
Certified Survey Map # Volume Page
~'arranti, Deed ? - (before 2007)Volume Paore
Sj;cc house 0yesolo Lot lino; identifiable ❑yesElno
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
Improper use and maintenance of your septic system could result in its premature failure to handle )A astes. 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
oNvner 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 andior (2) after inspection and pumping (if necessary), the septic tank is
less than L3 full of slud«e.
Uwe, the undersigned have read the above requirements and agrec to maintain the private sewage disposal system with the
standards set forth, herein, as set by the Department of Safety And Processional 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 3 days of the three year expiration date.
I1/we certif' that all statements on th* form are true to the best of my-our knowledve. I'we am!are the owner(s) of the
property described above, by virtue of a war anty deed recorded in Re,.tster of Deeds Office.
Number of bedrooms
r
err
SIGNATURE OF APPLICANT(S) DATE
"'I'Anv 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 Resister of Deeds Office and a copy of the certified survey map if
reference is made in the %~arranty deed.
(RENT. 04/12)