HomeMy WebLinkAbout038-1015-80-000 (2)
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
(ATTACH TO PERMIT) 600287
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: 7City Village Township Parcel Tax No:
DONALD JACKELEN TOWN OF STAR PRAIRIE 038-1015-80-000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
JN5 c'ST' 03.31.18.438
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic .fir Benchmark 16 /DJ Q 166
1QiiVv v
Dosing / Alt. BM
Aeration Bldg. Sewer
. 9~ 9g ~ a
Holding St/Ht Inlet
S 9 7.
Ci
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO P/L WELL BLDG. ent t Air Intake ROAD Dt Inlet
Septic ,75 ~J Dt Bottom
,Ito Dosing Header/Man.
Aeration Dist. Pipe
Holding Bot. System
PUMP/SIPHON INFORMATION Final Grade
Manufacturer Demand St Cover
GPM '75 1,6 i Z
Model Number y/
TDH Lift Friction Loss System Head TDH Ft z /
Forcemain Length Dia. Dist. to Well
,G,lo en e,le~-
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR
Type Of System UNIT Model Number:
DISTRIBUTION SYSTEM
Header/Manifold Distribution Ix Hole Size ix Hole Spacing Vent to Air Intake
Pipe(s)
Length Dia LDia Spacing I __j
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 Bed/Trench Edges Topsoil Yes No Yes ]N,
COMMENTS: (Include code discrepencies, persons present, etc.) Inspectio~ni #1: Inspection #2:
Location: 1144 CTY RD H / d~ Or 64,j
1.) Alt BM Description =
2.) Bldg sewer length = Z, 4-- Z,o _ ~v~G weX d w
G lea: ti
d-
-amount of cover
+11
Plan revision Required? ❑ Yes 0 1Z 1~ /
Use other side for additional information.
Date Insepcto ignatur Cert. No.
SBD-6710 (R.3/97)
KECE1 County
Industry Services Division St. Croix
0 1400 F_ Washington Ave P Nov P Sanitary Permit Number (to be tilled in by Co.)
S .Box 7162
~`^^n 1
540 7-IF62 (166207
ST. CROlX CalJN
- INITY o 6 01V8419G -
Sanitary Permit AppllcaLlV 1, VCI)58 State Transaction Number
In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmu-,.- unit Project Address (if different than mailing address)
is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWT'S are submitted to
the Department of Safety and Professional Services. Personal information you provide may be used for secondary Not yet as fined.
ur~oses in accordance with the Privacy Law, s. 15.04(I)(m), Stats. H-
-1. Application Inform n - Please Print All Information
Property Owner's Name Parcel #
Donald Jackelen, Jr. 0381(11580(10
3 J. 15
Property Owners Mailing Address Property Location
1144 C ~t, Rd H
City. State lip Code Phone Numbcr Govt. Lot
New Richmond, '1N1 54017 715-246-2361
NW ''/a, SE Section 03,T31 N, It 18 N1'
11. Type of Building (check all that apply) Lot # -
® I or 2 Family Dwelling- Number of Bedroom 3 2 Subdivision Name
CSI Recorded in Vol IV P 995
❑ Public/Commercial - Describe Use Block #
- ❑ C'ity of
❑ State Owned - Describe Use _ ❑ Village of
CSM Number
1Z L CS1`13108 V18 P12 ® Town of Star Prairie
In
111. T e of-Pcrmit_-(Check only o- box on line A. Complete line B if applicable) - - -
A. ❑ New System ® Replacement System I reatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain)
❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit "transfer to New List Prcx ions Permit Numbcr and Date Issued
l3.
Before Expiration Plumber Owner San. Permit 2931 (9/5/1980) Stag 11) 8002235
IV 'T'ype of POWTS ~rn/Component/Device (Check all tha ply
❑ Non Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. Of suitable soil ❑ Mound < 24 in. of surtablc soil
® I lolding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain)
V.Dis~rersal/Trcatme Area Information:
Design Flow (gpd) Design Soil Application -Dispersal Area Regmred (st) ~spersal Area Proposed (s1) Svstem Clecation
450 Rate(gpdst) NA NA N.v NA
V1. Tank Info Capacity in _
v
Gallons total # of
Manufacturer
Gallons Units g _4
New Tanks Existing Tanks U U C7 y
Septic or Holding Tank 2000 2000 1 Wieser Concrete, Inc. ® ❑ ❑ ❑
Dosing Chamber - - - - - ❑ ❑ ❑ ❑ ❑
VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print) Plumber's Signature MP/MFRS Number Business Phone Number
Randy Martin 675842 715.225.2203
Plumbers Address (Street, City, State. Lip Code)
11663 Cty Hwy F, Chippewa Falls, WI 54729
V111. C unty/D partment Use Only -
Approved ov . Permit Fee Date Is led Issuing ,t Signature
S - r Given R., n for DutialI S •
Conditions of Approval/Reasons for Disapproval
Za i A&A 6r 000tA , f :/~eQ o tef¢~l. ,tom..
Attach to complete plans for the system :md submit to the County only on paper not less than 8 I12 x I I inches in size
SBD-6398 (803/14)
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POWTS PLAN
PAGE 2 OF 4
f
CONCRETE HOLDING TANK DESIGN
Single Tank Option
INDEX AND TITLE SHEET
Project Jackelen Holding Tank
Owner Donald and Kelly Jackelen
Address 1144 Cty Rd H
New Richmond, WI 54017
Legal Description Govt Lot 4, NW 1/4, SE 1/4, Sec. 03, T31 N, R18W
Township Star Prairie County St. Croix
Subdivision Name CSM in Vol IV P 995 Lot No. 2
Parcel ID Number 03810158000
Plan Transaction ID Number
Index and title sheet Page 1
Site plan Page 2
Holding tank specifications & x-section Page 3
Holding tank management plan Page 4
Designer Leroy GIF a kyt_E C
Signature Phone No. (715) 723-0408
License Number NTS Desig D2 9-PSS Date 10/27/17
dreg } S I L 4O®k~ Designed pursuant to:
Holding "dank Component Manual For POWTS (Version 2.0)
SBD-10855-P (N. 03/07, R. 01/12)
Version 7.0 (11/12) Page 1 of 4
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P❑WTS PLAN
PAGE 2 ❑F 4
HOLDING TANK SPECIFICATIONS
3 Number of bedrooms
Non-residential estimated flow (gpd)
2000.0 Minimum holding tank volume required (gal)
2000.0 Proposed holding tank capacity (gal)
Weisr Concrete, Inc. Tank Manufacturer
WLP2000-MR Tank model number
SJE Rhombus Alarm manufacturer
101-01H 120v Alarm model number
Tank Dimensions and Data Tank Anchor Calculations
X for round tank 19430 Ibs Weight of tank and cover
36.0 Liquid depth below inlet invert (in) 1.25 Safety factor
8.0 Maximum depth of soil cover (ft) 1 Weight of anchor required
53.0 Height (in) Outside 20.0 i Soil cover req. for anchor or
L9H0 Length (in) Dimensions 4.5 yd3 Concrete counter weight
Width (in) Only
HOLDING TANK CROSS SECTION
both manhole covers - vent termil
8' dia PVC vent cap
sealed watertight with
locking device and \ vent pipe
warning label y
_ junction 42" min.
_T 4" min. box
F- 23 in.
conduit ~
min. 18"
tether 98.00'
y weight
building service 12.0 In blind plug
sewer inlet alarm on 0 to seal
invert outlet
97.25' Note: All tank joints, and
Electrical as per 24.0 in. joints between tank openings
and piping are sealed
NEC and 3SPS 0 300 316 watertight. All pipe and vent
materials comply with SPS
384.
93.58'
3 in. bedding under tank. Tank is anchored as necessary to negate buoyancy.
Project: Jackelen Holding Tank
Transaction Number: Page 3 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 60.0 to 400.0 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 Randy Martin Phone: (715) 225-2203
b. Service Provider Phone:
c. Co. Zoning or Health Dept. C Phone:
11. 64-.
Project: Jackelen Holding Tank
Transaction Number: Page 4 of 4
SPECIFICATIONS
JACKELEN HOLDING TANK SYSTEM
October 27, 2017
Wisconsin Department of Safety and Professional Services Page 1 of 2
Division of Industry Services
SOIL EVALUATION REPORT
In accordance with SPS 385, Wis. Adm. Code County
St. Croix
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include,
but not limited to: vertical and horizontal reference point (BM), direction and percent slope, Parcel I.D.
scale or dimensions, north arrow, and location and distance to nearest road. 03810158000
Please print all information. Reviewed by Date
Personal information you provide may be used for secondary purposes Privac Law, s. 15.04 1 m .
Property Owner Property Location ❑
Donald and Kelly Jackelen Govt. Lot 2 1/4 SW 1/4 S 03 T 31 N R 18 E (or) W
Property Owner's Mailing Address Lot # Block # Subd. Name or CSM#
1144 Ct Rd H 2 CSM in Vol IV P 995
City State Zip Code Phone Number ❑ City ❑ Village ® Town Nearest Road
New Richmond WI 54017 715 577-956 Star Prairie Ct Rd H
❑ New Construction Use: ❑ Residential/ Numberof bedrooms 3 Code derived design flow rate 450 GPD
❑ Replacement ❑ Public or commercial - Describe:
Parent material Glacial Dirft Over Muck Flood Plan elevation if applicable 921 ft.
General comments and recommendations: The only possible area for a mound system is unsuitable due to a high level of seasonal soil saturation and
compacted soil due to use as a parking lot for vehicles and boat trailers. High OM content throughout soil profile indicates prolonged wetness. Use of a holding
tank appears to be the only alternative for a replacement system. Existing tank is beginning to collapse.
1❑ Boring # ® Boring
❑ Pit Ground surface elev. 100.0 (919.5) ft. Depth to limiting factor 0 in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/Ftz
In. Munsell Qu. Az. Cont. Color Gr. Sz. Sh.
'Eff#1 "Eff#2
1 00-06 10YR 211 sicl 3m-cabk mvfi cw 2f 0.0 0.0
2 06-16 10YR 2/1 cld 10YR 4/6 sl lcsbk mfr cw 0.4 0.4
3 16-30 10YR 2/1 c2d 10YR 4/6 Is Osg ml 0.7 1.6
4 30-40 10YR 2/1 muck Om 0.0 0.0
❑ Boring # F-1 Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/Ft'
In. Munsell Qu. Az. Cont. Color Gr. Sz. Sh.
'Eff#1 'Eff#2
Effluent #1 = BOD, > 30:5 220 m /L and TSS > 30<_ 150 m /L Effluent #2 = BOD, > 30:5 220 m /L and TSS > 30< _ 150 m /L
CST Name (Please Print) Signatu CST Number
Leroy G. Jansk 71599
Address Date Evaluation Inducted Telephone Number
12758 43rd Ave., Chippewa Falls, WI 54729-6610 10/25/2017 715 723-0408
SBD-8330 (R04/15)
SOIL EVALUATION
PAGE 2 ❑F 2
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? DRAWN BY WCP SCALE: 1/4"=l'-O" PRE-POUR:
~o m wLP2000-MR MIESERGURGRETE REV.
m i SEPTIC MANUAL DATE: 00/00/00 DATE: POST-POUR:
~ Z W3716 US HWY 70 MAIDEN ROCK, WI 54750
° 800-325-8456 FILE: W1P2000-MR
TANK 1 1 @ Alarm e
Easy-to-install liquid level alarm system for indoor use.
This alarm system monitors liquid levels in lift pump chambers, sump pump basins, holding tanks,
sewage, agricultural, and other water applications.
The Tank Alert' I alarm system can serve as a high or low level alarm depending on the float switch
model used.
The alarm horn sounds when a potentially threatening liquid level condition occurs. The horn can be
silenced, but the warning light remains on until the condition is remedied. A green "power on" light
indicates power to the alarm panel
4
FEATURES SPECIFICATIONS
NEMA 1 enclosure, designed for ease of installation, rated for indoor VOLTAGE FOR 120 VAC MODEL:
use. Primary: 120 VAC, 50/60 Hz, 5 watts max.
Red "alarm" light, green "power on" light, alarm "test" switch, and (alarm condition)
horn "silence" switch. Secondary: 12 VAC
Alarm horn sounds at 86 decibels at 10 feet (3 meters). VOLTAGE FOR 230 VAC MODEL:
Can be used with any UL Listed / Recognized switching mechanism (not UL Listed or CSA Certified)
rated to include 1 amp, 12 VAC load. Primary: 230 VAC, 50/60 Hz, 5 watts max.
Alarm system (when installed on separate circuit) operates even if (alarm condition)
Secondary: 12 VAC
the pump circuit fails.
Complete package includes standard SJE SignalMaster® control ALARM ENCLOSURE: 6 x 4 x 2.5 inch
switch with 15 feet (4.57 meters) of cable (other lengths available) (15.24 x 10.16 x 6.35 cm), NEMA 1 metal
and mounting clamp.
Switching mechanism operates on low voltage and is isolated from ALARM HORN: 86 decibels at 10 feet
the power line to reduce the possibility of shock. (3 meters)
UL Listed. SIGNALING
Sno W ~L POWER CORD: 6 foot (1.8 meter)
CSA Certified. ~7
LR54245 usTEO Three-year limited warranty. 288x FLOAT SWITCH CONNECTION TERMINAL:
H GW9G uhc For float switch connection only. Do not
apply power. (Voltage across terminals
is 12 VAC. Maximum line impedance for
1 1 initiating device: 5 ohms).
When ordered with the alarm, this system is available with: FLOAT SWITCH: SJE SignalMaster`' control
switch with mounting clamp
alternate float switch models for high or low level warning. Cable: 15 feet (4.57 meters), flexible 18
gauge, 2 conductor (UL) SJOW, water-
/ 120 VAC primary voltage or 230 VAC primary voltage (230 VAC resistant (CPE)
model is not UL Listed or CSA Certified). Float: 2.74 inch diameter x 4.83 inch long
(7 cm x 12.3 cm), high impact, corrosion
resistant polypropylene housing for use in
sewage and non-potable water up to 140°F
(60°C)
SIE ,y
RhWifthus.
PO Box 1708, Detroit Lakes, MN 56502
1-888-DIAL-SJE • 1-218-847-1317
1-218-847-4617 Fax
SEE BACKSIDE FOR ORDERING INFORMATION. email: sje@sjerhombus.com
www.sjerhombus.com 77
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SEPTIC or HOLDING TANK SERVICING CONTRACT
j Contract Date -7
Thi s co ntract is m ade betw een the
Tank Owner(s) Name(s) and Pumper's Name
Ad bo" Pic,
We acknowledge the installation of (a) septic; holding tank(s) on the following property:
(Provide legal description): ~au} + t ~(j & i Q) ~ 2C 6 5-1-7-31A4 C_ r9 ~ I
f C2
i. The owner agrees to fle a copy of this contract with the local governnlemai unit (St. Croix County
Plan ning & Zoning Department) to doeuntent maintenance by a certified septage servicing operator as
requii~,d in Comm. S3.52(1)(e)2. Wis. Adm. Code and the approved Component Nlanual.
The owner agrees to have the septiclholding tank(s) serviced by the undersigned purnper 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 equ;ptnent. The owner further agrees to pay the
pumper for all charges incurred in servicing the septiclholding tardc(s) as mutually agreed upon by file
owner and pumper.
i
3. The pumper agrees to submit to the local governmental unit (St. Croix County) a report for the. servicing of j
the septic/holding tank(s) on a monthly basis. The pumper further agrees to include the following in the
morithly report:
a. The name and address of the, person responsiole for servicing the septic/holding tank;
b. The name o" the owner of the septic~lzolding tank;
c. The location of the property on which the septiclholding tank is installed;
i
d. The sanitary permit number issued for the septiclholding 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;
The disposal sites to which the contents from the septic/holding tar-Lk were delivered.
4. This agreement 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 govermnental unit named above within ten (10) business days from the
date of change to this service contract.
Owner(s) Name(s) (Print) Owner's Signa4~u re( Subscribed and sworn to me on this date:
~~bVl J4 C ke -7/, -7
t
Today's Date
Pumper's Name (Print) Pump .r's Signature Notary Public Signature, ~ i
I i
Pumper's Registration Number Commission Expiration
i
J I S~~
CHRISTINE E. BOARDMAN ~
Notary Public - State of Wisconsin