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Home My WebLink About014-1041-70-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: SAN-2018-148 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: Robert Duval TOWN OF FOREST 014-1041-70-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: / at5 6 f- " 19.31.15.303A TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Benchmark E~~ 3 D sing 4 g $ `7 Ae ion Bldg. Sewer 7.5 ,3 old' nlet 3ooa 9 4, (,,r- TANK SETBACK INFORMATION St/Ht Outlet 11'k- I TANK TO ~P1 WELL BLDG. vent to Air Intake ROAD Dt Inlet fV1 -1 1 7✓0 1 f Dt Bottom Dosing Header/Man. Aeration Dist. Pipe Holding Bot. System Final Grade PUMP/SIPHON INFORMATION Manufacturer Demand St Cover GPM Model Number TDH Friction Loss Sys ead H Ft 714 Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. f Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P G WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: I ~/I UNIT Model Number: DISTRIBUTION SYSTEM Header/Manifold Distribution ix Hole Size x Hole Spacing Vent to Air Intake 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 odded ix x Mulched Bed/Trench Center Bed/Trench Edges Topsoil xx Seeded/S ❑ Yes ❑ No ❑ Yes ❑ :N,] COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 2662 200TH AVE 1.) Alt BM Description = l'""7~ c•t•` 2.) Bldg sewer length = 4 - amount of cover = Plan revision Required? ❑ Yes No / _ ZZ r Q / _ ? Use other side for additional information. SBD-671 0 (R.3/97) Date Ins/rC'sSJigne Cert. No. l SYSTEM PLOT PLAN Project Name Duval Repair Design Flow 450galbns/day N Project Address: 2662 200th Avenue Attach design flow calculations for commercial plans BM1 Symbol: A BM Elevation: 100.00' Pipe Materials / ASTM Standard Scale: 1" = 60' BM Description. Top of foundation Tables 384.30-3 & 384.30-5 0 60 90 120 BM2 Symbol: Q BM Elevation: 4" SCH 40 ASTM D2665 BM Description: BM Description Slope Gradient of Tested Area: 15Z Well Symbol (if applicable) Notes: Notes Property Line i Building Sewer El. = 97.33' Gray water El.= 98.67' Tank Inlet El.= 94.65' -D 0 (D r 5fD Gray water line to be connected 947.06 to building sewer 3000 gallon J Holding Tan Well o Q- 3 Bedroom Shed BM1 House Drive Building sewer Center line 200th Avenue ST. CROIX COUNT' ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) This is to certify that I have inspected the existing septic and/or dose tank presently serving the following residence: (Street address) 2662 200th Ave located at: SW 1/4, SE 1/4, Section 19 , Town 31 N, Range 15 W, Town of Forest , St. Croix County Wisconsin. Upon inspection, 1 certify that 1 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 Did flow back occur from absorption system? Yes No X (if no, skip next line.) Approximate volume or length of time: gallons minutes Tank Capacity. 3000 Construction: Prefab Concrete X Steel Other Manufacturer (if known): Age of Tank (if known): Permit number (if known) 2 2 r ~1? John Schmitt (Lensed Plumber Signature) (Print Name) MPRS 223760 (Title) (License Number) MP/MPRS 6-R-1 (Date) Form to be completed by licensed plumber (Dept of Safety and Professional Services Chapter 305 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 2/2012 S AN-a0 _ /LIP - r ° ounty Sanitary Permit Application ST. CROIX COUNTY WISCONSIN ~ 1-1 ~ J I ord with Chapert 12 St. Croix County Sanitary Ordinance PLANNING & ZONING DEPARTMENT 1 I Personal i formation you provide may be used for secon ry purPo$es ST. CROIX COUNTY GOVERNMENT CENTER [Privacy Vw. S. 15.04(1)(m)] hT j 1101 Carmichael Road 7 2Q18 Hudson, WI 54016-7710 JUN 1 (715)386-4680 Fax (715)386-4686 County Attach ornplete plans for the system on paper not less than 8-1/2 x_11 inches in size.. - tiff ermit # Che v ion to previous application Comm ar,ltY 1. Application Information - Please Print all I R~Kmation Location: Property Owner Name 1/4 54- 1/4, Sec RQ `/2 ( in V A L T N, R E (or) W Property Owner's Mailing Address Lot Nu Block Number 2 (v lv L ZCO City, State Zip Code Phone Numer Subdiv on Name o CS umber II Type of Building: (check one) rdo~_ tPa y ❑ Village ®Town of ❑ 1 or 2 Family Dwelling - No. of Bedrooms: ❑ Public/Commercial (describe use): ❑ State-owned earest Road ~ U r ~ ~ tJ r- 11. Type of P Check only one box on line A. Check box on line B if applicable) el TaxNumber(s) 1W Repair 2. ❑ Reconnection 3.❑Non-plumbing 4. ❑Rejuvenation f~ , _ 7~ _ ~ Sanitation B) Permit Number Date Issued [03 State Sanitary Permit was previously issued kA- IV. Type of POWT System: (Check all that apply) ❑ Non-pressurized In-ground ❑ Mound z 24 in. suitable soil ❑ Mound !5 24 in. suitable soil ❑ Mound A+0 ❑ Sand Filter ❑ nd ❑ Peat Filter ❑ Drip Line ❑ Pressurized In-ground [9 Holding Tank ❑ Single Pass ❑ Other ❑ At-grade nit ❑ Recirculating V. Dispersal/Treatment Area Information: 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. System Elevation 7. Final Grade Required Proposed (Gals./day/sq.ft.) (Min./inch) Elevation VI. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic New Existing Gallons Tanks Concrete structed glass Tanks Tanks ❑ ❑ ❑ ❑ ❑ VII. Responsibility Statement I, the undersigned, assume responsibility for repair/reconnenction/rejuvenation/installation of non-plumbing for the POWTS shown on the attached plans. A license is not required for terralift repair or the installation of non-plumbing sanitation sy tem. Plumber's Name (print) Pa (no stam MP/MPRS.NQ. Business Phone Number Plumber's Address (Street, City, State Zip C ) ~ 1! & / -5v 774 / 169 VIII. County Use Only Di Sanitary Permit Fee Date Issued Issuin gent Sign re (N s) Approved Owner nitial verse / g (D Determination IX. Cond ions of Approval/Reasons for Disapproval: r ~ tco,, e- ID~t~L 1`/4-a t Io .'~~,Alq J ~V U-) 1o - ?r~' K Rev: 8/05 ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) This is to certify that I have inspected the existing septic and/or dose tank presently serving the following residence: (Street address) 2662 200th Ave located at: SW 1/4, SE 1/4, Section 19 , Town 31 N, Range 15 W, Town of Forest , 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 SP S. 384.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service x Did flow back occur from absorption system. Yes No (if no, skip next line.) Approximate volume or length of time: gallons minutes Tank Capacity: 3000 Construction: Prefab Concrete X Steel Other Manufacturer (if known): Age of Tank (if known): Permit number (if known) John Schmitt (Licensed Plumber Signature) (Print Name) MPRS 223760 (Title) (License Number) MP/MPRS (Date) Form to be completed by licensed plumber (Dept of Safety and Professional Services Chapter 305 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 2/2012 SYSTEM PLOT PLAN Project Name Duval Repair Design Flow: 450 gallons/day N Attach design flow calculations for Project Address: 2662 200th Avenue commercial plans: BM1 Symbol: AL BM Elevation: Pipe Materials / ASTM Standard Scale: 1" = 60' BM Description: BM Description Tables 384.30-3 & 384.30-5 0 60 90 120 BM2 Symbol: A BM Elevation: SCH 40 ASTM D2665 BM Description: BM Description Slope Gradient of Tested Area: 15` Well Symbol (if applicable) Notes: Notes I Property Line I I i 0 (D r CD Gray water line to be connected 947.06 to building sewer 3000 gallon Holding Tank Well o ^^L LL 3 Bedroom FShed House Drive Building sewer Center line 200th Avenue v r I HOLDING TANK COMPONENT DESIGN INDEX AND TITLE PAGE Project Name: Duval Holding Tank i Owners Name: Robert J Duval Owner's Address 2662 200th Ave. I Emerald WI 54013 Legal Description: SW1/4, SE1/4, S19, T31N R15W Township Forest County: St. Croix Subdivision Name: Lot Number: 1 Block Number Parcel I.D. Number 014-1041-70-000 Plan Transaction No. Page 1 Index and title Page 2 Plot Plan Page 3 Holding Tank Specifications Page 4 Holding Tank Servicing Contract Page 5 Management and contingency plan Page 7 Existing Tank Certification Page 8 Warranty Deed Page 7 CSM or Plat Designer John Schmitt Licnese Number MPRS 223760 Date: 6/14/2018 Phone Number: 715-760-0486 Signature G 7 Holding Tank Component Manual Version 2.0 SBD-10855-P (N. 03/07) Page 1 SYSTEM PLOT PLAN Project Name Duval Repair Design Flow: 450 gallons/day N Attach design flow calculations for Project Address: 2662 200th Avenue commercial plans: BM1 Symbol: & BM Elevation: Pipe Materials / ASTM Standard Scale: 1" = 60' BM Description: BM Description Tables 384.30-3 & 384.30-5 _ 0 60 90 120 BM2 Symbol: A BM Elevation: 4" SCH 40 ASTM D2665 BM Description: BM Description Slope Gradient of Tested Area: 152 Well Symbol (if applicable) Notes: Notes Property Line 0 (D (D Gray water line to be connected 947.06 to building sewer a) 3000 gallon Holding Tank m Well o ^L n - If 3 Bedroom Shed House Drive Building sewer Center line 200th Avenue HOLDING TANK SPECIFICATIONS 3 Number of bedrooms i Non-residential estimated flow (gpd) 2C1C0.J Minimum holding tank volume required (gal) 3000.0 Proposed holding tank capacity (gal) Unknown Tank Manufacturer Unknown Tank model number Unknown Alarm manufacturer Unknown Alarm model number Tank Dimensions and Data Tank Anchor Calculations X for round tank lbs Weight of tank and cover Liquid depth below inlet invert (in) Safety factor Maximum depth of soil cover (ft) Ibs Weight of anchor required Height (in) Outside in Soil cover req. for anchor or Length (in) Dimensions y d3 Concrete counter weight ( Width (in) +nIY Complete liquid depth in cell A16. HOLDING TANK CROSS SECTION manhole cover with locking device and finished vent cap junction warning label grade box - 4" min. 12" min. E-- 23 in. Manhole and vent locations conduit -~i vent pipe 18" min. tether weight - - 12.0 In. building sewer service inlet blind plug alarm on Note: All tank joints, and to seal joints between tank outlet openings and piping are Electrical as per 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: HOLDING TANK SERVICING:) CONTRAC T F •.ril > of ,r, hry:: n r` n~♦..,; s,: a --r ~eS V~Ie :~:.Y,?~:lfVieGge the sC'ar. ~31ic'3.t., v. ,a. ti,iJt.~ .2 v . ~Cl~tii.~a L e r "~~•>lsaC~v~~! ~`'vs'' I -a,. sig ..v " ?e µ S 3~ Tank {j:fil 2 c eei? E " t v' 7 3u 5-2 V'}S Afjrn Cede and i'?e app , ver; Ho l v ? iii ent Man a'. T his agTeer ne:^, w 'i aiso be ''fns 1J;: Vie St C' --q U .:i^ Y Zoning 1,)eparnmenlt. is ?i"e Owner ay grees to ti c'ar'e t iic rr ;ng ,a :nKiS ser•v:ce;d by V~e pumper anc ~'".ua aniees to permit the - pwi per na-Ve au ,ass &-ie, to e ,v w• v`-. -e y fC, C?uroose of ",-J ;tu 'Ohe •;ufui .g tanks r. The C'i'vvne` agrees n sagntal'n , ai, l-ess '-cad or dive so Vna''. ,he i.;+umpe! car Service the :~t'.s 4~ i '1~a i. _ s. , r.. .G agrees r i.c,, pui a+e"r ~vr a,:. ch tx V „ } r s. ? s .utua v aqq ee " on, -QV the CSwner & pumper. ei u ,ree; to suu b~,s"'s C s'?e v =3i ~C' P rit-ne ta< uniT hat,, nas 5!gr3ed the pumping agreement t L '-id iO'ri$ 'iL C'.ec- .d'iit' 3 n a 5em Cit?`iuat i✓as:5. 4 he .iPIer further ' agrees v . ...c,.. Ci^.., se`m t`.., ..1..,..., t. r^r?.. i a. t! e !?^ir tank. The n a a, of t~e persc-r 4r• Sent+_ -1 r ie c , - e _ , S C. The lv lio , .c .?-,e pinope [y v,. which tnG rcid g `a * r ,Smear ' t a`?? The Sa" iia`;~ Per:-,l' ,.,tT'~^ tccCer 'C~" e t e. The rates o if hlch e >,3inQ tats, -,uvas S rwf--eedl t. he vof lj'me• .;a;'--ns v he On eP.',s u npe--~ ,om tie nIC ! ~ tan-k f--.r each Ser is;na a' ....r• tel. *S -0--11 e 1..;, j;i"g L, K .V.re e-vCloy. tom. Mr:~ u ,.p d rl _ s . 'S ?n 'he U'1eS1: of a change in phis contmot. nle c°iv,,re -,Q-eeS tu- fife 2 vi f Ci a.--, nar-ges to this service contract a t e^ . 1; jai, t',e d 'ate v ``amae.''a '-is ,se"v'iCe cc itray« isiness c-, ic e late ~ fA R ra;~mper S Reel s..rativri Number N a`~` ~ k~ilC -t''. oust- 4vl S *€1i~~t~ ,r :;.ire K !.p HOLDiNG YANK 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), and the County Sanitary Ordinance. 1. This POWTS is designed to accommodate a wastewater flow of 60.0 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 Unknown Phone: b. Service Provider Joseph Berends Phone: 715-265-4623 c. Co. Zoning or Health Dept. St. Croix Phone: 715-760-0486 11. Project: Transaction Number: ~I