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HomeMy WebLinkAbout020-1374-14-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT sanitary Permit No: 420772 0 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 X Township Parcel Tax No: Landsted Homes Inc. I Hudson Township 020 - 1374 -14 -000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: 1 t '3 - 9 3.7.E S p. KQ �rt � ..n CS 12.29.20.2247 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM CD Aeration -- ' Bldg. Sewer olding St/Ht Inlet St/Ht Outlet TANK SETBACK INFORMATION •9b Q j .70 TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet l' Septic . — T L, Dt Bottom Dosing Header /Man. N Aeration ist. Pipe Holding ot. System `� 'v I 9• 84. S g Y s- S w 510 It. Final Grade PUMP /SIPHON INFORMATION Sow c��,{ 5 `�� 9�•�� Manufacturer Demand St Cover GPM Model Number - P c.-e_ r4 ,c E.26 90,40 � Cw fi• 90. k C 4, W , , se- .2$ TDH Lift n Lo System Head TDH Ft 'T, 1 R 1�QG .Z�, 4 z4 �. � c„r � A-n � o l Forc In Length Dia. Dis . ell . G ; ,.-a - 3 g JV1 r1 h Pl 9 3• S SOIL ABSORPTION SYSTEM w s� r 4- = 4 o , k_ BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. 7 uid Depth DIMENSIONS 3 SETBACK SYSTEM TO P/L JBLDG WELL LAKE /STREAM LEACHING Manufactu er: INFORMATION CHAMBER OR ' " % '. 14- r4 }c. f Type Of System: UNIT / Model Number: [ • ,Q CG i'1 L 9—Yl Z r- - J O c..{ - ........ 02 EJ CRO N ✓ � "l. DISTRIBUTION SYSTEM Header /Manifold Distributio x Hole Size x Hole Spacing Vent to Air Intake �. Pipe(s) ,� 7 1 Length IZ Dia Length Dia - -- - / J SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over . Depth Over xx Depth of \ xx Seeded/Sodded 1 xx Mulched Bed/Trench Center �� Bedlrrench Edges 7 Topsoil \. Ej Yes No f Yes F No COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: /d / / Inspection #2: Location: 249 Starr Wood Hudson, WI 54016 (SE 1/4 SW 1/4 12 T29N R20W) Starr Wood Lot 14 Parcel No: 12.29.20.2247 (� 1. Alt BM Description = Toty 0 6 57 C 1 2.) Bldg sewer length = iL1 - amount of cover Required? Yes �_I No i�c� F Date 41, 1� � q '_- � Insep Use other side for additional information. ( SBD - 6710 (R.3/97) ctor Plan revision Re 's Signature Cert. No. Safety and Buildings Division County ; ,. 201 W. Washington Ave., P.O. Box 7162 �j r ,siconsi� Madison. WI 53707 - 7162 Site Address ; Department of Commerce Sanitary Permit Appli � �v/CC Permit Number In accord with Comm 83.2 1. Wis. Adm. Code, personal ' otma Tf 1ide D ^ � may be used for secondary ses Pnvac La s15. 1 m ❑ Check if Revision d0 . Application Information - Please Print All Information APR 0 3 2003 State Plan I.D. Number perry Owner's Name ST. CROIX COUNTY Parcel Number NOS y ZONING OFFICE Property Owner's Mailing Address Property Location StZ_ i4 J11 ''A ; S T oC 9 N, R City, State Zip Code Phone Number [ Block Number i ubd ' 'on Name i CSM Number II. Type of Building (check all that apply) Dity _ ® 1 or 2 Family Dwelling r Number of Bedrooms age ❑ Public /Commercial - Describe Use ®Township 11 State Owned Z (i►t ls^ ' 3 �F� — q / I (1 q _ o- Nearest Road f M. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) A. County use 1 ® New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to sum Tank Only Existing stem B- ❑ Check if Sanitary Previously Issued Permit Number Q ]DateIssued IV. Type of Permit: (Check all that apply)(numbering scheme is for internal use) LcA -e_ v,-; 44 J9 Non - Pressurized In- Ground 210 Mound 47 11 Sand Filter 50 Constructed Wetland 31, 22 ❑ Pressurized In- Ground 41 ❑ Holding Tank 48 ❑ Single Pass 51 ❑ Drip Line j , - , 45 ❑ At -Grade 46 ❑Aerobic Treatment Unit 49 11 Recirculating 30 11 Other V. D' eatment Area Information: Design Flow (gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) ✓ Elevation VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Tanks Concrete Constructed Glass New Existing Tank Tanks - v Septic or Holding Tank i / &, Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installati of the POWTS shown on the attached places. Plumber's Name (Print) Plumber's Signature MP/MPRS Number Business Phone Number _?0 - �So PlumberX Address (Street, City, State, Zip e) d� Y /6 VIII ount /De artment Use Ohl Surcharge ) S Permit Fee includes Groundwater Date Issued Approved ❑ Disapp roved �' i ( � ing en[ Signature Stamps) ❑ OwneriGiven Initial Adverse Determination IX. Conditions-of Apprt val/Reasons for Disapproval 6D-63 f o7w,�., S`3. 3 � p 0—.(to tl a form sy*em paper than sin x 11 Inches In size (R. 05191) f - •.. ...PLO 67• j w - PLOT & CROSS SECTION PLANS QQoP�c IAPPA OROS. EXCAVATM INC Oi l* PLUMING UNIT ... . PROJECT 4 AV clxylfA4rG' S /iKt /N /iP� � 40M Al6w -� ;,� -� � /VET ��t�►c N Sys�l o 4S G.e,- t.3i rUe fit. ScPnc r'tiVC. N A w / ♦B°oo 1Gc �'o•� pRo� 'r'ci' � SCALE The Standard Infiltrator Chamber ����_• 1' Overlap at Latching Mechanism 81tiNED --� LICENSE' �2Y'7S'y 12' L 0 o DA TE' �as =- ,6 01 L TEOPO4 BY: 75' Effective Length aq 2­)� s7 1 ,Wisconsin Department of Commerce SOIL AND SITE EVALUATION / ,livision of Safety and Buildings Page ! of Bureau of Integrated Services in accordance with Comm 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and S Cfo I 3 percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # APPLICANT INFORMATION - Plea !ry ail inforrriafidh� eviewed y Date Personal information you provide may be used for oQ pu�et;riv Last; s.:`1 )&04 (1) (m)). / 7 Property Owner ° ' Property Location �C .., ,qovt. Lot 1/4:51L 1/4,S Z T 2 ? ,N,R ZV E (or) W Property Owner's Mailing Address loot # # � Block# Subd. Name or CSM# �� �T14fQ1� do� "tlN�W �'Y ; City State Zip Co FCE ci ty ❑ Oage Town Nearest Road New Construction Use: Residential / Number of bedrooms _ Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow 0 gpd Recommended design loading rate 6.7 bed, gpd/ft2 gpd/ft Absorption area required _ bed, ft ft2 Maximum design loading rate _ 2 bed, gpd /ft gpd /ft Recommended infiltration surface elevation(s) 5 ft (as referred to site plan benchmark) Additional design /site considerations LVAL.UATlyn1 60 RO'k 1 0 L A —, 4,PfiQOVA L - Parent material a id _rJ L Flood plain elevation, if applicable ft S = Suitable for system Conventional , Mound In-Ground Pressure AT -Grade System in Fill Holding T k U = Unsuitable for system [VS ❑ U L4 S ❑ ICI U S ❑ U S El 0 s ❑ U ❑ s WU SOIL DESCRIPTION REPORT Boring Horizon Depth Dominant Color Mottles Structure GPD /ft g Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench �' 5 . �' -4 JAS 3 / S �, l� c �- c s 2 .� ' xz m 5 rh I c I rb, s p. Ground y fnS O lev , ft. Depth to limiting 8'-p ( - 7 3, Z /07 Z <' factor v , Remarks: S �-!- 0 Boring # 1 1 : 11,11a Win:: 0 -3 l o' - / — SC, I rat Cr /re C S ti 4 p:� 4- Z W-144/4 56 t Z .o - z % /NVIR Ground SG le ft. Depth to / <, limiting (O factor >1 in. Remarks: CST a (Please Print) Signatu a Telephone No. Na J b wr4so j � d Ad ss Date CST Number Fa 8,, 9 1 M,LS6m Soo! _Z_ZZ SOIL DESCRIPTION REPORT �� PROPERTY OWNER Page of PARCEL I.D.# Boring Horizon Depth Dominant Color Mottles Structure 2 9 Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench 3 4-7 /ov12 DA g. -S5 /6yA 4-1 rh c.5 ,O"'�i Ground fQy'0 4l 3 the /Y) e-- — 0:7 6s z� doll Depth to limiting — factor 7 �s6 in. Remarks: Boring # A a- /oN n, bT _ �0 3 - SG 63 :o.'% 8 161 - s4 As th � o � :6.% Ground 9A- ft-Depth to limiting f c�r Sin. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # j�� r '� (, j jY, cr G Z 6 6 S gj -S� /0� n'1 1b1 LS 0 - 7 CS Ground I /I /� ,1 4 5�� (hS fn cs o l .� ft. " ` � L � A 4 4 Depth to limiting � r in Remarks: Boring # 13 Ground elev. ft. , Depth to limiting factor in ' Remarks: SBD -8330 (R.9/98) 4 / r JN i ° Q 6 � G ' 10 �\ / 1 r \ C \ f Mp , _ + _ El _ I N � POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page _/ of FILE INFORMATION SYSTEM SPECIFICATIONS Owner ^ _ �/ Septic Tank Capacity O gal O NA Permit # D d— Septic Tank Manufacturer ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer Q ❑ NA Number of Bedrooms y © NA Effluent Filter Model ❑ NA Number of Public Facility Units I1 NA Pump Tank Capacity al M NA Estimated flow (average) p0 galiday Pump Tank Manufacturer 0 NA Design flow (peak), (Estimated x 1.5) Pump d � al /da p M anufacturer ® NA Soil Application Rate gal/day/ft' Pump Model 0 NA St andard Influent/Effluen� M onthly average" Pretreatment Unit IS NA Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD 5220 mg /L ❑ NA 0 Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) 0 NA Biochemical Oxygen Demand (BOD 530 mg /L 19 In- Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L [S, NA L3 At -Grade 13 Mound Fecal Coliform (geometric mean) 510 cfu /100ml V ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size Y in dia. ❑ NA " Other: 0 NA Other: ® NA Other: 19 NA *Values typical for domestic wastewater and septic tank effluent. Other: 0 NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tankis) At least once every: I 88n(th(s) (Maximum 3 years) 13 NA Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA Inspect dispersal call(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA m year(s) ❑ month(s) ❑ NA Clean effluent filter As /�i✓Z;`� �. -At least once every: ® ear(s) Inspect pump, pump controls & alarm At least once every: 13 Y ear(s)(s} NA Flush laterals and pressure test At least once every: 0 month(s) NA ❑ year(s) ❑ month(s) Other: At least once every: 13 year(s) ®NA Other: 0 NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for. any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one -third (Y or more of the tank volume, the entire Operator and disposed contents of the tank shall be removed by a Septage Serv osed of in accordance with chapter NR 113, p p Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed'by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. GMW (4/01) - w Page _,;2 Of STARTUP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed b a se to a servicing op erator prior to use. Y P g g P P System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cells) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. T e to has not been evaluat o identify a u ble replac e�� area. on Nure df a �ae so and site e Lie on mu b erformef! to la ate a sue' abler lacem t area. `f rlo replace ent rea is hol an ma y _..� be s ad as a st son to re l ge4f►e failed POD. 0 Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < < WARNING > > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. I ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name Name i r> Phone Phone -?dp SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name ;,7" Name Phone L ✓S 2L -,2120 Phone This document vdas drafted in compliance with chapter Comm 83.22(2)(b)0)(dl &(f) and 83.64(1), (2) & (3), Wisconsin Administrative Code. ` ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND - OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address 4 f3 / _'SccoN :)L i ns Property Address . o1 -57';q2tL t,c>r:o_t�. (Verification required from Planning Department for new construction) City/State Parcel Identification Number LEGAL DESCRIPTION Property Location Sc %4, Sw '/4, Sec. T R q N -R W, Town of Ab1 + Subdivision J'�a 22 , Lot #. Certified Survey Map # , Volume , Page # Warranty Deed # 1 dle-7 9 , Volume a /_3 Page # /sue Spec house 410 yes ❑ no Lot lines identifiable* yes ❑ no SYSTEM MAINTENANCE 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. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restrictedplumber 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 Commerce 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 Zoning Office within 30 days of the three year expiration e. - / 6 /o 3 = -I6M A61CANT DATE OWNER CERTIFICATION I (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 warranty deed recorded in Register of Deeds Office. P C, ' AN DATE * * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed 'J 2 13 5 P 1 5 0 -7 1mg8Z3 9 XATHLEEN H. WALSH REGISTER OF DEEDS WARRANTY DEED ST. CROIX Co., MI DOCUMENT NO. RECEIVED FOR RECORD 02/07/2003 10:15AN This Deed made between STARRWOOD EXEMPT # PARTNERSHIP, LLP, a Wisconsin limited liability REC FEE: 11.00 TRANS FEE: 585.00 partnership, and LANDSTED HOMES, INC., a Wisconsin COPY FEE: corporation, Grantee, CERT COPY FEE: PAGES: 1 Witnesseth, That the said Grantor conveys to Grantee the following described real estate in St. Croix County, State of Wisconsin: Lots 9 an 14, Plat of Starr Wood in the Town of Hudson, St. Croix Cou isconsin. Tax Parcel No. 020 - 1374 -09 -000; and 020 - 1374 -14 -000 RETURN TO: This is not homestead property. Together with all and singular the hereditaments and appurtenances thereunto belonging; And Grantor warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances, and will warrant and defend same. Dated thisLy of February, 2003. STARRWOOD PARTNERSHIP, LLP �,Tumer (SEAL) TreCY public BY dith A. Green WotaN State of scons (SEAL) AND: G pa STATE OF WISCONSIN ) SS ST. CROIX COUNTY ) Personally came before me thk�ay of February, 2003, the above named Starrwood Partnership, LLP, by Judith A. Green and Gary T. Zappa„ to me known to be the persons who executed the foregoing instrument and acknowledged the same, being authorized so to do. f .I Notary Public, State of Wisconsin My Commis ion (expires): THIS INSTRUMENT DRAFTED BY: Barry C. Lundeen, Attorney MUDGE, PORTER, LUNDEEN & SEGUIN, S.C. 110 Second Street, P.O. Box 469, Hudson WI 54016 s 1 s f l em t -