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HomeMy WebLinkAbout022-1064-40-000 i Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 515156 0 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 X Township Parcel Tax No: Walen, Larry & Joy I Kinnickinnic, Town of 022- 1064 -40 -000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: 6 GST 22.28.18.P347C TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic , 1 �i�._ i J Benchmark /Am 7 I / , y � T Alt. BM �(' F; t Pd la �c J e ms- ► ,1{ �y. $ 8 Aeration U Bldg. Sewer 5 r Zlj 7�, 05 Holding St/Ht Inlet TANK SETBACK INFORMATION St/Ht Outlet '�•9 TANK TO E P/ WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic � S7 o f Dt Bottom J D ._� Dosing Header /Man. 9 3 Aeration Dist. Pipe 9z. �S Holding Bot. System ' a Final Grade n PUMP /SIPHON INFORMATION W �,� S� dt(,. 17 25. (P Manufacturer Dem and St Cove 1 -7 rJ J Model Number is 6 `76 51 � T H Li Friction Loss System H H Ft 71 S Force in Length Dist. to Well ?. ab i /, 5 SOIL ABSORPTION SYSTEM T f r S BED /TRENCH Width / Lengthy 1 No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth \_ DIMENSIONS '3 44 1y r 5 1 re-,- A � SETBACK SYSTEM TO /L BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR f�}'r��� Type Of System: UNIT Model Number: 71 A DISTRIBUTION SYSTEM Header /Manifold r/ Distribution x Hole Size x Hole Spacing Vent to r Pipe(s) , O✓�' .nd� Length Dia Length Dia ` Spacing \ \ f a SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over j xx Depth of j xx Seeded /Sodded xx Mulched Bed/Trench Center 3. 49 Bedrrrench Edges Topsoil X . Yes E] No Yes No COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: / / Inspection #2: Location: 1213 River Drive River Falls, WI 54022 (SW 1/4 SW 1/4 22 T28N R1 8W) NA Lot Parcel No: 22.28.18.P347C 1.) Alt BM Description = 2.) Bldg sewer length = 22 , - amount of cover = r Plan revision Required? Yes No 11 Use other side for additional information SBD - 6710 (R.3197) Date Insepctor's Sig ature Cert. No. I A commerce.wi.gov Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 i sco n s i n Madison, WI 53707 -7162 Sanita �': G ry Permit Nur�bes (to be filled in by Co.) Department of Commerce 50/ L ✓ � /` fJ , Sanitary Permit Application State Transa Number In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental /✓ unit is required prior to obtaining a sanitary permit. Note: Application forms for state - POWTS are Project Address (if different than mailing address) submitted to the Department of Commerce. Personal information you provide or secondary /� /� p urposes in accordance with the Privacy Law, s. 15.04 (1) (m), S ts. 1 % jcr I. Application Information - Please Print All Infor a io Pro pe y Owner's Name O Parcel # d'ri C e to pC ,,J��1 �F�GE C�aa� I�6 ^DDD Property Owner' Mailing Addr s �G & ZQ Property Location �34/ ` O p1AN Govt. Lot City, � %y State % � � Zip ode�� y, Phone Number l� S W � Section c � ` J ���~ 6 T N _ R rc1E ong�. eye II. Type of Building (check all that apply) Lot ,. {`vt T KI or 2 Family Dwelling - Number of Bed r s Subdivision Name f a Block # El Public /Commercial - Describe Use l4 �i ❑ Ciry of CSM Number ❑ Village of ❑State Owned - Describe Use _ aTown of J k1ki A ih A18A 5 At -54, III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A ' ❑ New System -Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B, ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber El Permit Transfer to New List Previo s Permit Number and Date Issued Before Expiration Owner Zx11rdw-t— IV. Type of POWTS System/Component/Device: (Check all that appl QU, . 4 r> on-Pressurized In- Ground ❑ Pressurized In- Ground ❑ At -Grade ❑ Mound > 24 in. ofsuitable'soil ❑ ound < 24 in. of ,;table oil ❑ Holding Tank Other Dispersal Component (explain) El Pretreatment Device (explain) I �C *' V. Dispersal/Treatment Area Information: $ Design Flow (gpd) Design Soil Application Ra gpdst) I Dispersal Area Required f) Dispersal Area Proposed sf) System Elevation �� �- VI. Tank Info Capacity in Total # of Manufacturer Gallon Gallons Units New Tanks Existing Tanks c u ° 1j 0 A. U in w CA Septic or Holding Tank \ _ t �g J Dosing Chamber l � VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shoffjaAaAht attached plans. Plu tier's Name (Prin P s Signature MP 5 Business Phone Num er I l k Plumber's Address (Street, City S yp de) , (���►� 1�r.�aa VIII. Coun /De artment Use Onl A pproved I ❑ appr Permit Fee Date Issued Issuing t Signatu El en Reason or Denial � I $ y75. /D z a� IX. Conditis" f&MAI easons for Disapproval 1. Septic tank, effluent filter and 3) - dispersal cell must all be services / maintained / as per management plan provided by plumber. yI/� QtJ� j / •, 2. -AN setback requirements must be maintained P c o comp a pans or 'e system and submit to the Co my only on paper not less than 81a x t 1 inches in she SBD -6398 (R. 02/09) Valid thru 02/11 9;9W ® a Itm { F�u fa 1 X1 ll)let !fcjC®PY pr�y�sell �o � -- -- - - - - -- 0 0 7,wslvp yap ° ° � P at's �e 7 0 c' �'1�r �I l I I V �I I - ,RECEIVED : 1 t OCt 0 2 2009 ►� ? Wisconsin Department of Commerce �u'A �FjWj IL EVALUATION REPORT page of v <v Division of safety and Buildings tJNING & ZONING P►A In accordance with Comm 85, Wis. Adm. Code County . Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must - C` O. include, but not limited to: vertical and horizontal reference point (BM), direction and parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road.. Please print all information. Revie by Date G Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner #$ Property Location �- ce h r sr 4! 'To ce Y /Iff ki Govt. Lot 5' VV 114 S W114 S : N R CY for) W Property Owner's Mailing Address Lot # I Block # Subd. Name o Al {v A City State Zip Code Phone Number ❑ City ❑ Village QSTown Nearest Road P ; -, Y e- ❑ New Construction User Residential /Number of bedrooms 3 Code derived design flow rate .5 GPD '(Replacement ❑ Public or commercial - Describe: ti Parent material Z o d /err S C C4 f Flood Plain elevation if applicable A/ l T ft• General comments ? v e co rh sir e and reccrn !i Y °? r '9 - .�; p1�7 A =. t / E] Boring ❑ Boring # ®, pit Ground surface elev. l �'� ft. Depth to limiting factor 0 T in. Sod A Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD1fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 I 'Ef F*2 / a -g /� - 5 os 9 1 S o Z 0S l- O a 6 -1-a -� X414 s �� r > - s Boring # Boring ® JK pit Ground surface elev. r /S - ft. Depth to limiting factor > �' in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Efr#1 "Ef 1102 c l S7 ds 3 W-40 2 Gi 11' 2 � 7S1X6 s c. -S .r 4 8 - L94 ' Effluent #1 = BOD > 30 220 mg/L and TSS >30 150 mg/L ` Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signature CST Number CtidrleS 6 7 .- . Address. Date Evaluation Conducted Telephone Number Property Owner cZ ) "" ✓ ' " ' � L' Parcel ID # •� �G `f ' ° ` � ®r' Page of J Boring # ❑ "Boring p a Pit Ground surface elev. / ft. Depth to limiting factor ' in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDW in. Munsell Qu. Sz. Cont. Color p Gr. Sz. Sh. *Eff#1 *Eff#2 © -7 lo/ 4f — t S o S 4 s C� -3� f• C� F-1 Boring # Boring ❑ ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *01#1 - 002 Boring F-1 Boring # Ground surface elev. ft. Depth to limiting factor in. ❑ Pit Sal ' gtion Rate .Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPQ/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz: Sh. *Eff#1 *Eff#2 * Effluent #1 = BOD > 30 220 mg/L and TSS >30 150 m91L * Effluent #2 BOD <_ 30 mglL and TSS <_ 30 m91L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608 - 266 -3151 or TTY 608- 2648777. SBD -8330 MOM) ' S Ke rc� S° , :I yalc� dtfo�e o ►-f Poi' LARR WA LE R 3 OP 3 � N E' 3b �v� f, y ho r or c to i o �. Nea yes 1` �v°�o lil� l acd7'i prt S�o.�.yt i s locate d „ 'kA o a� n ' t k ry N W/ CL a tYl (Q + Q CL CL ,'•. , �• C • ® a . o t o II -� ai - c 7 � a •�. � c '.��' c U w v cam•- - © � ,� , �.,.'•�►: system Management Plan Pursuant to Comm 83.54, Wis.Adm. Code send -- 'c Taankk The septic tank sW'be' maintained by an individual certified to s ervice "Pk t_nw w a be + sPWe -d of in ac. 6=nce with NR 113 Wis. Aden. Code. The under s_ 2A1 a6, of _tL Th cutlet filter S6 be d C9nd1'ti0n of the septic tank sad en3ure prat 0 "" * ' The t t once e•�er/ 3 years by inspecdon. i ne outlet bite: sa a be deaned as nmug -ri to e should not be Y removed unless provisions are nmde to retain solids in the tank that 9h off the fitter when remaveci fi em er - '^�W -8- !f UhS Wer is activated is e~ uippec wiih an aian, the kitEr &W be senrirad if UN m m W�. ifl�i inter oa = ma ittt�� ate surge septic tank shah have ks contends removed when the volume of y sludg =jm on tw* Motu storm. of the tank, tf the a, the tank are not removed at the time s iA the vdume of peel a ady- the lank. The addition Of bi s to be or do ar crtaim less than art scs<m and sp4P �n in . p sr�.h prvdt s Yes to enhance se;* tank prow= is 9&w* not rte, DMsiorL they shall be m owed for septic talc use by the Departmrent of C,artrrmerce, qty and unui Tank T111 pip Nosing) tank s1a8 be W"cW at least once every 3 yam All �, alarms. and pumps shall be tesMd to - ='� � e*- e� �.-� w,eaius the ionic t Stmt be and servkmd as nary_ At rade Coeoonent and Pressure made around the Distribution S stem ins be mad o.es s rn e s oa e p ante or a ove p to grow on the com oeent, Pla ro per -st p ar and the com onent shall be seeded and mulched as necessary to prevent erosion and to than for vegetative mainten ance)On the p component is not frost not allow d. Cold o wea her ations require the component to be heavily mulched for frost protection. Influent quality into the at -grade system may not exceed 220mg /L B0D5, 130 mg /L TSS and fo thi s ias P Ini fl t In for thi flow may not exceed the marU6 design flow specified in allatio_. the permit The pressta8 - Wenai be g Pm at the & eati is , and t is , MRWW b ta lt when ttae sysien was b determine 1 awe dMkV has is dTataribu m wlln ft dkpemW cell, 0bs ==`vat i;.n Pipes within the dispersal cell shall be'checked for effluent podding. Ponding levels should be reported to the owner and any levels above 4 inches considered' as an impending hydraulic failure requiring additional, mo frequent noultoring in accordance with•Comm 83.52 (2), General 8, tam shall be operated to accordance with Comm '82-84 Wis,Adm,Code and shall be maintained in accordance wit em 3 component manual SBD 3057 P• ($.6 /99)•and -local and state rules pertaintrig to system maintenance and maintenance reporting.. PU one shooid e+ antes sap�� >a tank since dangerous gaSeS may be present bat =0 %a Cammt ti~i.33, Wis, Adm. tie when pre W is we no kmger treed as ' c " krsen W W 853835nift risers and ceyr_r*_ should be iu r % tr ' 4'�ess and sou xiness. Access unsonard, dam, or b must s W be sealed waterW Won Me p�ettan of sarvk& -Any op&*q deened he: tnaegeaead - e knnSdrg device b or — kft � or cdm pmmlL _ aye ova nie !m* Or cwnponent shah be repaired or read to keep the :+vr t a5ve the deiaci+re ent siraB be or 10 a wmponw t o f the same or 9qW pe&=ux& If •the at -grade comp no a t`fails to accept �astasriter o"r�ii��33is'`>~'o �iac rge vaatexstti�to the X iOumd 'oaf, it map be necessary to iaataii sit seeable pro.-treatment unit or .replace the cfponent. Additional sit,& mod ' soil evaluations additional p� reaT nee$ to b i prepared red and a may aced to be . and ` Safety and Buil p p,T pp ;ov by the Department of Co�anerce, _ diags . �Queationa ahout operation or maintenance of this system should be diraecAdto :- The Coua _ h office. at The " inst a t . ° soV +r The tank manufacturer at� FS00- �ZS_$yS�, IESt?R The effluent filter' manufacturer at $pp - Z21. S1gz tea. �'�� U 1• �1 \Vil\ \J V V 1\ 1 1 SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer 19 1 '� Mailing Address Property Address Ste A4 (Verification / quired from Planning & Zoning Department for new constructi City /State k' Wey Gud Parcel Identification Number LEGAL DESCRIPTION /I Property Locatio ' /4 , `a '/4 , Sec. a0' , T 4 0 N R/ e' W, Town of ! enni oll t ' Subdivision , Lot # __ Certified Survey Map # , Volume / , Page # Warranty Deed # ` U �cC� , Volume V56 — ,Page # Spec house yes no Lot lines identifiable yes 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 §Comm. 83.52(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 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 Planning & Zoning Department within 30 days of the three year expiration date. Uwe 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. N7; Nu ber of bedrooms a j,,,, (2- NATURE OF APPLICANTS) 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. 08/05) �y r r � �6 , . � `� ? CAE! '�'� C�• $8C,°C�� ��'y � fir° bst) a ag� .#�� ► y t o iot :' ti es 4* 9' W'2�41. "; fi wto.tbe.vie� of begigping POP x '` t pe�tresr.' All besriage ba"4 !# .t tme of `gym : the Ift, 'Of, Soc-tion 22 be9.+ g -en eeemed��,�a,���,,; beeringltntt Fii {� ''•�, r ut s �Aj r v 1 t, RF��J9v. " 'x �,P+ '. a 6Si~ ) "�;v`t x z°en - N FEE s. - " re 7 77 lop - A W d , ^' ♦ ' -{ # 4 oA L {. d, RRe dd$L� 1••�. ' A 7 7 , F7 7 r a +�,,, ��s � Y ;..� a �' -'a,' 4 � '�:.' t r, ,+�� "�.: 5 �'r� �m �'� i '� i, a a »a x>ir'� ';t•+ � " a '' � �'� ���^. aa� s{ � ?.a� E x ` '�'', f e�� a�,� 'a � z• �i"TC �r�#, �� <�w.� � y ' s f c M17 r t �, r r RECEIVED , " f " ur` c OCT 0 2 2009 of 3 Wisconsin Department of Commerce SOIL EVALUATION REPORT page Division of Safety and Buildings ��� " pLANNll�i � with Comm 85, Wes. Adm. Code County Attach complete site plan on paper riot less than 81/2 x 11 inches in size. Plan must include but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. D .4 Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location 4- d 1 u7dt &' J +a Y C p` s ki Govt. Lot 5' VV 1/4 5 - -✓1/4 S T Z 8 N R der W Property Owner's Mailing Address Lot # I Block # Subd. Name or / CSM# City State Zip Code Phone Number ❑ City ❑ Village 25TOwn Nearest Road G py" Y E — . ❑ New Construction User Residential / Number of bedrooms 3 Code derived design flow rate 4 `J GPD '(Replacement ❑ Public or commercial - Describe: Parent material .5 a.a ✓y l o dkn S e 0 mcrr 't Flood Plain elevation if applicable /`/ R General comments v c car� svr r ta�� h �ed c lji% �/� d ' and recommendations: !/ �~ .9 �y ,�o t� '����'��c it•`iv cis „ �a tyd¢s fi � {�P + Y• / F1 Boring Boring # ® Pit Ground surface elev. ! ��� ft. Depth to limiting factorin. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDW in. . Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 "Eff#2 r 0 -1' /OM - �' o 5' 7 W s a 0S l- O a 6 -3a I r .& - ,V e -S �' s Cui ! 1. d 3 34 -s4 7 s YR -15 -` s � C- ❑ Boring # E] Boring _ pit Ground surface elev. S ft. Depth to limiting factor G in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ) `Eff#1 "E ` Effluent #1 = BOD > 30 220 mg/L and TSS >30 150 mg/L ` Effluent #2 = BOD < 30 mg/L and TSS —< 30 mg/L CST Name (Please Print) Segnatur CST Number Ct"arf /CYjs r �' -Lo 6 75 . Address Date Evaluation Conducted Telephone Number I Property Owner d kJ' Y ' " i Parcel ID # ' � S`t - � Page of 3 ® Boring # Boring q 1�- Pit Ground surface elev. ! s-� ft. Depth to limiting factor � in. !W Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roofs GPDff in. Munsell Qu. Sz. Cord. Color Gr. Sz. Sh. 'Eff#1 I 'Eff#2 © -� ��YR4/ � o as -2 a_� 1.0 a Boring # ❑ Boring ❑ pit Ground surface elev. ft. Depth to limiting factor in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDW in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 - Eff#2 ❑ Boring Boring # Ground surface elev. ft. Depth to limiting factor in. F El pit Soil Application Rate .Horizon Depth Dominant Color Redox Description Texture Stricture Consistence Boundary Roots GPD/ff in- Munsell Qu. Sz. Cont. Color Gr. Sz: Sh. `Eft#1 "002 I Effluent #1 = BOD > 30 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 BOD < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608 - 266 -3151 or TTY 608 - 2648777. $BD -8330 (R.07 100) � r .5 pow S * ;/ 4 d "O t {'i epov' ' ) LA wA�E 3 ri : yJ S3 i C-K% T -i to S7_ C-0 ;X c`h'i✓ f N 3 �? ar t P Y � Dr:✓Cwd)/ s Q � I � � lop F31 Oa F MCiPes?' P;'II 67CC /Ocd -"iaT s�lcwtyt , s a- PprOXi l�Q l"e f I Dr��?cY ti �jrlS we i� l ?o f� locd te d ! t Zoo