HomeMy WebLinkAbout026-1137-16-000 .Wisconsin Department of Commerce - P RIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division �
INSPECTION REPORT Sanitary Permit No: 420321 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:
Halle Builders Inc. I Richmond Township 026- 1137 -16 -000
CST BM Elev: Insp. BM Elev: BM Description:
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark /
O� 2. 8D Io CA •c7 �
Dosing Alt. BM
Aeration Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/Ht Outlet , I� 9 .z I
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic } I 1 I Dt Bottom
Dosing Header /Man. + (3'
Aeration D' a �• I
9�f .
Holding Bot. stem
q• go �•�� qz. �'
Final Grade .
PUMP /SIPHON INFORMATION
Manufacturer Deman St Cover
GPM
Model Nu ber
TDH Lift Friction Loss System Head TD Ft
Force mai Length Dia. Dist. to Wel
S ABSORPTION SYSTEM
B D/TRE Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS •3 ��-
SETBACK SYSTEM TO �• P/L jBL6G IWELL LAKE /STREAM LEACHING Ma ufa rqI
INFORMATION CHAMBER OR �F�'��✓ � CJAD
Type Of Sy 45. 1 Ltgt UNIT Model Number: r �t
l t
DISTRIBUTION SYSTEM
Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake
Pipe(s) SD t
Length Dia Len 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 Bed/Trench Edges Topsoil
Yes Dm No Fn] Yes [M:] No
COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: / /07 Inspection #2: /
C
L 10�6. Q C, New �,t d, WI 54017 (SE 1/4 NE 1/4 20 T30N R18W) Golf Vie Acres Lot 16 Parcel No: 21.30.18.972
1.) Alt BM Descriptio = C*il9n dLm��
2.) Bldg sewer length =
- amount of cover
3
4
S �
�y
Plan revision Required? Fie Yes No 1 Z �� E Jse other side for additional information.
1 -6710 (R.3/97) 1Y� 7 /� n _% Insepctor's Signature Cart. No
Safety and Buildings Division County
201 W. Washington Ave., P.O. Box 7162
N *iscan �i n Madison, WI 53707 - 7162 Site Address
Co mmerce �� — 2_ 4 1 q`
Department of Co 5
Sanitary Permit Application Sani Permit Number
In accord with Comm 83.21, Wis. Adm. Code, personal information you provide ❑ Check if Revision ��� ��
way be used for secondary ses Privacy Law, i;15-04(1 m
I. Application Information - Please Print All Information State Plan I.D. / N her
Property Owner's Name Parcel Number eqq/ / ! 3 7 AL-- P4-�
AU Property Owner's Mailing Address 2 Property Location oZ 4F 7Z
14 1f ; S T 3 N, R)
City, State Zip Code Pbbtk lkiitiibe�i Lot Numbe Bock Number
- Subdi Name CSM Number
I
H. Type of Building (check all that apply) i " ity
❑ 1 or 2 Family Dwelling - Number of Bedrooms / -A - ai4� A eAlJ� ❑Village a
❑ Public/Cominercial - Describe Use ❑Township
❑ State Owned -i�� Q�l1,L�Q/ �� �/ L' h`�" 1- Nearest Road-
y
3 xto �
III. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable)
A ' New 2 ❑ Replacement System 3 ❑ Replacement of 1 6 ❑ Addition to For County use
stem I I Tank Only Existing stem
B. ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued
IV. Type of Permit: (Check all that apply)(numbering scheme is for internal use) Gf
4 joNon - Pressurized h Ground 21 ❑ Mound 47 ❑ Sand Filter 50 ❑ Construe 3 �.
22 ❑ Pressurized In -Ground 41 ❑ Holding Tank 48 ❑ Single Pass 51 ❑ Drip Lice
45 ❑ At -Grade 46 ❑ Aerobic Treatment Unit 49 ❑ Recirculating 30 ❑ Other
V. Dispe rsaU'lteatment 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) 6 Elevation .60
y
(p Y3 S
VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel I Fiber Plastic
Gallons Gallons of Tanks D Concrete Constnrcted Glass
New Existing v
Tanks Tanks
SepdS r Holding Tank Mad / ,9,90
Dosing lumber
VII. Responsibility Statement- I, the undersigned, assume responsibility for of the POWTS shown on the attached plans.
Plumber's Name (Print) Plumber's Signature ber Business Phone Number
z 71? i 1 ')/Pi =a - 63
Plumber's Address (Street, ity, State, Zip Code)
VIII. /De artment Use Onl
roved ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued ing Ag m Signature Stamps)
Surcharge Fee) Cl
❑ Owner Given Initial Adverse �� 5
Determination
. Conditions of Approval/Reasons for Disapproval
*j
00 a a(.P�. -� �-� � -nom✓ � - �
compl (to the only) for the system on paper not less 6ea 81/2 x Il Inchea la Oie
SBD -6398 (R. 05101)
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Wisconsin Department of Commerce SOIL EVALUATION REPORT Page -- of 3
Bivision ofSafety and Buildings' .
in accordance with Comm 85, Wis. Adm. Code County
Attach complete site plan on paper not less than 8 M x 11 inches in size. Plan must S • r Ul
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.
b Date
Please pdnt all lnftrn>►�-
Personal information you provide may be used for secon t purposes (Privacy La*✓ s:
Property Owner / o Prope Location
R tv
1 ) _ d r`�}
S k ll C' SO +.� GovL� r 1/4 ) 1/4 S Zd T 30 N R E (or)17
Property Owner's Mailing Address n f r ,; Lot Block 11 Subd. Name or CSM#
10(02 1 C Acres
city State Zip Code Phone Number l4UN?Y q qjjyj ❑ Village (RTown Nearest R ad /
155 11n ( (n5t)7� &9q&E y. Ch
® New Construction Use: ® Residential/ Number of bedtob61 ii Code derived design flow rate 4 5 O GPD
❑ Replacement ❑ Public or commercial - Descrrbe--
Parent material rc t Flood Plain elevation if applicable ft
General comments Sy 54e vv\ GI e S• G
and recommendations: t-f . e(e , rf S.(D D fL� rn � C � / 0 ,+7
F-1 Boring # Boring
® Pit Ground surface elev. 9: (a d ft Depth to limiting factor 12-1 in.
Soil Appi iption Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fStructure
in. Munsell Qu. Sz. Cott Color Gr. Sz. Sh. *Eff#1 `Eff#2
I -14 — S i I 2.rrnc b m Jr C5 I v c .5 . 8
2
N-531 t0 -, 9 j q mFr C-
3 y3) I 5 rn — _ - r 1. Z
X5,0
Boring #
Boring
F - z ] ® Pit Ground surface elev. (0 6 ft Depth to limiting factor 111 in. Soi n Ice 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 *Eff#2
5 t�
;1 Zk � i v .5 S
Z -y2 1tJ 5 i v 2 s MR c • `{
R LP � IrJ r 4VP rY1S D s 1 _ — 1. Z
*
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 Pmt) S' re CST Number
rn
Aaon Sch kelr � 2533CA
Address Date Evaluation Conducted Telephone Number
2it3 s - - 8"'C) / C-11-5)v1-1-4609
I
Property Owner jy e 150 n Parcel ID # Page 2 of 3
[-3] Boring # ❑ Boring
❑K Pit Ground surface elev. W &e ft. Depth to limiting factor U b 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 *Eff#2
l 0 -i2 12 SO Z m C5 l v c .5 . 8
2 to � I�I — s'�► bk �!
3 tl0 iL ti — m5 rn�
❑ Boring # ❑ Boring
❑ pit Ground surface elev. ft Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Stncture Consistence Boundary Roots GPD/fP
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. *Eff#1 "Eff#2
Boring
Boring # Ground surface elev. ft. Depth to limiting factor in.
El Pit 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 *Efflt2
* 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.
SBDM30 (807/00)
it
PAGE 3 OF 3
NAME So LOT# 1(0 LEGAL DESCRIPTIONAIE ' / <N&.,SLO T 30 ,N,R 15 E (or)CX)
SCALE: F'= yd
BM I ELEVATION /CO • O
BM I DESCRIPTION & P o I / T R o y1 P e
BM 2 ELEVATION 9 9 7 a S� z
1 X
BM 2 DESCRIPTION lop vc.
SYSTEM ELEVATION _____ S• G
ALTERNATE ELEVATION c7S.
CONTOUR ELEVATION Ar .S?'a p c
■
a z
SIGNATURE t -- _ - DATE S
l
•a POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner Septic Tank Capacity O a l ❑ NA
Permit # °) " 0 Septic Tank Manufacturer ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA
Number of Bedrooms ❑ NA Effluent Filter Model ❑ NA
Number of Public Facility Units ❑ NA Pump Tank Capacity a l ❑ NA
Estimated flow (average) �(x al /day Pump Tank Manufacturer ❑ NA
Design flow (peak), (Estimated x 1.5) gal /day Pump Manufacturer ❑ NA
Soil Application Rate g al/day/ft' Pump Model ❑ NA
Standard Influent /Effluent Quality Monthly average* Pretreatment Unit ❑ NA
Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BOD :5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) :5150 mg /L ❑ Disinfection ❑ Other:
Pretreated Effluent Quality 1 Monthly average Dispersal Cell(s) ❑ NA
Biochemical Oxygen Demand (BOD 530 mg /L ❑ In Ground (gravity) ❑ In Ground (pressurized)
Total Suspended Solids (TSS) 530 mg /L ❑ NA ❑ At -Grade ❑ Mound
Fecal Coliform (geometric mean) 510 cfu /100ml ❑ Drip -Line ❑ Other:
Maximum Effluent Particle Size Y in dia. ❑ NA Other: ❑ NA
Other: ❑ NA Other: ❑ NA
* Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Inspect condition of tank(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA
❑ ear(s)
Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA
Inspect dispersal cell(s) At least once every: ❑ year( ►(s) (Maximum 3 years) ❑ NA
Clean effluent filter At least once every: [I mo
) ❑ NA
❑year(s)
Ins Inspect um um controls & alarm At least once ever ❑ mo nth(s ) ❑ NA
P pump, pump y' ❑yearls)
Flush laterals and ressure test At least once ever ❑ month(s) ❑ NA
P y ❑ year(s)
Other: At least once every: ❑ month(s) ❑ NA
❑ year(s)
Other: ❑ 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
contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113,
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)
Page of
START UP AND OPERATION p products or other chemicals
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting p
impede ersal cell(s). If high concentrations are detected have the contents
ede the treatment process and /or damage the disp
that may p
of the tank(s) removed by a septage servicing operator prior to use.
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
easures have been, or must be taken, to provide a code compliant
if the POWTS fails and cannot be repaired the following m
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.
❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site
evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank
may be installed as a last resort to replace the failed POWTS.
❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the b)omat 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.
ADDITIONAL COMMENTS
POWTS INSTALLER POWTS MAINTAINER
//t�
Flame 04rn ix Q. Name
Phone Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHOBITY
Name Name
Phone Phone )/ r
This document was drafted in compliance with chapter Comm 83.22(2)Ib)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code.
r .
' - ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer
Mailing Address 1113 e 6/ Oru
Property Address O g `�
(Verification required from Planning Department for new construction)
City/State Parcel Identification Number
LEGAL DESCRIPTION 0�( /� W Town of
� Q
i i 3 n N -R
Property Locahon� /., /,, Sec. �, T _L [.—
Subdivision Lot #.
Certified Survey Map # Volume , Page #
�g
Warranty Deed # Volume Page #
Spec house ❑ yes 9 Lot lines identifiable Q'yes ❑ no
SYSTEM MAINTENANCE
Improper use and maintenance of Y r our 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
mastWrplumber, 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.
Uwe, 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 stem has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
e three y xp' on date.
APPLICANT 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 pro erty described abo , by i e of a warranty deed recorded in Register of Deeds Office. ��
/ J1
NATURE O PLICANT DATE
« « « « «« A 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
f �
(t
� T
1J 1 9 15 F 4 8 3 682534
STATE BAR OF WISCONSIN FORM 2 - 1999 KATHLEEN H. WALSH
Document Number WARRANTY DEED ST. CROIX CO.,
This Deed, made between Hillvale Development Limited, a RECEIVED FOR RECORD
Minnesota Limited Liability Partnership, 06 -25 -2002 8:30 AN
WARRANTY DEED
EXEMPT t 17
Grantor, and Halle Builders, Inc.
REC FEE: 11.00
TRANS FEE:
COPY FEE:
CERT COPY FEE:
Grantee. PAGES: 1
Grantor, for a valuable consideration, conveys to Grantee the
following described real estate in St. Croix County,
State of Wisconsin (if more space is needed, please attach addendum):
Recording Area
Name and Return Address
opunt , 20 & 21, Gotfview Acres, Town of Richmond, St. Croix s aC BARK isconsin. POBmt4 17
aew Rkhagtb
This deed is given in fulfillment of that certain Land Contract between the
parties hereto dated July 30, 200), recorded August 7, 2001, in Vol. 1694,
Page 565, as Doc. No. 653153. Pt 026- 1012 -50
Parcel Identification Number (PIN)
This is not homestead property.
DI) (is not)
Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any.
Dated this day of November _ 2001
Hillvale Development Limited
" " By: Richard Nelson
AUTHENTICATION ACKNOWLED E gk3A,i, j`s•.
STATE OF WISCONSIN
Signature(s)
County
authenticated this day of m
Personally carne before me ryt. G ax'gf
0a,� 4a d
Nov-...--.
ber
Hillvale Development Limited, a Minnestta L I9lillity
• Partnership, by Richard Nelson
TITLE: MEMBER STATE BAR OF WISCONSIN to me known to be the person(s) who executed the foregoing
(If not, instrument and acknowledged the same.
authorized by C 706.06, Wis. Stats.)
THIS INSTRUMENT WAS DRAFTED BY
Attorney Kristine Ogland Notary blic, S e isconsin
Hudson, WI 54016 M Commission is permanent. (If not, state expiration date:
(Signatures may be authenticated or acknowledged. Both are not necessary.) LYE V:� �- I a , .)
" Names of persons signing in any capacity must be typed or printed below their signature. Ma nose vraew a e a comvwr. Fo b au LM vH
eoo.ues z W
STATE BAR OF WISCONSIN
WARRANTY DEED FORMNo.2.1999
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