HomeMy WebLinkAbout008-1074-10-100 (2)Wisconsin Department of Commerce
Safety and Building Division
PRIVATE SEWAGE SYSTEM
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT)
Personal information you provide may be used for secondary purposes (Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: City Village Township
Delmar Ziebart TOWN OF EAU GALLE
CST BM Elev: Insp. BM Elev: BM Description:
TANK INFORMATION
TYPE
MANUFACTURER
CAPACITY
Septic
Dosing
Aeration
Holding
TANK SETBACK INFORMATION
TANK TO
P/L
WELL
BLDG.
Vent to Air Intake
ROAD
Septic
Dosing
Aeration
Holding
PUMP/SIPHON INFORMATION
Manufacturer
Demand
GPM
Model Number
TDH
Lift
Friction Loss
System Head
TDH Ft
Forcemain
Length
Dia.
Dist. to Well
SOIL ABSORPTION SYSTEM
ELEVATION DATA
c°Unty: St. Croix
Sanitary ermit N
1 ena4�
State Plan ID No:
3076219
Parcel Tax No:
008-1074-10-100
Section/Town/Range/Map No:
26.28.16.385A
STATION
BS
HI
FS
ELEV.
Benchmark
Alt. BM
Bldg, Sewer
St/Ht Inlet
St/Ht Outlet
Dt Inlet
Dt Bottom
Header/Man,
Dist. Pipe
It. System
Final Grade
St Cover
BEDITRENCH
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
Type Of System:
CHAMBER OR
UNIT
Model Number:
DISTRIBUTION SYSTEM
Header/Manifold Distribution x 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
xx Seeded/Sodded
xx Mulched
BedlTrench Center
Bed/Trench Edges
Topsoil
Yes
COMMENTS: (Include code discrepencies, persons present, etc.)
Location: 176 CTY MUM
1.) Alt BM Description =
2.) Bldg sewer length =
- amount of cover =
Plan revision Required? ❑Yes ❑ No
Use other side for additional information.
Date
SBD-6710 (R.3/97)
Inspection #1:
Insepctor's Signature
Inspection #2:
Cert. No.
County
Industry Services Division
en f2 k V,
{,
1400 E Washington Ave
Sanitary Permit Number (to be filled in by Co.)
t 20 2®
P.O. Box 7162
pr MAR
Madiso,UI 707— 162
I
f;
5t ` n '
State Transaction Number
It A�]�I1C UQ,
In accordance S \1�s. Adm. Code, form
Q,
wit submission of this to the appropriate go ntal it
is required prior to obtaining a sanitary permit. Note: Application forms for stale -owned POWTS are submitted4o
Project Address (if different than mailing address)
the Department of Safety and Professional Servics. Personal information you provide may be used for secondary
purposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats.
� � �' / ^ n� � �
Vl
1. Application Information —Please Print All Information
Property Owner's Name 2LN
Parcel
Oo --� 100
Property Owners Mailing Address
Property Location
Ipe
u
Govt. Lot
/� r , 1 y/ , 4, Section (,.,
Cit , State
&W
Zip Code
Phone Number
k ` \
(circle one
T ON N; R _ F ort h D
H. Type of Building (clt ck all that apply) /
Lot #
Subdivision Name
Q 1 or 2 Family Dwelling -Number of Bedrooms
-• 7
El��� aS �J L�b>
Block#
PubliclComntercial-Describe Us i
❑ City
W TL
❑ State Owned -Describe Use
of ,-
Village of _
CSM Npnibcr Vol, �3 �7 ��
M
I X Dt �v/�V t�i
/3
own of A
�[i.a 4U
t:"ila
III. TY
po of Perini (Check only one box on line A. Complete line B if applicable)
7Z44A
z6jqA asePAr.
A'
❑ New System
❑ Replacement System
❑ Treatment/Holding Tank Replacement Only
❑Other Modification to Fxistin��c�l ((cl�i to
B.
�erinit Renewal
j❑ Permit Revision
❑ C,hange of Plumber 0 Permit Transfer to New
List Previous Permit Number and bate !ss cd
Before Expiration
/
Owner
U eJ U -1 I
IV. fPO S S stem/Coin onent/Device: Check all that apply)
❑ Non -Pressurized In -Ground ❑ Pressurized In -Ground ❑ At -Glade �It4oand > 24 in. of suitable soil
0 Mound <24 in. of
fftsuitabbl1e soil
❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) roil
o l
V. Dispersal/Treat cot Area Information:
lll
1
Design Plow (gpd)
Design Soil Application Rate(gpdst)
Dispersal Area Required (st)
Dispersal Area Proposed (sf)
System Elevation
�b
1 ut�
�i
lol.ot
VI. Tank Info
Capacity in
Gallons
Total
Gallons
# of
Units
Manufacturer
l / /� w�
G.I f
1.{�
p
2
2
U
e�"iFA
New Tanks
Existing Tanks
/ ✓
V, I ,�/
U
c�
in
w t7
F.
Septic or Holding Tank
b
Z
LeN 1 s Albels �/
Dosing Chamber
♦J
1
VII. Responsibility Statement- 1, the uudersi espousibilfty for ins t anion of the POW shown on the attached plans.
Plumber's Nam c (Print)
Ire t
MP/MPRS Number
Business Phone Number
e c l.L_
9n
5=�3 - ��S
Plumber's Address (St-r , City, State, Zip Code)
NMI. Coun
a artment a Only
ved
isappro
Permit Fee
Date Issued
Issuing A c
t�S/i�gu/attc
��
IS O'er
"
caner Gnr w-for Denial
Vrr •
IX. C �RI Approval/Reasons for Disapproval f
filter and 3 I p�(h t-� ��i�11%WI
j
�nt110 n S 1 /'1 XrM4"� 6
1. 54,lp le tank, efllueot
,
dispersal rel! must" ° viced/maintained J %,,
an per management p!an provided by plumber. CA n p11 U4b t ` 5J a-
2, All setback requirements roust be maintained (i �
a6 per applicable Code/ordinan05. , qf
�r
I b o 746
Attach to complete pinny for the system and subnrtt to the County only on paper oaf Icss t an 6 In x 11 loci s 4r size
!fie lL¢.d
�ll
SBD-6398 (RQ313)