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Home My WebLink About040-1160-05-000 (2)Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division 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: MARK & DEBRA WEBSTER City Village Township TOWN OF TROY 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 7TDH Ft Forcemain Length Dia. Dist. to Well 71 ELEVATION DATA county: St. Croix Sanitary Permit No: 617877 State Plan ID No: Parcel Tax No: 040-1160-05-000 Section/Town/Range/Map No: 250280208624A STATION BS HI FS ELEV. Benchmark Alt. BM Bldg, Sewer SUHt Inlet SUHt Outlet Dt Inlet Dt Bottom Header/Man, Dist, Pipe Bot. System Final Grade St Cover SOIL ABSORPTION SYSTEM BED/TRENCH 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 SOIL ABSORPTION SYSTEM BED/TRENCH 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 Bed/Trench Center Bed/Trench Edges Topsoil 0 Yes COMMENTS: (Include code discrepencies, persons present, etc.) Location: 164 DELANDER DR 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. I i�ranr�nr� nrar� �A-n f —3�� _ �, n4 rar-ir �vr� - County .a�pes �•^ Safety and Buildings Division �-7` �Ya ;��( 'i \� $ •( � APR �0 6 2020 201 W. Washington Ave., P.O. BOX 7162 Sanitary Permit Number (to be filled in by Co.) t p Madis WI 70 716 / r, \,tom t � \�nqv---- � � �� . _S` '�'�f St. Croix Count �. FFScI(11 ��:-� Y ani ary ermit Applica ion State,Tgransacti°° Nnntber Adm. // In accordance with SPS 383.21(2), Wis. Code, submission of this fotrn to the appropriate governmental unit /� is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to Project Address (if different titan mailing address) the Depamnent of Safety and Professional Servies. Personal information you provi may be used for secondary �� purposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats. I. A lication Information —Please Print All Information Property Owner's Name Parcel # � Property Owner's Mailing Address Property Location / �- �% '� �rd/! �L cy }�t- � .Y ('� Govt. Lot s.� , , /a, Section .�- City, State Zip Code Phone Number re� / J � L�� l {i'I' 1 T' / '`�- (_>� q �� _ � �i -.. 9�� c J �j/a, _�/�' �O (circle on W ' T N; R .�G -E�otl II. Type of Building (check all that apply) Lot # 1 or 2 Family Dwelling -Number of Bedrooms � Subd/ivision Name / Y j9 Block # ❑ Public/Commercial -Describe Use ❑City of ❑ State Owned -Describe Use ❑Village of CSM Numbe il' �{ ( III. Type of Permit: (Chet my one box on line A. Complete line B if applicable) A. ❑ New System eplacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System (explain) B• ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Num/ber and Date Issued ��u��998 Before Expiration Owner 3zoZo Z e of POWTS S stem/Corn onent/Device: Check all that a 1 n-Pressurized In -Ground ❑Pressurized In -Ground ❑ At -Grade ❑Mound > 24 in, of suitable soil ❑Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Otlter Dispersal Component (explain) ❑Pretreatment Device (explain) V. Dis ersal/Treatment Area Information Design Flow (gpd) Design Soil Application Ra (gp s Dispersal Area Required sf j Dispersal Area Proposed (sf) System Elevation VI. Tank Info Capacity itt Total # of Manufacturer Gallons Gallons Units D � o ,'�, � c 0 aUi y Y a ��' New Tanks Existing Tanks a U in �, rn i,.. C7 C%. Septic or Holding Tani: � � /��•� � G,C� � FyS P _�,/ I'�s! �L�I Dosing Chamber VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plutber's Name (Print) Plumber's Signature MP/totPftS Number B u %�1��`, �li3o�, Plumber's Address (Street, City, State, Zip Code) / VIII. Coun /De artment Use Onl �Approved ❑Disapproved Permit Fee $ Da a Issued �j�� Iss 'ng Agent Signature ��- � � ❑ Owner Given Reason for Denial IX. Conditions of Approval/Reasons for Disapproval 3 S gyp_ , � SYSTEM OWNER: J �_ (/s.� L-,� '� Z �„�,�,�. C�'�'r 1. Septic tank, effluent filter and � (, ''�' dispersal cell must be serviced /maintained 1 � a • � as per management plan provided by plumber: / � � be `�) ��-� � ^ n n � p Cw�es� Pa • 2. All setback requirements must maintained 111vLt�^ � aS per applicable COCX3(Sb9pjbli�llfi�l€te plans for the system and �� S: � 1 ��{�•�►��-� Iqg S i s w� tss� �; -s�� l9� .�;t sys� s) �i2 2��`19 � . �ppaper not less $+1n 8 t/z x 11 inches in size �e.,��-+�nr, ri� n{r�- a�c+tin i � 4 e't J Y 1 Mom_ r , C� 'FA k� w at I u �w f 0 1 TreatmentO Index and Title Sheet 0Wner, Project Name and System Type: Location, p Street Address f, Legal l Description a ,yam 1 Township/County f 4� . Contents: Page 1.' IN �> / Page 2: c 2, Page 3: �J:c��; / �.� 6�� t'-� Page 4: Page 6: ,�> ce - /T'%d,*f �� l /� �'�� a�.� � 4/ e Page 7: _C ei� (C r'61 Page 8% `r To"4''/ Page 9: Attachments: r redential NumberSigned: C:/�k % -�'' pate: } f � • /' -� -�� - �� { h UN %o µCu•is �• �¢Yf>'fdy �. } Q *00 V ilk 1 rf �V a0 X d AA -46 h. S'C11r'd4t D PvC r� fr, rl 7 L Q)e Eh,)� 61/k »/ a /' > S�IO �L-% �"'�G17 eJ l l..,l� •J"Y'�IrC6� *--5� cfd %'Z-,�.� k 4r' r2 j`'i✓l /I�•�I ?1.1 ffl °' �,':.' ,,.xs ..rVia. 't'•..��..eJ3 /f,, III rro,vs F 432" 0 n rri mz> -i I a -cn rmD 2„ rnmr- 371,. N Ni 2 2" n rn rn rnr D= mD mZ ° fTl 18" MIN. C r m m N D p o °fjr 0 37" 22,. �I I m 0 m 0� D D � r �D ZU) 77 1 N a m� (A m D r \ -� m FILTER CANISTER DETAIL WIESER CCt1CAETE DRAWN BY: o Z SEPTIC MANUAL W3716 US HWY 10 MAIDEN ROCK, WI 54750 DATE: JANI REV. JAN. 2010 800- 325- 8456 FILE: SHEET 13 a In rn mU ;u 00 IT'R::E yDD NAZ r z _00 IDy N :-j co 6" I o m SCALE: = 1' -POUR: y/5 FILE INFORMATION r Owner • ': Permit # Number of Bedrooms �¢ ❑ NA Number of Commercial Units ^0 NA Estimated flow (average) gal/day Design flow (peak), (Estimated x 1.5) c �� al/da Soil Application Rate s7 gal/day/ftz Influent/Effluent Quality Monthly average* Fats, Oil &Grease (FOG) 530 mg/L Biochemical Oxygen Demand (BODs) 5220 mg/L Total Suspended Solids (TSS) 5150 m /L Pretreated Effluent Quality ❑ NA Monthly average" Biochemical Oxygen Demand (BODS) 530 mg/L Total Suspended Solids (TSS) 530 mg/L Fecal Coliform (geometric mean) 510' cfu/100m1 Maximum Effluent Particle Size Y. inch diameter SYSTEM SPECIFICATIONS Septic Tank Capacity j o al ❑ NA Septic Tank Manufacturer ❑ NA Effluent Filter Manufacturer k ❑ NA Effluent Filter Model ❑ NA Pump Tank Capacity al gNA Pump Tank Manufacturer 6NA Pump Manufacturer NA Pump Model A Pretreatment Unit JXNA ❑ Sand/Gravel Filter ❑ Peat Filter ❑ Mechanical Aeration ❑ Wetland ❑ Disinfection ❑ Other. Manufacturer Dispersal Cell(s) ❑ In -ground (gravity) ❑ ln-ground (pressurized) ❑ At -grade ❑ Mound ❑ Drip -line ❑ Other: 4 Values typical for domestic (non-oommercfah wastewater and septic tank effluent. �* Values typical for pretreated wastewater. Service Event Service Frequency Inspect condition of tank(s) At least once every ❑ months ear(s) (Maximum 3 yrs.) Pump out contents of tank(s) When combined sludge and scum equals one-third (Y,) of tank volume Inspect dispersal cell(s) At least once every ❑ months .year(s) (Maximum 3 yrs.) Clean effluent filter At least once every 3 ❑ months year(s) Inspect pump, pump controls & alarm At least once every ❑ months ❑ year(s) NA Flush laterals and pressure test At least once every ❑ months ❑ year(s) NA Other. At least once every ❑ months ❑ year(s) NA Other. At least once every ❑* months ❑ year(s) XNA econ,s„e� %�'%� c.x,H�yr �° �%/r- ah� ��veix miY&lbsd Gv n @Gecos„'Pn a/ i�,4 Pr MAINTENANCE INSTRUCTIONS you,P" c/e.jh .Ptl-ter ,� eyeePdll �o Avg,, a�,�, 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 ch. NR 113, Wisconsin Administrative Code. , The servicing of effluent filters, mechanical or pressurized POWTS components, pretreatfinent components, and any other maintenance or monitoring at intervals of 12 months or less 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. 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 by a septage servicing operator prior to use. , System start up shall not occur when soil conditions are frozen at the infiltrative surface. Pagenf During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) 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. ABANDONN ENT 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 ch. Comm 83133, Wisconsin`Adminlstrative Code: 9 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. ❑ 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. r ❑ 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. ADDITIONAL COMMENTS '��c,' �/act _r• EPTAGE SERVICING OPERATOR PUMPER his re document was drafted by the stays of the Green Lake, Marquette and Waushara County Zoning and Sanitation agencies. This document meets he minimum requi ments of ch. Comm 83-22(2)(b)(1)(d)&(0 and 83.54(7), (2) & (3), Wisconsin Administrative Code. Use of this document does not ;uarantee the performance of the POWfS. miZ181 I=1 :1 Loll&I wilom �• •� t / P lam LOCAL REGULATORY AUTHORITY GMW (2/01) LOCAL REGULATORY AUTHORITY GMW (2/01) n 0 080 c c N 0 m N o np.. x ms cn pay O w � N m C N p o O N3@ va � owO W 2 j,QO U1 1 L5 ti Y : l kYlt_ � Sy}.• - :..• -fly. t49 .ow This is to certify that I have inspected the existing septic and/or dose tank presently serving the following residence: r-n:A (Site address)_ L r,-%`c c �� 6- located in the r %, E X or Go*.Section ' , Town ' C AN, Range W Town of / cf o y , Pierce County, Wisconsin. Parcel # � - j/ o _ OL5 - r_'j c> (7) J Upon inspectian, I certify that I have found the tank(s), fio the best of my knowledge, will conform to the requirements of SPS. 384,25, and it (they) appear(s) to be functioning properly and watertight. Did flow back occur from absorption system? Yes NoV (if no skip next line ) Approximate volume or length of time: Tank Capacity: - allA l� gons %, / minutes Tank Construction: Prefab Concrete Steel Other Manufacturer (if known): 5 Age of Tank (if known): Sanitary Permit number (if known) Inspection and form was completed by Wisconsin Licensed Plumber (DSPS Ch. 305 � Sec. 145.06, WI Statutes) OR Wisconsin Licensed Disposer (NR 113, WI Admin. Code): cw (WI Licensed Plumber/Disposer Signature) (Title &License Number) J (WI Licensed Plumber/Disposer Printed Nam() (Date) e sr CR IX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Naga ±. V _ ^ . zz" ?ropetty Address TOM itumdag i .►, I/l. rl for new •1 •i LewiLm �- ParW IdeatWeation Propcxiy Location S•�r' Z40 %, SCc• rZ✓� . T &L N Ry. e W. Town of M jar, • , Ocreffied 1ow X i 1 I/it ' ► , . .i 1 1 eed 9 poce. Polo. '.?,r fe evotame 13 / ► , 74 Lot H= 11►1t fi.• ► e, n• tlldo ►1 . •.r- 1.. ♦11 Hb 1K rl..•/.• . • 11 •. / r1I 1•.•. . wa t 11 1►. 11 ./..: 11t r. 11 / :w. • 41 •• ... • r« lrctuurlru.•.. •.1... ♦♦ •i un Ullt • It 'A I. '.N• t I,U • r 11/ ► •r:l♦. •. '.a •./.. '1 i.rr• .. , • •r1. r• 1'1/1/16w 11 IY. 1 1 1.11 111 • 11. rtt '1111 «1 •,1 • i1. r1.1 r.•• I _a 1.•/file 1-.r:. /n «n •. •u r. 1 u1 11rn -• bl .1 1 it • -• 1 . •Lf 11♦. . r 1 11/1 • . ►•t1\1 III,11 1 111/ • r w♦11 r •♦. 1 1111 Ir 11 ►•/ ` .•.. i'1t/{11 . r.\. 111• IIr.1 'll •'I .!•1 •• Y •, ,1 .• i •• 1w.'. • . w11 II 1e •• t ♦ rI: ♦ / • •.•11 • { •.t :: ,,•. •. i ► :11. ♦••�1 Ilt /1 1 •'/1111. 11 1 :►w•1•V•. , rA .• /11 •�/1 wtl•. I I I ♦is to Ilr: tl/•: 11 i/. t-\ ••: 1./ : / r •. It Y.w w11 •► • 11 1«•.:t 111 wll i �{. 11t 11.r • ::{I:1 it '. {.,. 111 .11 ♦ :Illir- 1 w•• /1 •w r. • i ••1 /•\11 �« 1 t ••: 1 { 1 '•Id• 1 it . 11 •• • . w/1 1 1 • rr1 /i ,Ir• It.•1. /111 • 1 •11/11• • •1 ... 1 • ri11 .1.• • i. �• • to •{�/• '1i1• it11 i / 1 it i�//.rr .. •{1► r. all ` We Y ft9 i so it ►. w.t1 mot\. 66 11 1st/ 1 1 i{ Lam♦ OF AI'PIC.[CANT DATE jaseet set «♦ Mil ITT ♦ i • 1�.:11I 1 1 •. / : :1 1 1 1 1 .1 1 -11/ wl ': ., 1.11CIEWC1 / 1a 9ftwpod 1 1:..1:. a / •/ the RjOgWerafDoodsotrice Copy /• Or(hccWWtOdS=cyMaPf 1 •1 v �`�� `Jv �� STATE B VR OF ��NAN`��M 2 982 v ` WARRANTY DEED DOCUMENT NO. I; Adrian D. Gulledge and Elizabeth H. Gulledge, hus,�nd and wife [he following described real estate in St. croiX County, State of Wisconsin: vY� i�� G-�y�tW� �R�G�STE�'a-� QFFICE r ST. CROIX CO,, WI RMG'd 1�ir Rcgbrd AUG 1 0 1998 9:45 A � -�'-two .�K.l� Re Istpr gf tj��d� THIS SPACE RESERVED FOR RECORDING DATA NAME AND RETURN ADDRESS WESTCONSIN PO BOX 308 RIVER FALLS CREDIT UNION WI 54022 PARCEL IDENTIFICATION NUMBER �2�A Lot Two (2) of Certified Survey Map in Volume Eleven (11) of Certified Survey Maps, Page 3212, as Document Number 555419, filed in St. Croix County Register of Deeds Office on Febn�ary 7, 1997, Being located in the Southeast Quarter of the Northeast Quarter (SEA/a of NEB/a) of Section Twenty-five , Township Twenty Eight (28) North, Range Twenty (20) West, Town of Troy, being Lot 1 o that Certified Survey Map recorded in Volume 7, page 1992, St. Croix County, Wisconsin. This homestead property. 3cls�dX (is not) Exception to warranties: Easements, is not TRANSFER � o y 2-- R restrictions and rights -of -way of record, if any. Dated this —t `T day of AUgU5t , A.D., 19 98 AUTHENTICATION e• _. r . _..- .• (SEAL) (SEAL) •. - � . Elizabeth B. Gulledge U ACKNOWLEDGMENT State of Wisconsin, ss. County. (SEAL) (SEAL) authencicaced this of August , 19 Personally came before me this day of 19 ,the above named r'\ 555419 AILED FEt3 p 7 1997 ► y(p3tiLESA K WALS" StCfobt 1 Deeft G'ER T I F•.I A 0 S LUR VE Y Meg P Located in the SE1/4 of the NE1/4 of Section 25, T28N, R20W, Town of Troy, being Lot 1 of that Certified Survey Map recorded in Vol. 7, pg 1992, St. Croix Coanty, Wisconsin, E1/4 Core Section 25 LEGEND 6 I s Berntsen Section corner monument. cap. � 1"X24" Iron pipe weighing 1.6$ lbs per line foot set. AV 1" Iron pipe foundl 2" Iron pipe found. CERTIFIED SUR VEY MA_P - - --------- - Vol. 9, pa.pe 2404 ............ Building s�tba�lc�in Lot 5 PLAINV.LEW v 0 Z ACRES OD v c*i O LLl _ O 1�i�LA T Ttwo -0,tw LANDS s N J � I 1� W DE'LANDE"R `O S O 4*42022"W 662 96' J 217.71'?• • 7 00 � b ` 'l.cingsetbaclr drive' rive y ACCESS 92013 Sq. Ft. ..............(2.11 acres)_...... ps. L®T 2 v V� �O..` N house E ® 7F 3 �as hs. V 15A . ` 14 9 �23 rn 3 Al CU O CU CIO z n n � m n s' . ;-.'- ��.':-�?UNT'{oO8, 543 Square feet (11.67 acres) ' sK:;�'.':' '•a;:=says of I I 6E7 LANDS 10' Utility easement Vol. 718, p g 10 N 01 UNPLAT . 47 J UNPLA T T ED LANDS 0 0 Cl N I- W w z_ o W J . Q 168 Delander Dr Adxian Golledge . m River m W 1 /4 Corner Section 25 I" iron pipe. Bearings referenced to the East-West quarter section line, assumed N87027202"W . This instrument drafted by* 4952429 VOL. 11 PAGE 3212 ST. CROIX COUNTY ZONING DEPAIZTMENT AS BUILT SANITARY REPORT /. Owner /•t1.-K "Plc6sfer Address e4 ve/j„ ever D�.'ve City/State /4:v�. to//r, w,o. S '+axal Legal Description: Lot Block S uhdj*i4sr>/CS M# 11 A 3.�L� / �/4 16 'A NF , Sec. 25 , TZ 8N-R 20 W, Town of rko�. `fJ aLa 1 7 �098 ST CROIX COUNTY T zONINGoFFICE , PIN # SdN/�ar..,.l' �/s. 3 •� �.0� CNFORMATION. Tank manufacturer Cye✓s'er Cu.�••ttSize ST/�2•��O/ ' Setback from Pump manufacturer Model -- Alarm location (BOLDING TANKS ONLY) N� Setbacks: Service road Meter location Alarm location Vent to fresh air intake SOIL ABSORPTION SXSTElVI: House Well N t, P/L /01 Water Line Type of system: %� �- � Width � -� Length ��-' Number of Trenches � Setback from: House o!r ,;7 Well N•r- 9fE P/L '� 8 Vent to fresh air intake 9 ELEVATIONS: Description of benchmark nd,'/ � � fr�� Elevation /od • OG Description of alternate benchmark rap o �' �; o * "eee, o/ r G w� a/a;0/a h Elevation / �g Building Sewer PC Bottom ^' ST/�F Inlet 9S" • 9/ ST Outlet-• �.S•• s' �' PC Inlet Header/Manifold 93• R l Top of STIPC Manhole Cover 7,9 �O Distribution Lines () p�?. 15r 3 () ( ) Bottom of System ( ) /`-�- 71 ( ) ( ) aa�of !op e 9 T• �3 Final Grade S. ? 3 () ( ) Date of installation ��/�/%�PCCmtt number 3.�a.�-y'� State plan number Plumber's signature 40*00�`� License numbere ato 6 7�5 Inspector /hfPa/Aa Datc ('omplc(c plot pinn K -Wiscorkin Department of Commerce PRIVATE SEWAGE SYSTEM *Safety and Buildings Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provice may be used for secondary purposes (Privacy Law, s.15.04 (1)(m)). Permit Holder's Name: ❑ City ❑ Village Town of: WEBSTER, MARK TROY CST BM Elev.:- Insp. BM Elev.: BM Description: b O 0 o -fir TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic, Dosing Aeration Holding TANK SETBACK INFORMATION TANK TO PUMP/ SIPHON P/L WELL BLDG. Air Intake ROAD Septic 1 Z S Al' ii- NA Dosing NA Aeration NA Holding INFORMATION Manufacturer Demand Model Number /GPM TDH Lift Loss ead Ft Forcemain Len th Dist. Towel] SOIL ABSORPTION SYSTEM SETBACK SYSTEM TO P/L INFORMATION TypeO �Ir System eftyA%u DISTRIBUTION SYSTEM / I No. Of Trenches ELEVATION DATA County: ST. CROIX Sanitary 20202 State Plan ID No.: Parcel T1160-05-000 STATION BS HI FS ELEV. Benc � l�. 13 wt -t 2 , � /03 • L� Bldg. Sewer St/ H{ Inlet 72 9S; St/It Outlet j 2s Jcj".3 $ Dt Inlet Dt Bottom Header / Man. 6 •$ Dist. Pipe %• Gl 3, (o � Bot. System "]. �2 qv 7 I Final Grade4�s o 3•S� �7•-j 51 • yyayhale 2. 33 `ate o BLDG WELL LAKE / ST �Cr w No. Of Pits LEACHING CHAMBER OR UNIT rer: Header /Manifold �� Distribution Pipe(s) � � �� x Hole Size Tf✓[ x Hole Spacing 'Z•G� Vent To Air Intake Length � Dia. Length �t Dia. Spacing F}C7 Z SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over BedlTrenchCenter Depth Over Bed /Trench Edges xx Depth Of Topsoil xx Seeded /Sodded ❑Yes ❑ No xx Mulched ❑Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: TROY 25.28.20,SE,NE 164 D/IE--LANDER DRIVE — LOT 2 -M 'To? 0 � av / >✓c� � GV G,�G d6U dt�it�G� 2` e�¢�f oi? b tom, S ewes ed� e�-ems"ter cl Z 7-'p7c�G.e3 Plan revision requirfoptEl Yes No Use other side for additional information. 1i L'L-j Siva Date Inspector's Signature C ��isconsin Department of Commerce SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code Safety and Buildings Division 201 E. Washington Ave. P.O. Box 7989 Madison, Wt 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less � county than 8 v2 x 11 inches in size.. ,�� Cvo 1'1C • See reverse side for instructions for completing this application State Sanitar�yjPermi�t Number The information you provide maybe used by other government agency programs ❑ Gheck if reGsio� pre�usZapplication (Privacy Law, s. 15.04 (1) (m)l. State Plan LD. Number I. APP I ATI N INF RMATI N -PLEASE PRINT ALL INF RMATION �"'""� Property Owner Name a ��. Gfle L stems .Property location s�- ,/4�(�' ,/4, s -2,�' T .� 8 , N, R.20 �{er) w PropertyOwner's Mailin Address lr>s �dsfi •�•Y.rat sr. Lot Number � Block Number -- City, State Zip Code Phone Number Subdivision Name Number 3 �/ ` E F B ILDIN (check one) ❑State Owned Public 1 2 Famil Dwellin No. bedrooms o It� p Vil age Th A Nearest/Road pC'l �!R �Cl- t�!h or - of Town OF III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Numbers) /!�� o�fD^ t IG o - D'3 1 ❑Apartment/Condo 2 ❑Assembly Hall 6 ❑Medical Facility/ Nursing Home 10 ❑Outdoor Recreational Facility 3 ❑Campground 7 ❑Merchandise: Sales/Repairs 11 ❑Restaurant/Bar/Dining 4 ❑Church /School 8 ❑Mobile Home Park 12 ❑Service Station /Car Wash 5 ❑Hotel /Motel 9 ❑Office /Factory 13 ❑Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1, � New 2. ❑Replacement 3, ❑ Replacement of 4. ❑Reconnection of 5. ❑ Repair of an ,______System Only______________ Existing System Exlsiln�System ________System _____________Tank ________ B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non -Pressurized Distribution Pressurized Distribution Experimental Other 11 j�.Seepage Bed 21 ❑Mound 30 ❑Specify Type 41 ❑Holding Tank 12 ❑Seepage Trench 22 ❑ In -Ground Pressure 42 ❑Pit Privy , 13 ❑Seepage Pit ��- r?2- 43 ❑Vault Privy 14 ❑System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Pert. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day/s ft.) (Min./inch) Elevation � % �O D ,; g �. b• 6 /� �o� - Feet �O Feet Vil. TANK Ca aut INFORMATION in allots g Total Gallons # of Tanks r Manufacturer s Name Prefab. Concrete $1te con- steel Fiber- glass Plastic Exper. App New Existin strutted Tanks Tanks teTank �2,5'O l�.5'O � L(J�r„�r Ca+eA�O/fC� ❑ ❑ ❑ ❑ ❑ lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VII(. RESPON5IBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Si ture: No Stam s) MP/MPf�Afidv.: Business Phone Number: C�Ga�-1cr �e.dsr�- �� .Sf� �/�s=.z.Z3� 3�¢-�O Plumber's /A.ddress (Street, City, State, Zip Code): �+ y�• / IX. COUNTY /DEPARTMENT USE ONLY ❑Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issw gent Signature (No Stamps) �jApproved ❑Owner Given Initial + /� � Surcharge Fee) �� Adverse Determination ! �V �� X. CONDITIONS OFAPPROVAL /REASONS FOR DISAPPROVAL: SBD�6388 (R.11/96) � DISTRIBUTION: Original to County, One copy To: Safety b auildings Division, Owner, Mumbe� Wiscdnsin Department of Industry, Labor evA Human Relations 'DM'' ion of Safety & Btsldings S®00_ AND SITE E/ in accord with III Attach complete site plan on paper not less than 8 112 x 11 ii not limited to vertical and horizontal reference point (BM), dir dimensioned, north arrow, and location and distance to near APPLICANT INFORMATION —PLEASE PRINT ALL IN size. Plasm cfhja %pslo�e R TI ;Z PROPERTY OWNER: PROPERTY OWNER':S MAILING ADDRESS 110 ) b�LtAIVD�R 121U� CITY, STATE ZIP CODE PHONE NUMBER 1Z.1la�Z 1-�-LLStl�1 SI��Z.Z(�1S1 �1ZS_oZZ7 �n RT �cr� 8 3 -/ Page l of ;'•i �IA�11 � I.UUNIY r t ire, b sca ARCEL I.D. # EVIEWED BY DA1 1/4 NE 1/4,S ZS T Z$ N,R Z p E LOCK # SUBD. NAME OR GSM # ST ROAD t4t�i��2 [� New Construction Use [ Residential / Number of bedrooms . Y. [ ] Replacement [) Public or commercial describe [ 1 Adtlitign to existing building Code derived daily flow 6 0o gpd Recommended design loading rate o • -1 bed, 2 0 , 8 2 Absor lion area required 8 S8 2 1 s o 2 gpd/ft trench, gpd/ft p e9 bed, ft _ trench, ft Mabmum design loadino rate o • —1 bed, 2 o . g Recommended infiltration surface elevation(s) q Z . ' gpd/ft trench, gpd/ft2 Additional design / site considerations RCTrlJrtK0hiD t Z' X z co,uu ft (as referred to site plan benchmark) t� � t�l� Q Parent material Sty SM1'N1k5jT ova S b �z GtzAUQt Flood plain elevation, if applicable N ft ' S = Suitable for system CONVENT1oNAL ®S D ❑ U IN -GROUND PRESSURE AT -GRADE U ;Unsuitable fors stem S ❑ U _ ®S U SYSTEM IN FILL HOLDING TANK ®S EJU ❑S �iU SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure in. Munsell Texture Consistence GPD/ft Qu. Sz. Cont Color Gr. Sz. Sh. ��' Roots o -t0 Bed Trend ] l��t�izCZ ZMSblT lv,��, cS Zvi 0.5 o.t4 s► l Z 5b)3 YA V. C Ground 3 ZS 3S ,.S L19b elev. 9 �"► C g p. 7 0, Q, ft, y 's-93 log �z y / (o S o s9 w,) o• � o, � Depth to limiting factor 3 LO C Remarks: - Boring # 1 0-9 �o��. z!z `� sal Zwlsb 9-33 S�ItZ 3/y iS Ground elev. 0 ft. Depth to limiting 4* 3 •?a >76t. Y -YY Remarks: Egerer o Print Arthur L. We erer Phone: 715-425-0165 oil Testing & Design Service-P.O. Box 74 River Fal1S,WI 54022 — S 31 Dale: --�5 CST Number: PLC' PLAN Page 3 of 3 SCALE I "= lj p l r� �RW�a %Z1.PF CST Signature 7 15 ) 4 5- n 7 n 5 l40 0 5 7 6 Date Signed Telenhone No rcr 4$