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Home My WebLink About040-1294-00-000 (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 Pamela Rohde TOWN OF TROY CST BM Elev: Insp. BM Elev: BM Description: IANK INF-UKMATIVN 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 county: St. Croix Sanitary Permit No: collbbO 600399 State Plan ID No: Parcel Tax No: 040-1294-00-000 Section/Town/Range/Map No: 1602801961685 BED/TRENCH idth Length No. Of Trenches DISTRIBUTION SYSTEM Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Dia I Length Dia Spacing SVIL (:UVtK x Pressure Systems Onlv xx Mound Or At -Grade Svstems Onlv Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil ❑Yes ❑ No ❑Yes ❑ No COMMENTS: (Include code discrepencies, persons present, etc) Location: 504 E COVE RD 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required? ❑Yes ❑ No Use other side for additional information. SBD-6710 (R.3/97) Date Inspection #1: Insepctor's Signature Inspection #2: Cert. No. C D ECE8 �! County S <, Safety and Buildings DivisionDD aS; K 01 W Washington Ave.!; P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.) 'a ? APR p Madison, WI 53707-7162 St VePlllt Application ro �T action NumberComm In accordance wit3iS7`5'383 ti , lVas.9b tub fission of this form to the a -- _-., ppropriate governmental unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to the Department of Safety and Professional Smies. Project Addre Sf (d different than mailing address) Personal information you provide may be used for secondary oses in accordance with the PrivacyLaw, s. 15.04(1)(m), Stats. I. Application information — Please Print All Information Property Owner's Name �Q Parcel # rim Property Owner's Mailing Address ( Property Location City, S Zip Code Phone Number e / ) GovtLot or 1/L�� t7 , A., Section l�L/ c II. Type of Building (check all that apply) Lot# ��--� I circle on • I � '` T=�1`'° RlT E �V( C or 2 Family Dwelling —Number of Bedrooms / 0 Subdivision Name + O4� per Muse, ��r Vy%, Block# 1 / q ❑ Public/Commercial— Describ Use�j Vibrh A jA 20 It) ❑ City o ❑ State Owned — Describe Use CSM Number ❑ Village of SiLI ii aim of r G IIf. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. �2 I lew Svstem ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existinge System (explain) t Renewal ❑ Perot Revision Change of Plumber ❑ Pemrit Transfer to New Previous Permit Number and Date Issued :11 Before xpiration Owner e o O Com onant/Device: Check all that a l~ -Pressurized In -Ground Pressurized In -Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ❑ oun < i I it Holding er ispersal Component (explain) El Pretreatment Device (expl ' V l ` V. Dis ersal/Treatment Area Information: Design Flow (gpd) Design Soil Application ds Disp ersal p ersat Azea RequDispersal Area proposed f) system Elev o VI Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units New Tanis agna a uo =� �A` v a` U on C v iS Septic or Holding Tank _ Dosing Chamber �r VII. Responsibility Statement- I, the undersign ume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) er's Signature WB*APRS Number Business Phone N ber �jj .. ,� Plumber's Address (Street, City; State, Zip de L 2�- / County/De artment se Only Issued Issuing Agent ZP.Approved Disa Permit Fe:n�v) Si e LDJate er Given Real Denial S y� / Za Z 4- DL Conditions of Approval/Reasons for D oval $Y$TEt+1GVr'ttER: �i��jllYa►� ► 1.Set;tic t.;tiv„ efltue;ltlter andnn u✓�C dispersal r.ell must b�sN[x D. %� (_(C(/�- IL66 2I � managen.rnt p:a I i cicdby plumber. o, per $, All autbdcl`Ilrillilo code/ordinar]roost ces�aintained �,� n I J / �� ublie SBA-6398 (R" 11/11) wttacu to to plants for She system and submit to the County only on per not less than 8 i2 z 11 inches in a� (� County Safety and Buildings Division t•� v' 201 W. Washington Ave.; P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.) Madiso )Q/l 53 07-7 2 MP Applicatio State Transacti r�Iumber 5t. cSxaVIE rmit (r'j, In accordance with SPS rs. Adm. Code, submission of this form to the appropriate governmental unit n required pri to a sanitary permit. Note: Application forms for state-owned POWTS are submitted to Project Address (if different than mailing address) the e Departmentty afand Professional Servies. Personal information you provid may be used for secondary purposes in accordance with th&Frivacy Law, s. 15. 1 m , Stats. L A lication Informati n Please P int All Information c, d /eZJ Property Owner's Name OLI Parcel # 416 d ah t1) Property Owner's Mailing Address perry Locati n �% City, S i Go ,CJ Ztp Code Phone Number r/, / �/y ^ Section (circle o h; R� E 11 pe of Building (check all that apply) Lot W 1-oi-2 Family Dwelling —Number of Bedrooms Su 'vision ' e ElPubliclCommercial— Describe lJse ❑ ❑ State Owned — Describe Use CSM . ber ❑ V o a To of IIf. Type Permit: (Check only one bo ine A: Complete 'ne B if applicablef A stem ❑ Replacement ❑ Treatment/Holding Tank Repiacetn ❑ Other Modification to Existing System (explain) B. ❑Permit Renewal El Permit Revision ❑Change of Plumber ❑ P fer 'ew List Previous Permit Number and Date Issued Before Expiration own c eWTS S stem/Com onent/Dev Check all that a 1 94:1a3pr=n—In -Ground ❑ Pressurized 1n-Ground ❑ At Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil El (..•(� Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. DispersallTreatment Area Information: Dpsrgn Flow (Vd). Design So Application dsf) Dispersal Area Required (sf Dispersal Area Propose (SO System Elevation , ��% � �y .3� `� �/ �( [ of VL Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units ° c o New Tanks Existing Tanta U Septic or Holding Tank Dosing Chamber VII. Responsibility St.Aementm I, the undersigned a me responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) P 's Signature MP/MPRS Number Business Phone N b 1 �6 f, '0 Phynbcr7s Address (Street, City, State, Zip ) VIII CountyMepartment se Only Approved ppr Permit Fee Date su Issuin ent Signature ❑ Given g$7' i 7 Reason for Denial DL Condi on§.for I1i.�approval ,I �: m, l fte* Oil 3) �c►t�2 u4�}iel si oeli must all be sgrilg> s r til� .i er hs per iTalragement plan o!'o doed by plwnbe.r% 2. AA eelbNk rfir.6Fk, terns mt}ut ua ., KirrtcJ l .e n pW #Vpilo W8 M do Attsrh In ' _..-....' _- ..............1 .....Iy .... yu y � SBD-6398 (R. I1/11) J 7