HomeMy WebLinkAbout022-1038-40-020Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT sanitary Permit No:
617874
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 Holders Name: City Village Township Parcel Tax No:
GREG GAMACHE TOWN OF KINNICKINNIC 022-1038-40-020
CST BM Elev: Insp. BM Elev: BM Description: Section/TownIRangelMap No:
2 $D 74iil Cov-&r I 14.28.18.212A-20
TANK INFORMATION l j_rj ZiyKs ELEVATION DATA
TYPE
MANUFACTURER
CAPACITY
Septic
Dosing
1
Aeration
Holding
TANK SETBACK INFORMATION L,d GN Ct jqj)J'
TANK TO
P/
WELL
BLDG.
Vent to Air Intake
ROAD
Septic
71&0'
bt
—7
!0t
�—
��•
Dosing
Aeration
Holding
PUMP/SIPHON INFORMATION
Manufacturer
Demand
GPM
Model Number
�\ 1 y�
TDH
Lift
Friction Loss
System, He-96
TDH Ft
Forcemain
Length
Dia.
Dist. to Well
SOIL ABSORPTION SYSTEM
e
STATION
BS
HI
FS
ELEV.
Benchmark
-3•O
1027
/ov
Alt. BM
Bldg. Sewer
SVHt Inlet
S.-7
c1'1r3
�QI
St/Ht Outlet
S r g
�( y r 2
Dt Inlet
.
� •45
i3.35
Dt Bottom
Header/Man.
Dist. Pipe
Bot. System
Final Grade
St Cover
BED/TRENCH
Widt
Length
No. Of Trenches
P DIMENSIONS
No. Of Pits
Inside Dia.
Liquid Depth
DIMENSIONS
t7XV,%
;
SETBACK
SYSTEM TO
I PIL
JBLDG
IWELL
LAKE/STREA
ACHING
Manufacturer:
INFORMATION
CH OR
T f S tam:
Y Ys
odel Number:
dV
DISTRIBUTION SYSTEM
Header/Manifold
Length Dia
bution
Pip s)
Len Dia Spacing
x Hole Size
x pacing
Vent to Nr tntake
SOIL COVER x Pressure Svstems Only xx Mound Or At -Grade Svstems Only } ter JiumAp. —
Depth Over
IDepth Over
Depth of
zx Seeded/Sodded
xx Mulched
Bed/Tre Cen r
Bed/ire E es
sail
IGfI yes O No
Yes O No
COMMENTS: (Include code discrepancies, persons present, etc.)
Location: 1378 CTY RD J L-VC K ve - (/{
1.) Alt BM Description =
2.) Bldg sewer length = 1+ 9Q - J - amount of cover = Lit 5 x _ ! 1 % , ^Sv `CI 4-e J 7
Plan revision Required? [A Yes I,$kNo
Use other side for additional information.
Date
SBD-6710 (R.3/97)
Inspection #1: jam//�?-p/ Z p Inspection #2:
,D . 5 4+ -44,& v% 1Alri I
I sep�0.wr. Cert. No.
'::ZAA(96.%—nFrS
Safety and Buildings Division_�5201
San@vy Permit Notches (inbe filled n by Cc)
W. WasNngton Ave., P.O. Bex7162
S
st Mad WI 5 707-7162X
..
Sanitary Permit AWlic
S'meT'�aa�rooN®bQ
_>
In V
Lem with SPS 38321(2), Weis. Aden Code, submission of this fcrm to the appropriate governmental wit
Address (if diffemm Wm mailing address)
h tl
prior toobtaining a sanitary pewit. Note: Application farms for suzeowved POWTS are sobmioed inProjecr
e
thDo8
of Safety and Professional Seevia. Personal information you provide be used for sundry
pustancs
in scasdma with the Pnvaq law, s. 15.(4(1)(uj StaM.
S4"`A-
L Als
'cation Information- Please Print All lnfortoatiou
Property Owner's N
�;rc
Pascal 0
zvlcl
Property Owner's
•
Property Location ZY.21
y, e /t y` seam
, Stare
Code Phone
Ntwber
T � N; MW /
ll
ll lot#
IL Type of Building (c eele that apply)
Name
of 2 Faraily Dwelling -Number of Bedrooms
Subdivision e
Block
❑ PublicACommercial-Describe Use
❑ City of
❑ State Owned - DesmbCS6
Use
❑ Ydlaga of
O 46 1
1
O �
own ofe Al
III. Type of Permit: (Check only one box online A. Complete tine B if applieab
A.
System
System
rr tdioWmg Tack ReplaceroemOoly
❑ other Modification to Existing System (explain)
B•
❑Permit Renewal
D Permit Rwisiot
❑Change.£Plumbs
I OPermttTmaferm New
Owner
Liu PreviousPerson N gDon: Unseal
�{9�{3� 3
Before Expvation
e/rnet
M Trpe ofPOWTSS Com onent/Devica Check all that apply)
Cr ❑ Non-Pressonzed In-owd ❑ Pressurized In -Ground ❑ Al-Giade ;gMe md> 24 in. of suitable and ❑ Monad <24 so. of suitable sod
❑ Holding Talc ❑ Odw Dispersal Component (exptam) 0 hareanneot Dmcc (CVI—)
V. DissisersaVrreatusent Area Information:
Design PlovG(gpd) ter`.-,�(,/p/�0 Application Rate(gpdsE
Disposal Am Regrmed (s)
Dispersal A= Proposed (sf) Systun
Eievanon
VL Tank
Capacity in
Crdlotts
Total
Gallons
p of
Unim
Mmatamno
._,/ /
"7 fJ ."� F'(�.
k
o
Neer Tacks sv,rna8
Tanks
129
'vi"
w
in
cab
G
Septic or Hotdou Tack
a
V
Dosing Cinnabar
VII. Respoosili ty Statement- the and a respo"ladity for installation of the POWRS Shown oa the attached plus.
PI s Name (Print) tH
MP/hIPRS Number
B¢9ness Phone N
4 !-/ )
,s re„r pty S ap
iI
/
XL�
VID. Cgom ADe partment se O
AP➢to"ed Disapproved
Permit Fa
S
D///1e Issued
Is
Is
u' Agent Si
���
,.
�/
❑ Owner Given Reason for Denial
/'
tl
roval'Reasons for Disapproval V Ffaa+1 GeVt�Aa/'e�f caw its
v�iv"��:
tac" �
1. Septic tank, filter
effluent and
"
�'� Cy//ZcAo I
dispersal cell must be service ! maim fined ^ '�'D � ` �'"�"T
as per management plan provided by plumber. 4i') �x $ "
AA W
2. All setback requirements must be maintained AWS&
as per appucaote cowavRiameew eras n-•rwa a^^ em� —
SBD-6398 (R 11111)
6)
,Z0
iU4
oM 4ss man rrtx it inraesume � 26�.
we V1 ate '5-Pa rK n,s at t.0
ti l - Prl�
guRr ii.a-& {o fin & u.'`d!° ,
I cet,ar et.er safa,o- Lk.t-a •s � boo , /
?war
System PLOT PLAN
PROJECT Grea Gamache ADDRESS 1378 Ctv Rd J River Falls Wi 54022
S 1/2 NE 1/4S 14 /T 28 N/R 18 W TOWN Kinnickinic COUNTY ST.CROIX
SYSTEM ELEVATION Existing 4110/20 BEDROOM 3
DATE
CONVENTIONAL AT -GRADE CONVENTIONAL LIFT HOLDING TANK
MOUND XXX SEPTIC TANK SIZE 1000/280 LIFT TANK SIZE DOSE TANK SIZE 750
HOLDING TANK SIZE LOAD RATE ABSORPTION AREA # of chambers
NCHMARK V.R.P. Top of manhole cover ASSUME ELEVATION 100' Filter Lifetime Filter
BOREHOLE O WELL +H.R.P. same as benchmark
System PLOT PLAN
PROJECT Grea Gamache ADDRESS 1378 Ctv Rd J River Falls Wi 54022
S 1/2 NE 1/4S 14 /T 28 N/R 18 W TOWN Kinnickinic COUNTY ST.CROIX
SYSTEM ELEVATION Existing DATE 4/10120 BEDROOM 3
CONVENTIONAL AT -GRADE CONVENTIONAL LIFT HOLDING TANK
MOUND XXX SEPTIC TANK SIZE 1000/280 LIFT TANK SIZE DOSE TANK SIZE 750
HOLL�DING TANK SIZE LOAD RATE ABSORPTION AREA # of chambers
/ 9�NCHMARK V.R.P. Top of manhole cover ASSUME ELEVATION loo, Filter Lifetime Filter
BOREHOLE O WELL 1H.R.P. same as benchmark
S� � fon�ra�-
Cg,,ti�( r2i+es.
s
20140048A F7-
0
04,520D
)8.6000
1.1921
9.8464 9X59
p.01 GOP bel�en Cme md $erpentine
ri
1? C,
SAFE 71'--�
SECTIONA—A
Septic System and Well Inspection Report
I Shaun Bird, certify that on
Bird Plumbing Inc
1432 120th St.
New Richmond Wi 54017
4/15/20
715-246-4516
sbird @frontiernet.net
XXX Inspected the Septic System (POWTS)
Inspected the Well
Obtained a drinking water sample
Property Owner/Buyer
Greg Gamache
As a result of my inspecton, I certify that:
Site Address
ECF' F
APR 17 2020
St. ( ; County
1378 Cty Rd J River Falls Wi
XXX In my opinion, the septic system was, on the date of my inspection, in working order and in
compliance with the standards set forth by the Department of Safety and Proffesional Services.
Any exceptions or needed repairs will be listed below.
Last date of pumping To be pumped 4/20/20 System appears to be sized for _3_ Bedrooms
.In my opinion, the well at the date of my inspection, is in good condition and complies with all WDNR
standards. Water sample sent to Quality Water Testing Lab Somerset Wisconsin.
See attached Property Transfer Wells form. Any exceptions or needed repairs will be listed below.
In my opinion, the septic system or the well is not working or not in compliance with the
Departmet of Safety and Public Services or WDNR. See attached Property Transfer Wells
Inspection form.
The mound system was found to be in working order and code compliant.
Septic System maintance information: Pump tank every 3 years and clean effluent filter if installed once a year.
For further information, contact your local zoning offict
Disclosure: This test is not a guarantee of future perfbut a proffesional opinion. Usage can change from
different owners. This is not a warranty of this systeim all Iiabilty for any loss caused by reliance on this
cerfication. Past problems with this system,( if anye disclosed by the seller.
Shaun Bird MPRS/CSTM #226900 DNR# 76 Date 4/15/20
POWTS OWNER'S MANUAL & MANAGEMENT PLAN
Page _ of
so -
'ILE INFORMATION
Owner
Permit # ( q ��j
Number of Bedrooms
3 0 NA
Number of Public Facility Units
'AM
Estimated flow (average)
gal/day
Design flow (peak), (Estimated x 1.5)
al/da
Sal Application Rate
/, auda /f?
Standard Influent/Effluent Quality
Monthly average*
Fats, Oil & Grease (FOG)
53o mg/L
Biochemical Oxygen Demand (BODs)
420 mg/L ❑ NA
Total Suspended Solids (TSS)
5150 mg/L
Pretreated Effluent Quality
Monthly average
Biochemical Oxygen Demand (BODs)
530 mg/L
Total Suspended Solids (TSS)
530 mg/L
Fecal Cofiform (geometric mean)
510° cfu/1OOml
'!,Maximum Effluent Particle Size
K in dia. ❑ NA
'Values typical for domestic wastewater and septic taNk effluent
MAINTENANCE SCHEDULE
SYSTEM SPECIFICATIONS
Z5� L-)
Septic Tank Capacity
l ❑ NA
Septic Tank Man
0 NA
Effluent Fitter Manufsrer
O NA
Effluent Filter Model
��
❑ NA
Pump Tank Capacity
l ❑ NA
Pump Tank Manufacturer
❑ NA
Pump Manufacturer
❑ NA
Pump Model
0 NA
Pretreatment Unit
0 NA
❑ Sand/Gravel Fitter
❑ Peat Firer
❑ Mechanical Aeration
❑ Wetland
0 Disinfection
0 Other.
Dispersal Cell(s)
0 NA
❑ In -Ground (gravity)
❑ In -Ground (pressurized)
❑ At -Grade
Mound
❑ Drip -Line
❑Other.
Other.
0 NA
Other:
❑ NA
Other.
0 NA
Service Event
Service Frequency
llnspect condition of tank(s)
At least once every:
0 °�(s) (Maximum 3 years)
0 NA
Pump out contents of tanks)
When combined sludge and scum equals one-third (36) of tank volume
❑ NA
Ilrspect dispersal cells)
At least once every:
q m0nth(s)qs) (Maximum 3 years)
3 $7e nth(
0 NA
Clears effluent fitter
At least once every:
months)
r(s)
0 NA
nspect pump, pump controls & alarm
At least once every:
month0 s(s)zliyeadr
❑ NA
19ush laterals and pressure test
At least once every:
months)
ear(s)
NA
Other.
At least once every:
0 mftth)s)
7ther.
EN:A
MAINTENANCE INSTRUCTIONS
!Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: aster
'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
=mbined 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 (ye) or more of the tank volume, the entire contents of
q1e 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,
land any servicing at intervals of 612 months, shall be performed by a certified POWTS Maintainer.
A service report shall be provided to the local regulatory authority ,Mthin 40 days of completion of any service event.
Page — of —,
START UP AND OPERATION ncLS or other chemicals that
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting prod
may impede the treatment process andfor damage the dispersal cell(s). If high concentrations are detected have the contents of thf;
tank(s) removed by a septage servicing operator prior to use.
System start up shall not occur when sal 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 calls) in one large dose, Overloading the call(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 Pacer to thde
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 POVJT$:
antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat foundation dralin
(sump pump) water, fruit and vegetable peelings; gesolime; 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 servioe the following steps shall be taken to insure that the system is propejlY
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 property disposed of by a Septage Servicnng 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 ComPTient
replacement system:
❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soJ absorption systekn.
The replisoernent area should be protected from disturbance and compaction and should not be infringed upon by requhled
setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the neled
for a new soli and site evaluation to establish a suitable replacement area. Replacement systems must amply with the rules in
effect at that time.
❑ A suitable replacement area is not available due to setback and/or sal 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 sail 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 sal absorption systems may be reconstructed in piece following removal of the biomat at the infiltraiive
rface. 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 O� A
PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE.
ADDITIONAL COMMENTS _
POWTS INSTALLER
n
Name
s c� 7
-';>;
Phone
—d
SEPTAGE SERVICING OPERATOR (PUMPER)
Name
Phone
r
POWTS MAINTAINER
Name C4-�
Phone
LOCAL REGULATORY AUTHORITY Y
Name
Phone
�1I=3k�6— h
This doaanerit was dratted in compliance with chapter SPS 383.22(2)(b)(1)(dWf) and 383.54(1), (2) & (3), Wisconsni Administrative Code.
ST. CROIX COUNTY
SEPTIC TANK MAM 13NANCE jtGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer Gr��j ff YIMI, G cuy'r~.cok-0 - - --- -
Muling Address 13 9 V R-A :T P-WAIL.. FAJIS, LA.) - 6140_ 1 --
Property Address _) 3_ t� Ic t 0 tA f lL-Use l/ I i tom' LID
2 ?
(Verification required from Planning & Zoning Department for new construction.)
City/State �111�1 � �ttft4 tl ( t Parcel Identification Number t) a�-A - (0 3 -- 0.10
LEGAL DESCRIPTION
Property 1,ocatio t Z'✓,✓/. , Sec. f 28 N R (S W, Town of IC I w t, Nri i L
SubdivWon 0 1 ik -- (o 15b 0 (0 Lot #
Certified Starvey Map # Volume _ .1 � Page #
Warranty Deed # �3 (p0 6b�r Volume _� Page #
Spec horse yes (M ) put li, identifiable no
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
lmpmper use and manizz ante of your septic system could resun in its prcmahae failure to handle wastes. Proper
wambensium consists of Pumpmg out the septic tank every tbree years or strtmer, it needed, by a licensed pamper. What you put into
rho System can affect @tie ftmction of the septic tank as a treatment stage in the waste disposal system Owner mainsemnce
tetptmstbilities tie specified in ¢Conn. 93.52(1) and in Chapter 12 - St Croix County Sanitary Ordimrce.
Tye property owner agrees to submit to St. Croix County Pluming & Zonng Department a certification fora, signed by the
owner and by a master phumber, jottrmyman plumber, restricted plumber or a licensed punper 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
lees tban in hill of sludge.
I/we, the nmdssigned have road the above requirements and agree to maintain the private sewage disposal system with the
standards am forth, heroin, as act by the Department ofCommucc and the Department of Natural Resources, State of Wisconsin.
Certification stating that your septic system has been maintained must be compleWl and returned to the St. Croix County Planning &
zoning Department withm 30 days of the three year expiration date.
llwe certify that an statements on this form are true to the beat of my/our k wwlodgo. l/we s'7v'= the omwr(s) of rite
property desc ibad above, by vktue of a warranty toed recorded in Register of Deals Office.
Number of bedroo� 3
� v
S O� APPLIC
ANT(S) DATP
Lion t' 'srepresemed result in the sanitary permit being rrrvoked by the I'La-Mg & Zoning Deparrmeat aaa
,**Any' cites
with rids application a recorded warranty deed from the Register of Deeds CGfficc mad a copy of the cerblied survey map if
�» is nm& m the warranty deed.
forrince
("V, 08/05)
yYr/ �y AS BUILT SANITARY SYSTEM REPORT
>
t/q
�-� '1'OWNStIIP � • t I SECJ� T*'OH-R_lf W
IIRESS ,' � - ST. CROIB COUNTY, WISCONSIN.
,,
SO BD IV 15ION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H63
SNOW EVERYTHING WITHIN IOU FEET OF SYSTEM
1
Q
0
I f a[ t r ih krr
w
BENCHMARK: (Permanent reference Point) Describe:
Elevation of vertical reference point: Slope at site:
SEPTIC TANK: Ma nuf a cure r-.iqu id Capacity: IDOD
Number of rings on cover ' 'rank manhole cover elevation:
_
Tank Inlet F.IevaLf,",: Tank Outlet Elevation:
PUMP CHAMBERManufa• /� _}._.
Number of gallons �rD
(�(�.1
cot
y"1 .
l
Number of gal. pump scr i r d rye te_ _ _gal ions; Total capacity
Number gal
distribution Ines _ gaIIn., s fe of pumpwEd'A head;
gallon per inf nu u: horse out r_ ;brand name of
Of
pump
and model number
'Type of warning device
HOLDING TANK: Manufacturer Number of gallons
Elevation of manhole cover
Type of warning device _ _
SEEPACE PIT SIZE; of pits_ feet diameter
_ _Number
Pcec liquid depth____ seepage Pit inlet pipe -elevation
bottom of seepage pit elevation _ feet.
SEEPAGE BED SIZE: number of lines width Iength C11e
depth
SEENCGI TRENCH: width length —
_
PERCOLATION RATE AREA k6U1RED AREA AS BUILT
PERCOLATION
I
INSPECTOR
DA'I E'D PLI1
UMBER N JOB��
' LICENSE: NUMBER u w
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969 BUREAU OF PLUMBING
MADISON, WI 53707
''CONVENTIONAL ❑ALTERNE MR. Man ID III~
N aw,I.m
❑ Holding Tank ❑ In -Ground Pressure Mound 'Zi -01348
ZN
NAME OF PERMIT HOLDER ADDRESS OF RERMIT MOLDERINSPECTION
DATE'
Thomas (Dugan) Wilson RR# 2. Hwy. J, River Falls, WI
c4okua(, 19 5q
BENCH MARK IPmmanw,l nNnae~11 DESCRIBE IF DIFFERENT FROM PLAN
REF. PT. ELEV.-
TREF PT ELEV
SW NE, Section 14, T28N-R18W, Town of Kinnickinnic
m.1 Plump.,
MNMPRSW N,,
Caumy
Sam Yhrmrt N.~
49437
Thomas A. Wang
3231
3t. Croix
SEPTIC TANKIHOLDING TANK:
MANUFACTURER LIQUID CAPACITY TANK INLET ELEV
'\c�v
TANK OUTLET EL
/ o PROVIDED.
ARMING LA LOCKING LOVER
PROVIDED
WC1Se/V /000 /4.7Q
(_ p
MYES ON ❑VEST END
BEDDING
VENT CIA
VENT MATL HIGH WATER
NUMBER OF
'ROAD
RCIERTY
NE��
ELL
UILOING V NT TOF SX
AIR INLfT
C ALAHM
FEET FROM
11
7�y
���
OYES NO
❑YES ONO
NEAREST
OP
DOSING CHAMBER:
MANUFACTURER BEDDING
LIOUID CAPACI IV
PUNY IF POMP,S&ON MANNUTAA}CTIIRER W"AFINING LABEL LO�CyKING COVER
IDEO PI
MPM to
-0cl59 ❑YES ❑NO
% SO
`M0
V OMX�Y LNYES ONO YES NIOED O
GALLONS PER CYCLE:
PIAB AN coxTR LS OPERATIONAL
NUMBER OF PNngfwrY wfLL mrDIN
LINE
v o
AIR INLET
(DIFFERENCE BETWEEN
FEET FROM
PUMP ON AND OFF) %15.5
04s ONO
NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing
or excavation. (1( soil can he rolled into a were, construction shall cease until
FORCE
LENGH
IAMETEI,
2
MATERIAL AND MARKING
4 O
MAIN
3D
J
r
the Soil is dry enough to continue.)
ONVENTIONAL SYSTEM:
4YIOTX LENGiH NO OF
DISTR PIPE SPACING
COVER
INSIDE I.
iP1TS LIQUID
BED/TRENCH OFOF I
MATERIAL' PIT
DfPTII
ONS DIMENSI�'
4V LD TH FILL DEPTH
UIS R PIP1 UISTq PIPE DI PIPF MATERIAL
NO D181R
N BE DF Y
WELL
BUILDING
V NT FRfSH
tlELM PIPES ROVE COVER
ELFY 19LE1 ELEV END
PIPfS
FEET FpOM LINE
LE
AIR INLET
NEAREST
MOUND SYSTEM:
Mound site plowed perpendicular to slope
Check the texture of the fill material for
PROVIDE A DIAGRAM OF SYSTEM
and furrows thrown upslope:
mound systems to make certain that it
ON REVERSE SIDE. SHOW E LEVA-
the criteria for medium sand.
TIONS MEASURED.
I�JES ❑NO
IL OVER EKTURE PERM4NEN7
M4RKEH5 Otl5ERV4T10N
WELLS
❑NO
'YES ONO
J^�1
ES
UEPEH OVFR Tq NCH BEO
DEPTX OVER 1HENCH BFU
DEPTH Of TOPSOIL
OUEU
fEFDEO
VLCNED
CENTER / —
EDGES
J
5-0
ONO
•
•
DYES NO
YES ❑NO
ecTES
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH
WIDTH
LENGil1
NO. OF
TRENCHES
LATERALSPACING GRAY LOEPTHSELOWPIPF
FILLD PTN4 V q
/
r�
3.2 / i
1 , S
DIMENSIONS
,5 3
lD
.MANIFOLD
MIMP
MANIFOLD
DISTR. PIPE
MANIFOLDM4 ENIALD
NO DISTR
DI iR. I
I mIBUTION PIPE MAT ER1AL a MA q KIN G
ELEVATION AND
ELsY 9
E4V/, Q
DIA
LIE
ELE� ��
? �J ( q
PIPES
0 A
l)
I BUl ION
DISTR
INFORMATION
HOLE 61IE
HOLE SPACING
CNILLfJCORREC ICY COVER MATERIAL
VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
/ `I
3
/J
VE ONO / /
OYES ❑NO
COMMENTS:
PERMANENTMARK S
OBSERVATION WELLS
NUMBER OF
PROPERTY
un
WELL.
BUILDING
T
SJ f
1W
YES ❑NO
YES ❑NO
NEAREST
Sketch System on
Reverse Side.
DILHR SBD 6710 (R. 01182)
Ez:
—APPLICATION FOR SANITARY PERMIT
1�I.HR COUNTY
(PLB 67) UNIFORM SANITARY PERMIT,e . nib« mn e e bne
—Attach complete plans in accord with s. H 63.05, Wis. Arm- Code for the system, on paper not less than 8'%x 11 inches in size.
—See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY OWNER
M t0, an !Jilsah
MAI LI G ADDRESS
�c_'` w le(Vtr Ff%s bi'sr-
PROPERTYLOCATION.
S 1/4 E1/4, S T V,?N, R If (or /J(y/
CITY:
G
LOT NUMBER
BLOCK NUMBER
SUBDIVISION NAME
"NEARESTROAD, LAKE OR LANDMARK
� T
STATE PLAN I.D. NUMBER
TYPE OF BUILDING OR USE SERVED
X 1 or 2 Family Number of Bedrooms: 3
❑ Public (Specify):
THIS PERMIT IS FOR A:
❑ New System ❑ Tank Replacement ❑ Repair
Replacement Soil Absorption System ❑ Revision ❑ Privy
LJ Alternate System ❑ Reconnection ❑ Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
❑ Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank
EJ System-ln-Fill ❑ In -Ground Pressure ❑ Vault Privy ❑ Pit Privy
❑ Existing, For Which A Previous Permit Is On File, Permit # issued
El An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions.
Septic Tank Capacity
Total
Gallons
#of
Tanks
Prefab.
Concrete
Site
Constructed
Steel
Fiberglass
Plastic
Lift Pump Tank/Siphon Chamber
-
Holding Tank capacity
Manufacturer:
IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ® Mound ❑ In -Ground Pressure
Septic Tank Capacity
Total
Gallons
#of
Tanks
Prefab.
Concrete
Site
Constructed
Steel
Fiberglass
Plastic
00
Lift Pump/Siphon Chamber
tt,,
/ io
%
Manufacturer: 'd pSy ATO-Tv—
PERCOLATION RATE I
(Minuuttess per inch):
7 Q
ABSORPTION AREA
REQUIRE[ rl.are Feet):
J J
ABSORPTION AREA
PROPOSED
�(Square Feet):
✓ 6 Y
WATER SUPPLY:
Private ❑Joint ❑Public
I, the undersigned, hereby assume responsibility for installs ion of the private sewage system shown on the attached plans.
Name f Plumber IPnntl: Signet
a
d�
l� Cc J
MP/MPRSW No.:
23
Phone Number:
17/S 1 5 99s8
Plumber's �ssa _ off,
Name
igner:
COUNTY/DEPARTMENT USE ONLY
Signature of Issuing Agent:
y
Fee:
��/
(� /
Date:
��/ _
�+C1 Approved
❑Disapproved
❑Owner Giwn Initial
Adverse Determination
Reason for Disapproval:
Alternate course(s) of Action Available:
DILHR SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber