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HomeMy WebLinkAbout026-1294-28-000 (2)Wisconsin Department of Commerce Safety and Building Division GENERAL INFORMATION Personal information you provide may be used for DAVE DONOVAN By Elev. ANK INFORMATION le— C PRIVATE SEWAGE SYSTEM INSPECTION REPORT (ATTACH TO PERMIT) Law, s.15.04 TOWN OF RICHMOND TYPE MANUFACTURER CAPACITY Septic � � Dosing Aeration Holding TANK SETBACK INFORMATION "®Mm® e., ®IWM__- ®M MAIM �A WA ®K--„_I_ AM,At PUMP/SIPHON INFORMATION Manufacturer Demand GPM Model Nu ber TDH Lift V Fri ion Los Sys!Head TD t Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM ELEVATION DATA STATION BS HI FS ELEV. Benchmark AIL BM O Bldg. Sewer SUHt Inlet SUHt Outlet Dt Inlet Dt Bottom Header/Man. Dist. Pipe Bot. System Final Grade St Cover BED/TRENCH DIMENSIONS Witlm� s Length^ ( �C/ No. Of Trenches_ �9 — PITDIMENSIONS No. Orions Inside'd Depth SETBACK SYSTEM TO P/L I BLDG IWELL LAKE/STREAM LEACHING j Manufacturer:-G INFORMATION Type Of System 1 C .a I MQ. CHAMBER OR UNIT /V+ 7 M r /9'• Model Number: C DISTRIBUTION SYSTEM Header/Mandolds'(, (yr.r ` , , LengttFF �� ea Distribution Leng(h) Length Dia Spacing x Hole Size x Hole Spacing Vent to Air Intake SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Q Bedlfrench Center D�.r iN4 Depth Over xz Depth of xx SeededlSodded xx Mulched Bed/Trench Edges COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: Location: 1155 134TH AVE A 1.) Alt BM Description = 2.) Bldg sewer length - amount of cover Plan revision Required? Ez Ye\ .Nb Use other side for additional information. Inspection #2: £x;sA;r� bvitd`1 suer- s4:11 tr ofcctf- , d�l5,1 i►1c/b,1(A off f 1 uv XCa U� b.1l�+ Lwas� Date Inse ors Se lature Cert. No. SBD-6710 (R.3/97) "VW -2020-I my Sanitary Permit Application San ST. CROIX COUNTY WISCONSIN (� 0 with 12 Sit. Croix County Sanitary Ordinance PLANNING & ZONING DEPARTMENT �r I inlor anon you providalnay be itor s and pur s -- ,, [Privacy Law: S. 15.0n)j , ST. CROIX COUNTY GOVERNMENT CENTER 1101 154016-771chael d0 Hudson, WI Q 2�� 715 386-4680 Fax 715 386-4686 Attach comp to plans for thssystem on paper no x 11 Chas in size. Co�t{>�cSb1i a ❑ Check if revision to previous application St Cc Oe"\o i. licatlon of - lease Print all Information Location: PropeM Owner ame j�^ va 5 G t/a, sec Z I V") ^ 7 N, ff R E o W Property Owners Mailing Address1 Lot Number Block Num r V 1 City, Slate Zip Code Phone Numer Subdivision ame or SM Number �\ 5�)' T of Building: (check one) V A41S miry � ❑Village Qwn of FII or 2 Family Dwelling - No. of Bedrooms: ❑ Public/Commercial (describe use): Nearest Rolad �3 ❑ State-0wned It. Type of Permit: (Check only one box on line A. Check box on line B if applicable) Parcel Tax Number(S) ) A) 1.❑ Repair econnectio OZ,/CC /B)rmitDate "Nmbng❑Rejuvenation Is ued lZ State Sanitary Permit was previously I O O�o IV. Type of POWT System: (Check all that apply) on-pressunzed In -ground ❑ Mound x 24 in. suitable soil ❑ Mound 5 24 in. suitable soil ❑ Mound A+0 ❑ Sand Filter ❑ Constructed Wetland ❑ Peat Filter ❑ Drip Line ❑ Pressurized In -ground ❑ Holding Tank ❑ Single Pass ❑ Other ❑ Al -grade ❑ Aerobic Treatment Unit ❑ Recirculating V. Dispersal/Treatment Area Information: 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5, Percolation Rate 6. System Elevation 7. Final Grade q Required Proposed (Gals./day/sq.tt.) (Min./inch) Elevation ` 1. Tank Information Capaicty in Gallons Tot al # of Manufacturer Prefab Site Con- Steel Fiber- Plastic Gallons Tanks Concrete structed glass New Existing Tanks Tanks C 49, ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ II. Responsibility Statement I, the undersigned, assume responsibility for repair/reconnenclion/rejuvenation/installation of non -plumbing for the POWTS shown on the attached plans. A license is not required fo erralift repair or tA installation of non -plumbing sanitation system. Plu j ers Name (print) Plu is Signature (no stamps): MP/MP S No. Business Phone um Plumbe s Address (Street, Ci y, Slat ip Cod vt �. 'L w Vill. County Use Only Disapproved Sa itary Permit Fee Date Issued ssu' g Agent Signature (No stamps) Approved O Gi n Initial Adverse l— S/ k 1`�11 A Det do Z % ZVZO J �t,�;„`, IX. Conditions of Approval/Reasons for Disapproval: re w 3) , - , S Wa f-' Kae� / 7p r � 0 W� SYSTEM OWNER: '(G�' p� ^"n''C'si'1 1. Septic tank, effluent filter and dispersal cell must be serviced it maintained / 0 management by as per plan provided plumber. i 11GC 2. All setback requirements must be maintained [�1 P S Ma as per applicable code/ordinances. / v to 1aQr Rev: 8105 . CJ A3 y !, '44 VALo"f t . ,elA) i✓s<f I COPY 'sa r /7,4AAej . f(.L FILG�ON UEar40 >2on I' ,,f,4;f/LL i} dl Ise'i. IS I I— 3- C.easJ-�lcrna (.vo sc.LE) IIsA �df/L rAAreti Qi.,uc D� I ai/ LNw.vAEas�rcl.✓cN I //8 LA'A.✓lEa,r — Ys TAL . � N i I A4. � /Joy- Ta/ of %y /�•^ � ,srrrc L<r PAP! e of /2 Y t!o r a8 1 1 �OAius�AY i✓ser 1 COPY <a r 4.4,4m!2 GL -1J7' -- Ys1 9(. t �l r0 Ar (Jfa r !A/ > /i'/At of u u � � ,QAGKf/tt I} 5.62. Cwarl-Slcr�..+ �No s[Fu) LISE �,✓fi[ T.t./Te.c g.�cr y GHAn'Ql..t �,3 r y it /1 0� 1 aij� L.VA.va/.cs�T.LI��' 1 �/8 L u veE� - r• roc �ro f� N I � � 1 0 'fed.- 1.4AZ ft /V 6 t ivrr. 87. Y� S!y`T 40 r t 1 t� srElc Lor o.Pr e ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer I-ticLlL �O Nov' Y--.—'---•------ Mailing Address Property Address, (Verification required (mm Planting & Zoning Department for new construction.) City/State Parcel Identification Nuiaber _ 0 a- 6'' 12�_Oro LEGAL DESCRIPTION s- t 2� - 3ON l� Property Location /. , G /. , ec. R I' _. W, Town of Subdivision Zt_- --- Lot # Z V Certified Survey Map # -----`---,--_. Volume Page # --- Warranty Deed # Volume QQQQ��� Page # —_ Spec house yes pro) Lint Goa idetrtifiable /yes' so SYSTEM MAINTENANCE AND OWNER CERTIFICATION v Improper use and maintenance of your septic system could result in its premature failure to handle waste$. Proper maintenance consists of pumping out the septic tank every three years a sooner, it needed, by a licensed puuyar. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system Owner maintnance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St Croix County Sanitary Ordinance,. The property owner agrees to submit to SL Croix County Planning & Zoning Department a ecctificatim fart, signed by the owner and by a master plumber, jouneytmn plumber, restricted plumber or a licensed pumper verifying that (1) tffi on -site wastewater disposal system is in proper operating eomdition and/or (2) after imape amn and pumping (if necessary), the septic tank is less than 1/3 fan of sludge. Uwe, tiro undersigned lavo read the above reyuttemenls and agree to maintain die private sewage disposal systemwith the standards sat Earth, herein, us set by the Department of Commerce and the Departmom of Natural Rcsouera, Sun of Wisconsin. Certification stating that your septic system has been maintained must be rampietc.l and retired to the St. Croix County Plating & Zoning Department witbin 30 days of the three year expiration data. 1/we certify that an statements on this form are mew rho best of my/= knowledge. I/we an✓aro the owners) of the property described above, by virtue are warranty deed recorded in Register of Deeds Office, Number of bedrooms 3 SIGNATURE OF APPLICANTS) S lam/ 2�w DATE ***Any information that is misrepresented may result in the sanitary permit being r.wked by the Planting & Zoning Department *** Include with this application a retarded warranty deed from the Register of Deeds Ciff)ce and a copy of the citified survey neap if reference is made in the warranty deed. (REV. 0afl15) Septic System and Well Inspection Report I Shaun Bird, certify that on Bird Plumbing Inc 1432 120th St. New Richmond Wi 54017 5/17/20 715-246-4516 sbird@frontiernet.net XXX Inspected the Septic System (POWTS) Inspected the Well Obtained a drinking water sample Property Owner/Buyer Dave Donovan As a result of my inspecton, I certify that: Site Address 1155 134th Ave New Richmond Wi XXX In m opinion, the septics stem was on the date of m inspection, in workingorder and in compliance with the tandards set forth by the Department of Safety and Proesional Services. Any exceptions or needed repairs will be listed below. Last date of pumping scheduled to be pumped 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. House burned down a year ago. System has not been used since then. System is working properly. 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 office. Disclosure: This test is not a guarantee of future performan ut a proffesional opinion. Usage can change from different owners. This is not a warranty of this system. I ' I m all liabilty for any loss caused by reliance on this cerfication. Past problems with this system,( if any) nee lsclnsed by the seller. Shaun Bird MPRS/CSTM #226900 DNR# 7640 Date 5/17/20 R.'II'ORTANT NO'I8 a955 w TII MIIrrE�IImI ga ryR m � M T :®III© L§©L3L-10Lr3 0 a e U FONT ELEVATION ul.Yp A W V ® ® o Lf B $z o°o CLEFT ELEVATION y RK+Ni ELEVATION ueRo,En e& ® ?of r REAR ELEVATION _• •, w•. Ya Al Q.IPORTANT NOTG: I. _____ ______ _________________ yqq ----------------- 2 s i --- --- _____ ----------- ----------- -- v i I , ----- v w I ' y IRmIfAVA}m _ 0 - n/ mz ----- -, --- ------- -------------- ;UN TION PLAN FAR wua w . re a2 I j IF I i � Y c0 a t e j 1 Ot4 X j 1 al 3 e6 � F7 Z i I } O ip POW MVK&fMAnM i E a DONOVAN RESIDENCE h �� NAW LEV®.PIAM �omu.. uuaawumv•uoxrmmm�u. I iE mocum�s�w.�o�-exam wvou d Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Buiktinq Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy taw, s.15.04 (1)(m)[. Permit Holdees Name: City Village X Township Smith, Gerald I Richmond, Town of CST BM Elev. Insp. BM Elev: BM Descnptiom /Do 1 13/Yl I GS TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER .w'S r CAPACITY Septic /006 1305111 Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic ! Z7 7 76 Dosing Aeration Holding PUMPISIPHON INFORMATION Manufacturer Demand GPM Model Number TDH Lift Friction Loss System He TDH Ft Forcemain Le Dist. to Well SOIL ABSORPTION SYSTEM STATION BS HI FS ELEV. Benchmark Alt. BM.� F,•I Bldg. Sewer SVHt Inlet SVHt Outlet Dt Inlet Dt Bottom t �� Header/Man. 93. � Dist. Pipe 11 • 1/• 95 9-1 • / 17Z . S Bot. System IT-3 qZ , /5 Final Grade y • 9y gs St Cover • $ q7, b s BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No, Of Pits `— Inside Dia. ` Liquid Depth DIMENSIONS �1 / �O Z l2r•C SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer �,I / •��` INFORMATION CHAMBERDT OR Type Of System: () CanJQ,wi-jo -fir' 1z / 7d / .fig ►) Model Number: h ;� WL DISTRIBUTION SYSTEM /, L.t- Header/Manifold rl Ani Distribution z Hole Size z Hale Spacng Vent to Air�r+ta q 1 -T Pipe(s) \ 2,,,-a1( la�L Length 1 Dia Length Dia Spacing - l rnVFR - o.e«— c—.— n. 1- — u.. -� n. ea:mdc Svctams Onlv Depth Over Betl/rrench Center % GG Depth Over BedrTrench Edges xx Depth of Topsoil\ xx SeededlSadded zz Muldied \ Yes No \ \ Yes No COMMENTS: (Indude code discrepancies, persons present, etc.) Inspection #t / /_ Location: 1155 134th Avenue Unknown NW 114 SE 114 28 T30N R18W) Richmond Acres Lot 28 1.1 Aft BM Description = F, I L.n,�. NW C1, c:N..9 I-0eJ-5 2.) Bldg sewer length = Z"7 / - amount of cover = 1 Plan revision Required? Yes xNo I Z 7 dQ Use other side for additional information. Dace SBD-6710 (R.0/97) Inspection #2:_/_/_ Parcel No: 28.30.18.1510 LLN T347 5 Can, No. Safety d Buildings Division County ` 201 W. Was mgton Ave., P.O. Box 7162 yj1- C err l c/�O/�C,N Madison, WI 53707 - 7162 Sanitary Puma Number (to be filled in by Co.) DB artment of Commerce (608) 266-3151 L�C19 2-6 Z State Plan LD. Nu/mµlou Sanitary Permit Application In accord with Comm 93.21, W is. Adm. Code, information you p ide Project Address (if different than a uiling address) )•// 1155 may be used for secondary purposes Pri LMa C D f [ C L Application Information -Please Print lI tion Property(]n s Name Parcel M Block M E.fA �jy/F ST. CROIX COUNTY_ aS \ Property Owner's Mailing Address Property I.acetian /LD O r/F. 6/ t1L�CV. XEY., sea. �$— \ City, State Zip Code Phone Number L,t urrdecaac) / L. T jd N, R /P io® Q. Type of Building (c eck all that apply) t5k o.a 6rJbrr`.i �1 or 2 Family Dwelling- Number of Bedrooms Subdivision Name CSM Number �odk��s�— ❑ PublirlCommeroid-Describe Use /C/G✓/ys.dd /�CAFS Bm- yP'�}y� o`-*1riP of /l.S�iYSJD t, []State Owned - Describe Use.,?Y1`�Esl-� t.) 22i+2 C : -5. iD. Type of Permit: (Check only one boa on lice A. Complete Buell if applicable) Z % _ - OdC) A. Wj�m- System ❑ Replacement System ❑ Trestment/Holding Tank Replacement Only ❑ Other Modification to Existing System B. Permit Renewal Permit Revision ❑Change of ❑Permit Tmmfer to Now ist Previous Pemtit Number sod Dare Issued Expiration Before Expiration Plumber Owner ' oI f Z I . T of POWTS System: Cheek all that apply) Non -Pressurized In -Ground ❑ Mound > 24 in, of suitable soil ❑ Maud c 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Faber ❑ � Corutnrctod Welland ❑ Presuriad In -Ground ❑ FlWding Tank ❑Peal Filter ❑Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter ❑ Leeching Chamber ❑ Dri Lice ❑ Gravel -less Pi ❑ Okher( lain) :�7A0 1d-fw4re.- V. DispersaVIrreatment Area Information: Lkj . Design Flow (gpd) Design Soil Application Ra Dispersal Arcs Requi. (st) Dispersal Area Proposed (at) System FJevatioo So ✓ e 5 VI. Tank Info Capacity in T I Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass I Turks T s= septic or Mol&.P�e d `- /d60 /gSl2 `o✓G. r� Aerobic Tredmem Uva Dairy Chamber VIL Responsibility Statement- 1, the, assume reapossibility far installation, of the POWTS shown on the attached plans. Plumber's Name (Prim)��l Plumber's urc MP/h9= Number Business Ph" Number ErJ 7/S G7�-SIGG Plumber's Address (Sweet, City. stare, Zip Code L � 98 fir. ,frA/r, as �ueC.�a/O t✓I .Sf�7,d G VID. ern /De rtmeot Use Only fi*peed ❑ SanitaryPerm@ Fun (includes Groundwater Data bsuod Issuing S' s ❑ ia) rvm Reason Surcharge Fee) �} -7! 6D �({ 2 • /� .30 DL Condition of ApprovaUReasons for Disapproval (� SYSTEM OWNER: 3, IOJt�t eflhmnl 1. Septic tank, S ar Wd I I dispersal cell must all be serylon f mahfaYkad as per management plan provided by plumber. 1� 2 N setback recluker eeft must be makilWad as per epplicellb Code Attaehe W*ft Pleas(b the C*coty dy)(w rh rystaa as paper err ku dun SIA 111 lab la doe SBD-6398 (R- 01/03) — - - AL ♦ eF/tJ - P 4 r .78 I I � I /"AoPiseA i I BOA/dE.JAY � ,✓sar 1 ,f VAGof y%u[ pL f� J 1 `wry n rr q� F�F sv �o IRS ' �[ COPY u AL - - A r /IA,CK'2 e,?37 ' Uca r CAA � I I J E'i. yrs Lmo scAL!) !./sE /,dFic rfAre.t. Qc.iue 5� CNA.veEts �3 x!� K12 aL 1 Al I yB C.✓ANDE.c1 — Ye T.IL T N I a ,i'o ya �x;opy � N Alf. '/ate - Ta/ of v [i srr�c Lar P/PF e