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HomeMy WebLinkAbout020-1168-20-000 (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)) INFORMATION TANK SETBACK INFORMATION PUMP/SIPHON INFORMATION Manufactur r N Demand M Model Num r TDH Lifction Loss System Head T Ft Forcemain Length Dia. Dis TOWN OF HUDSON ELEVATION DATA STATION BS HI FS ELEV. Benchmark �•.y� a( T+ �OZ' •� Alt. BM Bldg. Sewer SVHt Inlet SUHt Outlet Dt Inlet Dt Bottom Header/Man. r7 p f• O pu q© �i ( Dist. Pipe u Bot. System 935D - i •ihD•l Final Grade IF s o gT'. . 7b /06 -sv DiJ�V J' �• � p r N H idth�I Len s' No. re ches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth SETBACK INFORMATION SYSTEM TO P/L DG a Ty p Of Sy ^ > 15 / I0t WELL LAKE/STREAM LEACHING CHAMBER OR UNIT r Y � t Mad mn DISTRIBUTION SYSTEM Header/Mandold O on x Hole Size x Hole Spacing Vent to Air Intake iPa(s) '�• B7 l Length Dia Length Dia Spacing SOIL COVER It Pressure Svstems Only " Mound Or At -Grade Svstems Ontv Depth Over Depth Over xz Depth of xx Seeded/Sodded xz Mulched Bed/Trench Center Bed/Trench Edges Topsoil ❑`a Yes L No ® Yes No COMMENTS: (Include code discrependes personspres1e-n_t,.etc.) Inspection#1: Location: 1060 COTTONWOOD DR C�j)-:V'd•M( $ tr. SA(J, 1.) Alt BM Description/ t �y �`GL J C�y�iSQJI/ ?C�O`) O�J•itn� l 2.) Bldg sewer le t f ngth\ ^w \) O� r �r n p �& lYv1�+ w,'o - amounocove T �' 3jr-i,., 13 Plan revision Required? N Yes xNo 0; /)., _4O� Use other side for additional information. /� I• I / ft S8D-6T10 (R � � Date r Insepctors Signat , dA(Z), G o r; V SAN -�Oa a) 05 ''o JUL 13 2020 m St. Croix County Industry Services Division 1400 E Washington Ave P.O. Bbx 7162 Madiso 53707-7162 lrjj jr County Sanitary Permit Number (to be filled in by Co.) om m u n eu o m it Applic ' Mate Trensection Number In accordance with SPS 383 21(2), Wis. Adze. Code, submission of this forth to the pp en unit is required prior to obtaining a sanitary pemtit Note: Application forms for sbteowrmd POWTS i d to the Department of Safety end Professional Services. Personal information you provide may be used seconder; in accordance with the PrivacyLaw, s. 15.04(1 m Stars. Project Address (if differertt than mailing address) � ' I. A licaBon Information-P rintA Information Property Owner's Name \i @, Parcel a Property er's Mai ing Address Property Location Gaya ob le Vt. Lot� e_ VL y4 Section City, State Zip Code Phone Number [y ircle T1_N; R W I . Type of Bail l rg (check all that a 'oy!> 2 Family Dwelling -Number of Bedrosms-> ❑ Public/Commeroial- Describe UseBlock Lot a Subdivision Nax �Q a ❑ City of ❑ State Owned - Describe Use ❑ Village of CSM Number own of III. Type of Permit: (Check only tioon line A. Complete line B if applicable) A' ❑ New System lacement System Treatrnem/Holding Tank Replacement Only Cl Change of Plumber ❑Permit Transfer to New Owner ❑ Other Modification to Existing System (explain) List Previous t N r arrQ Issued {OT 1L'/j( LfJ00 B. ❑ Permit Renewal Before Expiration ❑ Permit Revision ofPOWTSS stem/Conaonent/Device: Check all that apply) Pressurized In -Ground ❑ Pressurized In -Ground ❑ AtGrade ❑ Mound 224 in. of suitable soil ❑ Mound <24 in. of suitable soil CT'RoldingTank ❑Other Dispersal Component explain) ❑ tment De ice( plain) V. Dispergairrmatiment Area Information• Design Flow (gpd) Design Soil Application sf) v Dispersal Area Required (sf) ✓ Di Area ed (sQ 2 111 v •`� 59, ystem evatio a O VI. Tank Info Capacity in Total GallonsUnits a of ManufacturerGallons / ./_ t �. , e 14 {(.;r_ r VNewTanka U iii oi I0 T Ezisdng Tanksri Septic or Holding Taro L�t7 Dosing Chamber VII. Responsibility Statement- t, the undersigned, aptaille responsibility, for installation of the POWTS shown on the attached plans. Plumber's Name (prim) - ! v PI ignature MP/MPRS Number zz6 Business Phone Number 7s Plumbers Address (Street, City, state, Zi Cod Z a 5 N IZi t.✓i V11I. Court /De artment Use balv Approved 11 a ❑ n oDemal IPermit Fee a Dale issued / 2.0 Agent Sgmu IX. Conditions pprova 1 p1 S STEM OWNER: 3/'tit S�f t �S i� te• Septic tank, effluent filter and -to dispersal cell must ba-geni( Qd / maintained tA4 SS Vie- as per management plan provided by plumber. I +5 � � R� t.f. t 2E m roe the syabm an av su rt b the y an not how t �a laja l vchn se nan as per applicable code)ordices. q %.4 6.6 SBD-6398(R.08114) q PROJECT Dennis Biornstad SE 1/4 NE 1/4S 12 System PLOT PLAN ADDRESS 1060 Cottonwood Dr. Hudson Wi 5416 /T 29 N/R 20 W TOWN Hudson COUNTY ST. CROIX SYSTEM ELEVATION 95.0/94.8/94.6/94.4 5' below CONVENTIONAL XXX 7/12/20 BEDROOM 3 DATE _ CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .4 ABSORPTION AREA 1 142 If of chambers 56 ,, BENCHMARK V.R.P. Bottom of siding ❑ BOREHOLE O WELL +H.R,P. same as benchmark Od Property Line O �. '�r1c Failed System " 100, WIN 30' Valve B-3 l . e B-1 98' Well 50' Existing 3 Bedroom House T 0' B.M.' ASSUME ELEVATION 100' Filter Lifetime Filter 1� Cottonwood Drive Scale = 1 /4" = 10' g B^2 4-3' X 58' cells with >3' spacing 7% Slope >6" of Cover 4' Lon¢ 12 Quick4 Standard Leaching Chamber with 20.0 ft2 of Area \5.6ftA2/pair of end caps .LGrade at System Elevation All piping shall be ASTM SDR 30/34, within 10' of tank, piping shall be ASTM F891 ��CppV Property Line Cover Page Shaun Bird Bird Plumbing Inc. 1432 120th St. New Richmond Wi 54017 715-246-4516 Date: 5/22/20 Owner:Dennis Bjornstad Location: SE1/4 NE1/4 S 12 T29 N,R 20W 1060 Cottonwood Dr. Hudson Manuals Used: In -ground absorbtion system (version 2.0) Page# 1. Cover Page 2. Plot Plan 3. Chamber Cross ct n 4-6. Maintance a t' ency Plan 7. Existing Sept' form Signature �/ r#226900 PROJECT Dennis Biornstad SE 1/4 NE 1/4S 12 System PLOT PLAN ADDRESS 1060 Cottonwood Dr. Hudson Wi 5416 /T 29 N/R 20 W TOWN Hudson COUNTY ST. CROIX SYSTEM ELEVATION 95.0/94.8/94.6/94.4 5' below DATE 7/12/20 BEDROOM 3 CONVENTIONAL XXX CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .4 ABSORPTION AREA 1142 # of chambers 56 BENCHMARK V.R.P. Bottom of siding ASSUME ELEVATION 100' Filter Lifetime Filter ❑BOREHOLE O WELL 'H.R.P. same as benchmark �— Property Line Failed System " Well / ,rl 50' ---WO Existing 3 Bedroom House 11'1'��� 1 Valve . -. 1 Cottonwood Drive Scale = 1 /4" = 10' 7j B^2 4-3' X 58' cells with >3' spacing j/� 7%SlopeALong Vent j Quick4 Standard Leaching Chamber 100' with 20.0 ft2 of Area 99, 5.6ft^2/pair of end caps 60' 2" B-1 Grade at System Elevation 98' 34" All piping shall be ASTM SDR 30/34, within 10' of tank, piping shall be ASTM F891 Property Line of Qu►ck 4 Standard Leaching Chamber Cross Section section for 2 of 4 cells Typical cross sec Quick 4 Standar ber with above grade Leaching Cham To be'1 grade elevation a'r. of end plates Finish 99 chamber 5 6ft 2 p Typical Installation Vent Grade Vent 4' 4' 4 30134 Septic Tank 1" 4° Long made at System Elevation 5, 3 4„ 4' Long t Grade at System Elevation 34„ Spacing 5�--� X 5a' Cells Observation on n end not Cells 4 3' To be located oen Same on other end 14 chambers per cell A B C p System elevations: A1g5.01 B_94.8' C1g4.6 p 94.4' POWTS OWNER'S MANUAL & MANAGEMENT PLAN Paga_of_ it ILE INFORMATION OwnerTP U Permit # Lj DESIGN PARAMETERS Number of Bedrooms 3 ❑ NA j Number of Public Facility Units NA Estimated flow (average) -?,r jgal/day Design flow (peak), (Estimated x 1.5) yji� allda Soil Application Rate allda /fly Standard Influent/EfFkwernt Quality Monthly average* Fats, Oil & Grease (FOG) 5W mg/L Biochemical Oxygen Demand (BODs) 5220 mg/L ❑ NA Total Suspended Solids (rSS) <1so mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (BODs) S30 mg/L Total Suspended Solids (TSS) 530 mg/L Fecal Col'rform (geometric mean) 5704 cfumoomi Maximum EfAuerd Particle Size Ili in dia. ❑ NA lOthec A "Values typical for domestic wastewater and septic tank effluent MAINTENANCE SCHEDULE SYSTEM SPECIFICATIONS Septic Tank Capacity l ❑ NA Septic Tank Manufacturer ❑ NA Effluent Fitter Manufacturer _ ❑ NA Effluent Filter Model ❑ NA Pump Tank Capacity al NA Pump Tank Manufacturer NA Pump Manufacturer NA Pump Model NA Pretreatment Unit ❑ Sand/Gravel Filter ❑ Mechanical Aeration ❑ Disinfection ❑ Peat Fitter ❑ Wetland ❑ Other. NA Dispersal Cell(s) Ground (gravity) ❑ At -Grade ❑ Drip -Line ❑ NA ❑ In -Ground (pressurized) ❑ Mound ❑ Other other. ❑ NA Other: ❑ NA Other. ❑ NA Service Event Service Frequency rnspect condition of tank(s) At least once every: j m ()a) (Maximum 3 years) ❑ NA Pump out contents of tank(s) When combined sludge and scum equals one-third (Y,) of tank volume ❑ NA inspect dispersal collie) At least once every: ❑ month(s) (Maximum 3 years) >14 year(s) ❑ NA Olsen effluent filter At least once every. onth(s) a s) ❑ NA nspect pump, pump controls & alarm At least once every: p year(s)s) NA Flush laterals and pressure test At least once every: ❑ month(s) ❑ ear(s) NA I� At least once every: ❑ month(s) ❑ year(s) NA ether: Na. 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, POW7S Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identity 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 oell(s) shall be �Asualty, 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 indicaie a failing condition and requires the immediate notification of the local I-agulatory authority. i,Nhen the combined accumulation of sludge and scum in any tank equals one-third (Ys) or more of the tank volume, the entire contents of !fie tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. [NJ other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at irdervals of 512 months, shall be performed by a certified POWTS Maintainer. ;� service report shall be provided to the local regulatory authality xithin 10 days of completion of any service event Page __ of _, START UP AND OPERATION products a other c hetniceis the For raw construction, prior to use of the POVdTS check treatment tank(s) for the presence of poi ng prod may impede the trash. ant 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 sal conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When pourer is restored the excess wastewater will by discharged to the dispersal ced(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of eftluenit. To avoid this situation have the contents of the pump tank removed by a Sepia" 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 lice Ida of the PO A(T$: antibiotics: baby wipes: cigarette buts: condoms; cotton swabs; degreasers; dental foss; diapers; dWwrledants; fat; foundation drain (sump pump) water, fruit and vegetable peelings; gasoline; grease; herbicides; meat saaps; medicstlons ON; paining produc*; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS falls and/or m permanently taken out of service the following steps shall be taken to insure that the system is propa'ly and safety abandoned in compiler= with chapter Comm 93.33, 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 Servidrg 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 falls 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 requlrled setbacks from exishi g 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. Baring advances in POWfS 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 sutable replacement area. Upon failure of the POWTS a sal and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tarn may be installed as a last resort to replace the failed POWTS. ❑ Mound and at -grade :roil absorption systems may be reconstructed in place following removal of the bkor at at the infiltrative surface. Reconstructions of such systems must comply with the rules in affect 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 TANIf UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE 01` A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE Name Phone POWTS MAINTAINER Name l/,c�, ` 2 Phone "/.?—c;; � SEPTAGE SERVICING OPERATOR(PUMPER) LOCAL REGULATORY AUTHORITY Name Name i L Phone L Phone This document was dratted in eonpliance with chapter sPS 383.22(2)(b)(1)(d)S(t) and 3113.54(1), (2) & (3). Wlscorsam Administrative Code. ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have insJp)�cted the septic tank presently serving the �r j �;prp� �[ residdennce located at: Section /Z T?-� N, R Z-0 W, Town of y'l,cy4 jy- Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced: Did flow back occur om absorption system? Yes No (If no, skip next line) Approximate volume or length of time: Capacity Construction: Prefab Concrete Steel Manufacturer: (If known):4�f� Age of Ta (If known) : / (S ture) (Name) Please rint (Title) 1 - / 2_-z-J gallons minutes Other Date ZZ�,C,4j (License Number) Form to be completed by licensed plumber (s.145.06, Wisconsin Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative Code) Plumber (applying for sanitary permit) Certification: In accepting the above statement reg condition, I certify that the tank to 1 conform to the requirements of ILHR 83 inspecti n opening ver outlet baffl Name �� Signat� ing existing septic tank best of my knowledge will is. Adm. Code (except for MP/MPRS �Z�j ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address / 0 6 U Property Address Sl U (Verifi City/State _ LEGAL DESCRIPTION Property Location SE '/< Subdivision Certified Survey Map # __ required trom Planning & Zoning Department for new construction.) Parcel Identification Nur.iber (Ja D _ /l6 ?' 90— 01'ed '/4 , Sec. t t_ , T ZI N R_2ZL W, Town of llc — Lot Al 3 . _ __, Volume ,Page # _ Warranty Deed # b34S�-j -, volume 1S6 _, Page # 4-ki . Spec house yes no Lot line: identifiable(q no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, it needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the was ie disposal system Owner maintenance responsibilities are specified in §Corr. 83.52(1) and in Chapter 12 - St Croix County Sanitary Ordinance. The property owner agrees to submit to St Croix County Planning & Zonng Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper 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 less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the DeparmMnt of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. I/we certify that all statements on this form are true to the best of my/our knowledge. I/we am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Dmis Office. Number of bedrooms S OF APPLICANTS) % // 24U DATE ***Any information that is misrepresented may result in the sanitary permit being n-voked by the Planning & Zoning Department. *** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08105) RAN CH W OOD W751t LOCATED IN THE SEI/4 OF THE NEI/4 OF SECTION 12,T29N,R2OW,AND T THE SEI/4 OF THE NWI/4 OFSECTION 7,T29N, R19W, TOWN OFHUDSON,SI 0 HE CORNER ``) SECTION 12 I EOOEW000 ` \ ESTATCS _m j T29N,R24W Y„Q6 I Jai L \ OUTLOT I _ EAST LINE OF THE HE I/° I y7P�7 Q \ pp\Y\ 533•1536•W I \�'369.1336•W 226.TBu EOOEWOOC NI.13'41••m ESTK !`AT<&R ON% iZ^�•S 3 130.00 15119 see -III sow 16L1i �. Ts 33.0i S6T•46'12 W 2561.16' - 1 OaA"1 a11. Bd,SN AP. �°a � N6 a is„�, OYaa• 1N.m • G. I Not. 4 •°. £ a '•� 1.998 f. O m� .,2" IRON PIPE OL 122.51 182.13• 100.00' 120.00• 100.00 160.00 20 w TLOT I Is R a 14 T 15 21,81A[ n P],M4 SF. .; _21d3e 6A-IIa,NOs.F.+ e 29dip AS . �°•nm m W ry r .. ..146.93'... 7►A3...,. T2.9i_. _..... .... 262.9i Q- LAN i� 5 NBT98'I 'u"G 25942 .106.23' e: :mm j •_ 7 rv_ 55 •ti 6- u a 9 ry 10 -ml .�22,]v�SF. m Cf,N9AF. m 39,2)38.f 328M m 41,13152 Z 4,•8i91f Oi b• :s,a» Property Owner _ Parcel ID # Page —of Boring # ❑ BoringS pit Ground surface elev. Irk.O ft. Depth to limiting factor _4111 in. Soil Application Rate Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPDlff 'Eff#1 'Eff#2 0-5- 10 f '-� CS I l� 3 d s ,✓AIA Boring# El Boring ❑ pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/ff 'Eff#1 I 'Eff#2 ❑ Boring Pit Boring # Ground surface elev, ft. Depth to limiting factor in. ❑ Soil Application Rate Horizon -1epth in. Dominant Cola Munsell Redox Description- Qu. Sz. Cont. Cola Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPDM 'Eff#1 I 'Eff#2 Effluent #1 = BOD, > 30 < 220 mgrL and TSS >30 < 150 mgA. ' Effluent #2 = BOD, 130 mgrL and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SAD-uro(R,d ) Soil Test Plot Project Name Dennis Bjornstad Address 1060 Cottonwood Dr. H d W' 54016 Bird u son i iCSTM #226900 Lot 3 Subdivision Ranchwood p e 7/12/20 SE 1/4 NE 1/4S 12 T 29 N/R20 W Township Hudson Boring Q Well PL Property Line County ST. CROIX VRP Assume Elevation 100 ft. Bottom of siding System Elevation 95.0/94.8/94.6/94.4 *HRPSame as Benchmark Wisconsin geparmenl of Commerce PRIVATE SEWAGE SYSTEM `aYety andBtiiding Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for sewrWery purposes [Privacy Law, s.15.04 (1 xm)I. Permit Holder's Name: City Village X Tnvmship B'ornstad, Dennis Hudson Township CST BM Elev: Insp. BM Elev: 13Description: 9i0 90 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY Septic I An �1 '\ OV V Dosi Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. vent to Air Intake ROAD Septic Dos' Aeration Hoding PUMP/SIPHON INFORMATION ufacturer Demand G Model Number _ dction Loss System Head TDHgth ;EE Dia. Dist ell SOIL ABSORPTION SYSTEM /A - C - _ _ I. County. St. Croix Sanitary Permit No: 383819 0 State Plan ID No: Parcel Tax No: 020-1168-20-000 STATION BS HI FS ELEV. Benchmark Z. l0/ 90 All. BM Bldg. Sewer S tInlet U lOutlet �9 95,3 Dt Inlet Dt Bottom Header/Man. 9.39 9y 9G Dist. Pipe Bot. System A\L R //,V/,.g 3-sr .r Final Grade 8, 18 Q4. 17 9 . St Cover BEDRRENCH Width Length Length No. Of Trendies PR DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS —� S' 3 SETBACK INFORMATION SYSTEM TO Type Of System: (i— PIL S "�O BLDG `/ 7 Z , 1WELL �Z-S r LAKEISTREAM G C OR IT ManutacWrer S Mo K'7 DISTRIBUTION SYSTEM HeaderAAanifold 113istribution x Hole Sim x Hole Spacing Vent to Air Intake Lf d Length _ Dia Pipets) Length 6Z S' Dia Spacing '/-6 1 r / -� /5 SOIL COVER z Pmssum Suatems Oniv Yr Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth or xx Seeded/Sodded xx Muldwd BedfTrench Center BedrTrench Edges Topsoil ® Yea [:] Nc NJ Yes Q No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: /� I—Lr o/ Inspection Location: 1060 Cottonwood Drivle� Hudson, WI 54016 (SE 1/4 NE 1/4 12 T29N R`20W) Ranchwood Lot 3 Parcel No: 12.29.20.1040 1.) Alt BM Description = 'oY d t We 1' yJ Syns FN"`" G /re / 3 �1 ,4c 5 /-f 1V6d/ 2.) Bldg sewer length =' y O i Z 1 5f; P ?0 - amount t cover = 3 3-��be C bcr .i/ec �Ue4f 7 Plan revision Required? ® Yes Use other side for additional information. UD.t. SBD-6710(R3197) Insepdoes Signature CM No. T i• r E Oj Z.> IOLD Cp Sanitary Permit Application Safety & Buildings Division `�, In accord with Comm 83.21, Wis. Adm. Code 201 W. Washington Ave. `seonsin See reverse side for instructions for completing this application PO Box 7302 Personal information you provide may be used for secondary purposes Madison, WI 53707-7302 Department of Commerce [privacy Law, s. 15.04(I)(m)) (Submit completed form to county if not state owned.) Attach complete plans (to the county copy only) for the s stem on paper not less than 8-1/2 x I I inches in size. County Statc Sanitary Pcrtnit Number i i t)rt vious application State Plan 1. D. Number Geo/x 3g3g V - u L Application Information - Please Print all Informatio .,a Location: Property Owner Name [{' 0J Property Location zqd C. 1/4 C 1/4, S f T ,N, I (or) W FIR ProOwners Mai in Ad (-� ,:_... '— pert' g ,L '.. ,. Lt+ Lot Number Block umber City, State Zip de Ph iCE Subdivision Name or CSM Nmbcr NO —A �� ( man 1 . IL Type of Building: (check one) O City FiL 1 or 2 Family Dwelling -No. of Bedrooms :_ - -- - ❑ Village ❑ Public/Commercial (describe use):_ CkToxn of/ ❑ State -Owned UQ Sq Nearest Road /O 3 K 73. r wow IS Parca az nm' s tIR -j Il ) M. Type of Permit: (Check only one box on line A. Check box on 1' e B if applicable) y . '31. 2n, 1&40 A) 1. New 2. ❑ Replacement 3. ❑ Replacement of 4. 5. 6. 0 Addition to System System Tank Only Existing System B) Permit Number Date Issued ❑ A Sanitary Permit was previously issued IV. Type of POWT System: Check all that apply) Of Non -pressurized In -ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland ssurizcd In -ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line ❑ At -grade ❑ Aerobic Treatment Unit mirculating ❑ Other: nn �/P V. Dispersal/1'reatment Area Information: ✓ — DO 1. Design Flow ( ) 2. Dispersal Area Required 3. Dispersal Area Imposed 4. Soil Application -' 5. Percol Rate ys m cv yYr r e Elevation ^O S Rate (Gals./day/sq. ft) (M' ( ! f'jy ' .� do S = 93. Vb VD. Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks Con- Con- glass New Existing crete structed Tanks Tanks /! em — �Ltw�ai.td ❑ ❑ [1❑ ❑ VIIL Responsibility Statement 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. umbe s Name nn[) Pigo (p Ma. BusrePhone r i , -A - ' Plumbers Address kStrect, City, State, Zip Code) IX. County/Department Use Only Disapproved SanitaryPermit Fee (Includes Gmandwahr Date Issued Issuing Agent Signature (No stamps) )&.Approved ❑ Owner Given Initial Adverse I SeOarge Fee) Determination c;LS7. 3 X. Conditions of Approval �//R�CI$sons fore Daa1gq�ag_p roval: / � SRCYxa[ : `v`S�WaU So S'C'G. (MArtYrR.c _"� C.v.➢+.. bad$ r S W :t'ka,K Rr9"YwN k I -4:;F �p. 11�,.:� «� sr.['!({�,•�-+w .r1 /� .-(} {ter-aau�n/ vw,.:� w.u+wVlel,nt. 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