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HomeMy WebLinkAbout020-1018-40-200 (2)Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County. St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 630343 GENERAL INFORMATION State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village Township Parcel Tax No: Bradley C & Lisa J Larson I TOWN OF HUDSON 020-1018-40-200 CST BM Elev: Insp. BM Elev: BM Descriptio 1 SectionrTown/Range/Map No: eq.of IA �ivt� 13.29.19.87B-10 TANK INFORMATION � ELEVATION DATA TYPE MANUFACTURER CAPACITY Septic r i IDS 1�G/ Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic v 1� 5 Dosing Aeration Holding PUMP/SIPHON INFORMATION Manufacturer Demand GPM Model N Tber TDH Li Fric'on Los Syst Head T H Ft Forcemai Length Dia. Dis . o Well SOIL ABSORPTION SYSTEM STATION BS HI FS ELEV. Benchmark 8 3 7 31 Qg 0 l• L AXAcc O CO 1.11 �'S• Bldg. Sewer l A SUM Inlet �� SUHt Outlet y �� Dt Inlet Dt Bottom Header/Man. C,ZS BI r 4(0 Dist. Pipe rd 0 44ft-f TZ 4,25 1 2- 6T. D (o O (o Bot. System TI 1-1,ZS .06 06 Final Grade St X544M A I� !( �� 7 "7_ Z -!- Z '7- (_ ►nou t. )%..-e 13EDrrRENCH DIMENSIONS Width i 3 Lengthy t /O L No. Of Trenches Z PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth - SETBACK INFORMATION SYSTEM TO Type Of System: P/L I 7106 • BLDG i0U WELL G rJ tS LAKE/STREAM �— LEACHING CHAMBER OR UNIT Manufacturer: 4 Model Number: Qvtt I DISTRIBUTION SYSTEM Header/Manifold Distribution in Vent to Air Intake Pipe(s) GI _ �r, Length Dia Length Dia Spacing rWWt' u SOIL COVER Y Pressure Svstems Only YY Mound Or At -Grade Svstems Only Depth Over Bed/Trench Center 's_ t Depth Over Bed/Trench Edges 1 t� xx Depth of iTopsoiles xx Seeded/Sodded xx Mulched Z ME N o es 0 No COMMENTS: (Include code discrepencies, persons present, etc.)` I Inspection #1: J Location: 867 YELLOWSTONE TRIL I ^ t/ a I � 1 n5+h �t r/ / 1.)Alt BMDescription =Mom^Ito& cols r —$ 5-le Vn,q bNSJL%&/ 2.)Bldg sewer length = �x44t Qp%l Jypt� - amount of cover = t J n l 3` Plan revision Re uired? rvYes (] No Inspection #2: r/ �usf /4c c6�"-c� ! � SO t l �lp� S,1Skw, Use other side for additional informatiL on. wt.V'cte -- ohaa�uf e SBD-6710 (R.3/97) l�AP r(Dve/ SOI'1 r o� F Cert. S 1.) IN f� Sew-aOao -3x� MWED Services Division 1400 E Washington Ave sty , C ko Ix (IxP.O. Box 7162 Sanitary Pandt Number (m be filled in by Co.) 12 2020 Madison. Wl 537'16 63na3 43 St. Croix Cou permit Application 't State Transaction Number v I in Code. sae of this form to the a�p o utrit is required prior to obtaining a snhary permit Note: Application farm for PO fitted to die Department of Safety and Professional Services Personal iofamalma, you 'do may be used f Project Addnm (if diffaeot tbao mailing address) PurPOsm in aixtadame with the Privacy IeW, s. 15_ 1 m Sus 7 V I. Apphcafim IefWambon - Please Prim AS la&nmlt o Property Owner's Name Parcel # ` geny L40 es%N i LtsQ La-f 01& Property Owaa's Mailing Address Property location �Wl Gov<IN C {/� � l� J •V %S 5 G iS SBCSectionn City, state Zip Code Pbone Number �� z� -• ,u T N; RQeleaoe) EtrW H. Type of Building (check all that apply) Lot # Subdivision Name ❑ I or 2 Family Dwelling -Number of Bedrooms _ 4 ❑ PublwA:oomiercial - Describe Use �- Bfodr # ---�-- ❑ City of ❑ Slate Owned - Describe Use ❑ Village of CSM Number Y.14fP• 2ci l 19 Town of PW>Sw- a'. (23&S'4-T m. Type of Permit: (Check aely tree box an Use A. Complete Bee B if appticabk) A ❑ New systvn eplacnMa,stlml❑ Treativendfi olding Tact Rgricrnieot Only ❑Other Moikficetim to Existing System (explain) B. ❑ Permit Renewal ❑ P®it Revision ❑ Change of Plumber ❑ Permit Transfer to New P list Previom Permit Number and Date Issaod Before Expiration Owner ," J c �y 15 9/z T himo IV.Type of POWn S ' e: Cheek an that % Cnound ❑ Pressmiad In4koimd ❑ At -Grade ❑ Mound> 24 no. of swW& mil ❑ Wood <24 is of s ieble and ❑ Tam ❑Other Dispersal Component tom) ❑ Prefreotmeat Device (expiate) V. 111hperuilffrestmetit Area Iufermatioe: Dqp ; �Flow (MA) Design Soil*Applieation R f) DispasaZ Retlaired (st) Dupas;i �� tsf) /V1 8 �� _ Systm�.kwtion `ll �QJ VL Taak lefo Capacity in Total # of Mannf whucr Gidlons Cullom Units $ 3 � New Tanks Eusstog Tanks Zal�( f Da n u in m i; o a Septic or Holding Tads tr 4 f naming CMiii6a VIL Re spoimill0ty Stateoneat- 1, the mWenigsd, au r�N iti►y for bread d the POVM shwa m the attacked places. Pt ' Name ) 's Si MP/MPRS Numbs Business Phme Number � ►� LA. -en , 9 v � 71313 w9ob Plumber's Addre�11ss (S City, State Ap}r\Code) _ V i Wt `` /mj � M t pVULC W Approved ❑ Ihsapprovod PetmR Fee Date Issued Slgeat $ 5�-- /`/z%/z� e Given forDmial ix. Conditions Approv 3) Str M S SYSTEM OWNS < pp 1. Septic tank, effluent filter and t 1�a i OrSt7b I dispersal cell must be serviced I maintained as per management plan provided by plumber.- 2. All setback requirements must be maintained ab,rCt cdpi.(:u01v •.ts®m"a�yePapgq. rtamu�tiraesss ( ✓�l •'l�t� ��_�. II - nI t SBD 6398 (R 08/14)� rt L 4-,QQI hv q Jvj t4%�doo Ool Project Name: Owners line: OwnWs Addizss: Legal Des-Tiptign: Township: (-;guniy: SubdivLmn Narne- Lot Number varml ID l L►es.�r Date: geed wssm-.T. m C-Cli�l--WIONAL tOOMPOWENT DESfGN Residen4al Aupro itm U90 X AM T±i LE PAGE %1 q 5 Nuos5N �. C,ec.►k ibis- yb-cap, Page 2 t-'lat ?lEm Page 3 Sreton S-e,.,.g-a C-a Page a HIter Spars —_-- Pap 5 ROIsrRIaA=a M&WI �,'1 -- l Page 6 Mam-mgm-tisl ran Rage i SL CrL* G' r S-=p5c Tank ViambmapOa FmM Page 9 VNanantp Deed Page 9 CS&I or PWt ScE Absm tan Cnmpm-ien: R4a.jua! ;o: poWTS ih_rinn 20 SBD i67�P ,7a.O11D1)- - Fact ; -z d +LQQ S 94ol_ if ) /T "A ur�l �"',s i i aMo --Z� --> 400 AOLV al -AN S-10241,/ v 21wr S ��� Lealft Charm r &" Sy'1adWe AD ;t a ff �. $Y•2� it )Q- der wit- . And Made EiSfi Ra+?g r ?, 3e; . i,�; �ii. ApprWai�� ©tad tea, t 90 Desgr# SOD &Dpriicaticn R Iza Ei15i3 vfaws Or " of Page of POWTS OWNER'S MANUAL AND MANAGEMENT PLAN FELE INFORMATION Owner ltb Permit # DESIGN PARAMF.TF.RS Number of Bedrooms (100 m) Number of Commercial Units Estimated flow (average) Ggal/day Design flow (DWF) = estimated x 1.5 0 l/da Soil Application Rate da /W Influent/Effluent Quality (O NA) Monthly Average Fats. Oil & Grease (FOG) 5 30 mg/L Biochemical Oxygen Demand (BOD5) < 220 mg/L Totat Suspended Solids (TSS) < 150 mg/L Pretreated Effluent Quality (O NA) Monthly Average Biochemical Oxygen Demand (SODS) <_ 30 mg/L Total Suspended Solids (TSS) <_ 30 mg/L Fecal Coliform (geometric mean) < 10 cfu/100mL Maximum Effluent Particle Size 1/8 inch diameter SYSTEM SPECIFICATIONS Septic Tank Capacity J A C a] O N Septic Tank Manufacturer O N Effluent Filter Manttfacturzr {'e) 4t O N Effluent Filter Model 5 O N Pump Tank Capacity gal 11 N Pump Tank Manufacturer N Pump Manufacturer N Pump Model O N Pretreatment Unit (O NA) O Sand/Gravel Filter O PcetFilter b Mechanical Aeration O Wetland O Disinfection O Other. Manufacturer: Model: Soil Absorption Component (O NA) (3 In -ground (gravity) O In-ground(pressurized) ❑ At -grade O Mound Cl Drip -line O Other - Vertical Distance TankBottom to Service Pad: It Horizontal Distance T s) to Service Pad: It Dispersal Usk MfgJModel Number: O NA Calculations: Soil Dispersal End Cap (Dispersal Unit EISA) DWF on = Area Reutred - EISA — or (Trench Width) _ # Units or Total Length of Trench(s) vc _ _ aS , _ _ 3 = y x 55 O "Design of Pressure Distribution Networks for Septic Tank -Sod Absorption Sysbems" Publication 9.6 (SSWMP Manual) O "ICC Flowtech Mound Component Manual" Version 1.2 O "EZ Flow Mound Component Manual" Version 8/202007 O SBD- 10854-P (R.1112) "At -Grade Component Manual Using Press= Distribution" Version 2.0 'A SBD-10705-P(N.01/01)"In Gad Soil Absorption Component Manual" Version2.0 ❑ SBD- 10691-P (N.01/01) "Mound Component Manual" Version 2.0 O SBD - 10657 P (IL6/99) "Drip -line Effluent Disposal Component Manual- 0 SBD - 10706-P (N.01/01) -Pressure Distribution Component Manual" Version 2.0 MAINTENANCE M010TARING qrH niTr.R - MAINTENANCE. ANn MANAI-MR41 APIr Service Event Service Freq Pumprmspect dispersal ces clean filter At least once . O 13 months ❑ 3 years Cl Other. hispect pump 8 pimp controls, alarm retreatment unit At least once every, Cl months O 3 years Cl NA Flush and press= test laterals At least once every: O months O 3 years O NA START UP AND OPERATION: For new construction, prior to using 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 tanks) removed by a septage servicing operator prior to use. System start upshall uotnecur when soil conditions are frozen at the infiltrative surface. The property owner is responsible for the operation and maintenance of the POWTS and submission of required reports. The quantity and quality of the wastewater stream will affect the performance and longevity of your POWTS. The installation of water -saving appliances and fixtures along with prompt repair of leaks reduces the wastewater volume. Also the brine or waste from water softeners, iron removal units, other clear water treatment devices and foundation drains should be discharged to the ground surface whenever possible. Note: this does not include laundry waste, showers, dishwater, etc. This system is designed to handle domestic strength wastewater, however, the disposal of food based greases, oils, vegetable/fruit peels, seeds, bones, and food solids, such as those produced by a garbage disposal should be minimized. Toilet tissue is the only paper that should be discharged into the system. Other non -biodegradable items, such as baby wipes, tampons, sanitary napkins condoms, cigarette butts, dental floss, and cotton swabs, should not enter the system_ Chemicals, such as petroleum products, paint, disinfectants, pesticides, antibiotics, solvents, etc., should not be flushed into the system be aze they can seriously damage your POWTS and contaminate your Page of drinking water supply. Maintain a regular steady flow by spreading laundry washing throughout the week. Avoid vehicle traffic over all system components. Compaction of snow overthe dispersal unit may cause it to freeze up. INSPECTIONS & MAINTENANCE: Inspection shall be made by an individual carrying one of the following licenses or certifications: Master Plumber, Master Plumber Restricted Sewer, POWTS Maintainer, or Septage Servicing Operator (per the attached Maintenance Schedule). Tank inspections must include a visual inspection of the tank to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and check for any backup or ponding of effluent to the ground surface and test all electrical equipment such as pumps and alarms. Any defects shall be promptly corrected. Exposed openings greater than 8 inches in diameter shall be secured with effective locking devices to prevent accidental or unauthorized entry the tanks. When the combination of sludge and scum in any tank exceeds one-third (1 /3) 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 Admin. Code. Specific servicing mechanics must be provided if vertical is > 15 feet or if horizontal is > 150 feet and instructions to be provided below. The outlet filter(s) shall be inspected and cleaned to remove any accumulated solids according to manufacturer's specifications. Solids washed from the filter shall be retained in the tank. Filter cleaning may be necessary at more frequent intervals than stated in the maintenance schedule to keepthe system operating. Alarms should be tested on a regular basis by the home owner. If an alarm sounds, contact an individual licensed to service POWTS, There is normally a 1 day reserve under regular operating conditions, however water should be conserved until any problems with the system are corrected to prevent back-up of sewage into the dwelling or surfacing. ABANDONMENT: Wben the POWTS fails and/or is permanently taken out of service the following steps shall be taken to ensure that the system is properly and safely abandoned in compliance with Ch. SPS 383.33. Wisconsin Admin. 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 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 other 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 soi 1 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 limes and wells. Failure to protect the replacement area renders it unusable. Replacement systems must comply with the rules in effect at the time of replacement O 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. O 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. 17 Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions ofsuch systems must comply with the rules in effect at that time. WARNiNGrm SEPTIC, PUMP, AND OTHER TREATMENT TANKS MAY CONTIAN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP, OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OFATANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS: POWTS INSTALLER Name: h yr, G 4 n Phone: POWTS MAINTAINER Name: Phone: SEPTAGE SERVICING OPERATOR (Pamper) LOCAL REGULATORY AUTHORITY Name: Name: ST.jQb )C ally;N Phone: Phone: % 1 I m ST. CROIX COUNTY SEPTIC TANK MARTITNANCE, AGREEMERIT AND OWNERSHIP CERTIFICATION FORM "ter (Lot oc th Mailing Address Property Address (Verification required from Planing & Zoning Department for new eonstructim) City/StateParcel Identification Number G C' ' d QU ��tbSOi.`. �v � LEGAL DESCRIFTTON P-operty I ocabon5 '/ S 1/< , Sej. 1Q T N R f 9 W, Town of �► D 5 (J ni Subdivision Plat M45-4�N ,Lot Certified Survey Map # (p 3 O 5-2 7- , Volume I "f Page # 'Warranty Deed # (33 More 2007)V-ohme Page # Spec bwse ❑ yes ijno Lot lines identifiable des Ono SYb t M A�iAINTgi11ANCE AI�-D O�ZIt CERTMICATION improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance cs,ncterc of pumping out the septic tank every throe years or sooner, if ne ded, by a licensed pumper. What you put j= the system can affect the function of the septic tank Ps a treatment stage in the waste disposal system_ Owner maintenance respom-bilides are specified in §Comm. 83.52(1) and in Chapter 12 - St Croix County Sanitary Ordinance, The property owner agrees to submit to St Gbin County Planning & Zoi i,-ig Deparoneut a certification form, sighed by the owner and by a master phnber, 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 Uwc, the undeagaed have read the above reTweme nts and agree to alai itao the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natival RRsonices, State of Wisconsin_ C.at&cabm stating that your septic system has been maintaned must be completed and returned to the. `e" Croix Comity Plarming & Zoning Department within 30 days of the three year expiration date l/we certify that all statements our this farm are true to the best of my/our knowledge. Uwe am/we the owner(s) of the property described above, by vamx of a warranty deed recorded in Register of Deeds Office. bedr _ 10 Ie71 �O;OD SIGMA OF APPLICANT(S) DATE :"Any in,5btmation theta is misrepresented they result in the sanitary permit being revoked by the Planning A Zoning Department *s 3 Include vAtb 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 dead_ (REV. 09107) ST_ CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING -SEPTIC TANK This is to certify that I•have inspected the septic tank presently se ing the C3w-An b.Rf residence located at: �, $ , Sec. 13 , T A9 -N, R_W, Town of huystN St. oix County, Wisconsin. Upon inspection, I certify that I have found the tan and baffles to be in good cond'ti n, and it appears to be functioning prope ly. Last time serviced Did flow back occur from absorption system? Yes_ No� (if no,' skip line. Approximate volume or length of time: gallons minutes Capacity: Construction: Prefab Concrete, �� Steel -Other Manufacturer (if known) : —f Age offTank ( * f known) : a 9-5 l rn 1 J o u W1,�p- SR (Name), Please Print -a-,i AbV (License Number) Form to be completed by lice -used plumber (s. 145.06, Wisconsin Statutes) licensed disposer (NR 113 Wisconsin Administrative Code) Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank conditic certify that the tank, to the -beat of my knowledge, will conform to requirements of ILHR 83, Wis.' Adm. Code (except inspection opening outlet baffle). Name J , BOG m��S�}Z Signature MP.IMPRS 71 1- 90y or I LOCATED IN PART OF THE NW1/4 OF THE NE1/4 OF SECTION 24 AND IN PART OF THE SW1/4 OF THE SE1/4 OF SECTION 13 ALL IN T29N, RIM TOWN OF HUDSON, ST. CROIX COUNTY. WISCONSIN. 4 OWNER \\ BRAD AARSON \ 611 NYE STREET \ HUDSON• WI 54015 \ W 0 Lu f� O mI i nz z LOT 7 C.S.M. IN VOL. 9, PG. 2. 2513 Si/4 CORNER SECTION 13 Nso°NVE416M - N1%4 CORNER e-� 5 • 1 1 6 A B..1 B•2 LOT 8 26.55 ACRES 1,112,920 SQ. Fr. �.o " NOTE' IN �gb PART OF LOT 8 M WITHTHE 0 SPECIAL WELL CONSTRUCTION AREA, PLEASE CONTACT THE DNR FOR MORE INFORMATION. SOUTH LINE OF THE SW114 OF THE SE,/4, SE( NbRTH LINE OF THE NW1/4 OF THE NEi/4, SE NW'04 S 1328.03' CURVE DATA NUMBER CENTRAL ANGLE RADIUS CHORD DIRECTION CHORD LENGTH ARC LENGTH TANGENT IN TANGENT OUT _. N8M%rE 2M05 1 2 72'01'15' 162.O1'15' 55.97' 80.00' S85.02'03.5'E N49'57'56.5'E 65,81' 158.03' 70,35' 226.22' N58.57'19'E S496O1'26'E S49.01'26'E N31.02'41'W ......... I. ............. �............... 'SLOW....�....... HA S�TO U.S. R33 .... AREA ............. uNEPERT1S210 .. How- py 12• .......... DIFTTAlL \ A,, , (not toaly \ uj ♦� NE o� to �— NSB'0 5PE 1328.07 W LI 0 w AU b F 9 cc O ,•I LLI m O t i 0 RC _.......... w: O ( ) PF 1. .. B-1 Sc $ Jig; •• ..... r_r`__-_'.`_� L- - _ V g': Nj1aHWp`Y �12' — �pgH1AY R A _ $ — — vi SCALE IN FEET 1" = 2W ua coFwER �- �� SECTION 24 200 0 200 400 Parcel #: 020-1018-40-200 Valid as of 10/28/2020 02:04 PM Alt. Parcel #: 13.29.19.87B- TOWN OF HUDSON 10 ST. CROIX COUNTY, WISCONSIN Owner and Mailing Address: BRADLEY C & LISA J LARSON 867 YELLOWSTONE TRL HUDSON WI 54016 Districts: Co-Owner(s): Physical Property Address(es): * 867 YELLOWSTONE TRL Dist# Description Parcel History: 2611 SCH DIST OF HUDSON Date Doc # Vol/Page Type 1700 WITC 11106/2000 633109 1557/16 1 WD Abbreviated Description: Acres: 25.550 03/30/1998 576051 1310/151 LC 07/23/1997 803/391 SEC 13 T29N R19W PT SW SE & PT NW NE SEC 24 NKA CSM 14/3955 LOT 8 25.550AC Plat Tract (S-T-R 401A 1G0% GL) Block)Condo Bldg * 3955-CSM 14-3955 020-2000 13-29N-19W SW SE LOT 8 2020 Valuations: Values Last Changed on 09/25/2018 Class and Description Acres Land Improvement Total Gl-RESIDENTIAL 2.000 105,000.00 403,700.00 508,700.00 G4-AGRICULTURAL 12.000 1,600.00 0.00 1,600.00 G5-UNDEVELOPED 2.550 1,900.00 0.00 1,900.00 G5M-AGRICULTURAL FOREST 9.000 33,800.00 0.00 33,800.00 Totals for 2020 General Property 25.5501 142,300.00 403,700.00 546,000.00 Woodland 1 0.0001 0.001 0.001 0.00 Totals for 2019 General 6 r1 2020 Taxes Taxes have not yet been calculated. Key Primary Wisconsin Department of Commerce Safety and Buildings Division .GENERAL INFORMATION PRIVATE SEWAGE SYSTEM INSPECTION REPORT (ATTACH TO PERMIT) Personal Information you provice may ne used for secondary purposes IPnvacy Law, s.15.04 (1)(m)l Permit Holder's Name: ❑ City ❑ Vi g ❑ T-- nof, Larson, Brad uedson �wnship CST BM Elev_: Insp. BM Elev.: BM Description: tom. O' -D ` = C�1;Kk I TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic L I Dosing Aeration Holding TANK SETBACK INFORMAL- TOfq— TANKTO P/L WELL BLDG. vent to Air Intake ROAD Septic NA Dosing NA Aeration NA Holding PUMP / SIPHON INFORMATION Manufacturer D Model Number GPM TDH I Lift � on stem TDH Ft Fo am Length Dia. Dist elt 7 County St. Croix Sanitary,P�r{git, 0: State Plan ID No.: Parcel T No a0-1018-40-200 STATION BS HI FS ELEV. Benchmark O.`{/ Alt. 8 qs •9a' Bldg. Sewer iµ St/Ht Inlet r(•�o 3Jr St / Ht Outlet p) ' Dt Inlet r — Dt Bottom Header/Man. 13'¢D W.p(r Dist. Pipe ( .Coa 8S 8r' Bot. System S,D S. 4 �, Final Grade 17 -70 •s( St cover SOIL ABSORPTION SYSTEM6 c-\ _ 6 _ I _, 6 I - - 0 0@04jAENCN--Width I Leng h No. f enches� PIT ~ No Of Pits Inside Dia Liquid Depth DIMENSIONS 3 ' 2 N I N SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Man ure : t ' SETBACK INFORMATION CHAMBER Type ! d o el Number, System: C.", > foci,'- 1rA OR UNIT DISTRIBUTION SYSTEM v Header!;�o, old Lt Distribution Pipes) x Hole Size x HoleS acing Vent TO Air Intake Length Dia- Spacing ( 7 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 Hed/Trench Center BedITrenchEdges Topsoil ❑ Yes ❑ No ❑ Yes [I No r COMMENTS: (Include code discrepancies, persons present, etc) Inspection #1: 16120/4b Inspection #2: / / Location: 867 Yellowstone Trail, Hudson, WI 540 r6 (SW 1/4 SE 1/4 13 T29N R19W) - 13291987BIO -Lot 8 1.) Alt BM Description ��) 2.) Bldg sewer length = -amount of cover = > f2 y) p i O., 3 c I w Plan revision required? ❑ Yes No 12. 13 000 6 �1 Use the side for additional information �.,,,� .x 5-) 50 �"�^^'=^ �+^ V"�l`T�`�" te,, °-`QS � S offmpector's signature Cert. No SBD- 710 (R.3/97) 0 � ye llouk_4 ,fie . Sanitary Permit Application Safety & Buildings Division In accord with Comm 83.21, Wis. Adm. Code 201 W. Washington Ave. PO Box 7302 Viseonsin See reverse side for instructions for completing this application Madison, WI of •7/ oeparrmanroF Commerce Personal information you provide may be used for secondary Purposes (Privacy Caw, s. 15.04(1)(m)] countyif (Submit completed form to county if not state owned. Attach complete lane to the co a system, on paper not less than 8-1/2 x 11 inches in size. County r (z O State Sanitary P it revision to lication 'L State Plan 1. D. Number I. Application Information - Please Prin form Location: Pro rty Owner Name w pCC Property Location Tt t •� 1`f Q� ��(�1/4 ` Cl/4.S /. ,1 N.AE or Property Ownces Mailing Address 1 r. , ` Lot Number Block Number �,� 90* .- /l S% ss City, state I zip Code \ jl\ SubdivisionNm CSM umbe t�GO o�• -,3 euN I1. Type of Building: (check one) (; J ) y ❑city ❑ Village CH I or 2 Family Dwelling -No. of Bedrooms: --+ --� .Town of ❑ Public/Commercial (describe use):_ ❑ State -Owned N Road Parcel Tax Numbers) _ r III. T e of Permit: Check only one box on line A. Check box on line B if applicable) /Li•11. 8?13 -po A) 1. NJ New 2. ❑ Replacement 3. ❑ Replacement of 4. 5. 6 rl Addition to System System Tank OnlyExistingSystem B) Permit Number Date Issued ❑ A SanitaryPermit was previously -issued IV. Type of POWT System: (Check all that apply) CONon-pressurized In -ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland ❑ Pressurized In -ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line ❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other: V. Dis ersa"Treatment Area Information: �facf3E 1. Design Flow (gpd) 2. Dispersal 3. [hspersal Area 4. Soil Application' 5. Percolation Rate 6. Systcm El 'on Propo�sed--7S �� Rate (Galslday/sq. R) (Minlin 7. Final Grade Elevation Capacity in Total # of Manufacturer fob Site Steel Fiber- VD. Tank Plastic Information Gallons Gallons Tanks Con- Con- glass New Existing Crete strutted Tanks Tanks ❑ ❑ ❑ ❑ ❑ VIII. Responsibility Statement 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached tans. Plumber's Name (pant) Plumber's Signature (no stamps): MP/MPRS No. Business Phone Number Plumbers Address (Street, City, State, Zip CDddy l (ao 6LW'5('�A) IX. County/Dep rtment Use Only ❑ Disapproved Sanitary Permit Fee (Includes Gro dwater Date issued mg tS' (No stamps) Approved ❑ Owner Given Initial Adverse Surcharge Fee)rf6 Determination /� X. Conditions of Approval /Reasons for Disapproval: i NudsCA0ZotnLq r 0,101. :wiorle L Ac'e'dPj'%jA — w Y�esepfrZY. �e�t'l"Cw�T4�er e►�ktR 0�/Ner yit.c��l.-u�,�t� SdrL, iir;lJ� ((f11�. Setif w�—�{bcd�ov�+s Iyo > &CIO �OQ�'{Zl�7d`{�kz�GGµid�bct� 21.11 C601nd_VP . 3 D �� r✓hatwlprti'� r,�. c�,��l /i rnl 961 ovmAmoa- rr of WOOOP Posh' 09)WO tk fl a anbAX Tip of WoorrN TIkjLQ P.Jt Foff oNt 'Up" 191 BOK') f O WO6rXN I tNC P rl P�sfi Well') S�i�c, 1 Sy fit)* �U�pQ,o4I" 4 WPA o11UbJ' O � 1-3 A l J ^r to Q � � • as 0 I I T x (� 8s.y� m m f;l.nl GRoae 8`9.sb ro m� °BCD c0 E Or X C U .fl ,.9 N ti mE U C Xy m N V T> a O.O a C _5: o �I M enfofldings SOIL AND SITE EVALUATION -. Pageof,,� .+�4aftMy and, i afTnteg idea in accordance with s. ILHR 83.09, Wis. Adm. Code i ate site plan on paper not less than 8 1/2 x 11 Inches in size. Plan must comfy 1 not limited to: vertical and horizontal reference point (BM), direction and ro 9, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. R JCANT INFORMATION - Please print ar"lloIrmIation. Rpvw"ecl by, Data Pembnal intomrarion you WavkM maybe used for puryoiee *144y# aw;`L 16-04 (1) Property Owner p Property I.ocabo O `1 R t ov!AoO 1/ 1/4,S T ,N,R - E(odV Property Owner's Mailing Address JJ v K Block# Subd. Name or CSMS ri ": ` r' P&Laszw city state Zip Ph .�_ % Y ❑ V01age m Town Nearest Road New Construction Use: ZlPleslden't-14ujje64bAddition to existing building ❑ Replacensent ❑ Public or comma - Describe: Code derived daily flow _ kV gpd Reoamrended design loading rate yZbed. gpd* . 2' trench. gpd P Absorption area required bed, it �, ft2 Ma)dmum design loading rate yZbed, gpd*_,Y—trench, gpd412 RecommeroJed infiltration surface elevations) — 1 ft (as referred to site plan benchmark) Additional design/site considerations STFw4 S e z4gw e /;2r ) /f 7)q— rmogwr h!F AhgE Parent matenal 'w PLA. &i k Flood plain elevation, N applicable ft S = Suitable for system IConvemionle I Mound hi -Ground Pressure I AT -Grade System in Fill Holding TO U Unsuitable for system 0 S ❑ u ❑ s QI U 14 S❑ u ❑ s ;6 u ❑ s ;Mu ❑ s SOIL IPTION REPORT Boring # Ground L Depth iD limilling falIct''o/rr U Remarks: # Z " A4 ?#1 44 Boring # =s Ground elev. gzgft. Depth b imitirg factor -Z 7�QIn. Remarks: r Name (Please Print) Signature Telephone No. � Address IDate CST Number Tu XAJ �fAPVNb e B .E r �n� i r'r --%O - $-1 FArA-ce po,T� �•o. e 4 = i3M+� Te� eF wovp�n� 7,rNcc • � $v1�'✓G O = arorPEA j OA/-i= Pef% L 0� n D,6 52 1 (f 0 V EJz1Ae-AOL,*ff* Y,4? );zrr4-6 DAIM FOGY 1:i; UCKMd T i pArddvr ��y{p23 4q.3656 71s-3 yG-�/ y� 0