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INSPECTIONTO REPORT 1530355
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TANK SETBACK INFORMATION
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CSRTIPICATION STATENEWT
MR UTILIZATION OF AN EXISTING SEPTIC TANK
This t is to Certify
the jTryajt I have inspected the septic tank presently se;
a 11 Geldiw
Sec. _I residents located at: $LJ
T N, R I N, Tovn of 1'
county, Wisconsin. u4b1U1J
upon f��. St. )
baffles to be in good re:'101, on, I certify that I have found the cenl
Legit time serviced trod' io and tr appears to be functioning Dinpe
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Did line floe back occur from absorption system? yes NO2�L (if no skip
ypraximate volum or length of time pacity: gallons __ minutes
conecrvction: pre Concrete
Vanufacturer (iF known): 4Prett 9tee1 Other
� Of Tank [if known):
and
ROM to bdiscompleted by licameed plumber (e. 145. 06, Wisconsin Statutes) o
poser (NR 113 Wisconsin Administrative Code)
Plumber (applying for sanitary permit) certification:
In accepting the above statement g existing septic tank condition I
certify that the tank, to C regardin
requWill irements of ILNR E3, beat of my knowledge, will
vtlet baffle). ' '' Code lexcap for conform to he
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WARINUIR�
1$1 BVNC. PUMP. AXD OI1geR TRRYIK 1'1' TAXIS MAY Ce"ady tad W GA NOR ANDYM WSUgM[IRNT
OXYGEN. DID NOT ENTER A SEPI'IS PUMP. OR MORK TReATMENT TANK UNDER ANY CIRCUMSTANCES DEATR
MAYRESULT.RPBCUEOpA PERSONPROM TRRINCIMIU R OFATANK MAY EED1pEM;11LT M IMPOppld
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ST. CROIX COUNTY ZONING DEPARTMFA4T:�
AS BUILT SANITARY REPORT !y PfCU♦/EO \
k
Ceuta sAM /JI/CtCRP :ter llea�
Proputy Adthma /eu 3 zAVA2GE /ev�z
wa
CI{yl$(mC Hall?JCN WI Syet /f. C0.'xh
xY'W (IrpCE i
Legal Descriptlow
Lotas 9lak — sabdinandcsM AHoMt 5MAD
S� V, .'/., Sm. I I . TAN-R!jM Town of HOPJON PM M NR
/ Slsl'l'Ll:'1'AIVIC' — DOSE CHAMBER — HOLDING TANK INFORMATION:
Tank manufaeturar WE/J62 Sim ST/PC/a / Sefta from: Houm30 Web zo— P/L r! s
Pump manuachum ^— Model
Alarm loeation �
(HOLON'G TANKS ONLY)
Setbacks: Service road Vent to frceb air make Water Line
Meter location
Alarm Ironton
SOIL ABSORPTION SYSTEM:
Type of system: IEA40 'W' Width 61 Length SG ti Number of Tmnches Setback from: Rom 7 T, Well /40 • P/L /ei Vent to treat air imake / J0
ELEVATIONS:
Dccription of benchmarkI t.T ?PeEcp— N/ Qot NE/1_ E / = 0.15 Elevation 0w
DmaiphonofalleremebenchmarkT P Or IW SE FaNOT.TMN 7.47- Elevation z.z
7�.41
Building Sewer 13�zp STAff Wd 14.4 ' 7S ST Oudm /S.2' 7 PC Wet
74.7 3
PC Botom HeWwMamfokl )I°'OZ Top of ST/PC Manhole Cova t Su r " I T-
EApT 41 EiT
Distributionlancs( la,Oli i4.13O IG oLe 74'7J ( )
Bottom of System(
Final trade O li•og _b7Jf�)Id•OD;827SO
Date ofiustellatiod'e/z 1IIP1e(rmitn�u�mber 324L57 Statne�plan number
PlumbePnn nature/"la�UsWX(/ License number/N?R S'01500 Dete/Z 9
Inspector 1
c*•exx wu ram
NOTICE: Please provide the fallowing:
A plan vmw sketch showing everyWng wnlun IW feet of the system
Two honwnlal reference pmn6 to center of septic Wik manhole aver
Show allmute benchmark, if appliahic
Wisconsin nepawom N Dommam, PRIVATE SEWAGE SYSTEM
Gary xa Bdlmnes DinnerINSPECTIONREPORT
GENERAL INFORMATION (ATTACH TO PERMIT)
Pemnwm vmpum�rr YWIWwreemnea 15,04(I)fm1I
P`�% ee`SIITf .ee oaao
p
I� w0D
TANK INFORMATION ELEVATION DATA
avnyST. CROIX
nrS
tin n
A9800546
TYPE
MANUFARURER
CAPACITY
STATION
BT
I HI
I FS
ELEV
Dosing
Adhesion
Bldg Sewn
14D5
Holding
St/Ht Inlet
/S.s
TANK SETBACKINFORMATION
St/H1 Outlet
Ica
TAN PTO
P/L
WELL
SLOG
A e
ROAD
Or Inlet
Sepxe
NA
Or Bottom
Dosing
NA
Header/Man
�(,�
Aeration
NA
Dist paper
HMdln9
Tt System
yayA
r•ye
(E'
pl.
PUMP/SIPHON INFORMATION
final Grade
urer
as
_ GWA
Mode Number
µf,N r
.L
TDH
Lft
if
ft
for emaln
I LengUr Dla.
Din Tow<n
SOIE
BED/TRENCH
Werth
rengt
xo Oltrercnn
%T
r•ov'doeNn
S
SYSTEMTO P/L
BLW
WFIL
LAKF/STRF
LFAOIING
q
Io lbAkd✓'
SETBACK
CXAMBER
INFORMATION
Typo
r
OR UNIT
SYSTEM
xeww/u n
n m�
. xo a he
prting
vein oAu r e
unpin_
o10
L"ita5425-0,e
TJ
L.5
• 1}0
SOIL COVER x Pressure Systems Only are MoMM Or At -Grade Sisel Only
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COMMENTS: finches code discrepancies, persons present, etc)
LOCATION: HUDSON 11.29.19,SE,SN 1003 LABARGE ROAD — HOMESTEAD LOT 26
U KAE4(Ks(d„7rwa f
a ",6m -To i% op maw (avafLfrrLn
FlU vi 16
Plan revision reWlredT ❑Yes N
Use other vde for additional lnforr2ono
Pd
ENDW10(B197I now InfpMoies-1 rota Gn. xo
Beach M EWelhas Coleco
SANITARY PERMIT APPLICATION
Pot w Washimmm Yn„
a iSE:oI19ip In hours with LAR 93 05, We Am, red,
ee
99 Bm73(Q
Medwry WI 537DI
Atlach complete plans(to the county copy only) for she system, on paper not Is%
court p
than 8la x 11 inches msrse.
J 4. C('O16(
• See reverse side for Instructions for cwmp ceng this application
wa San pa,
Nmnal mbmm6on you phase, may a, wed for a,momy pupows
�'ema
qxe It miXF� a;kreiun
IPmaey bay 1504 p1(ml1
SYte"shin Number
APPLICATION INF T - PLEASE PRINT INFORMATION
emperry Owherua
Lv O
L
Prtyerry LxaeanS l T L ,N.R I E( W
r Ntlbnr
Number
eWkNumMr
�Owne'iNalLng
ii
Cn .Sal Zq<o umber
SUEdemon Name or<SM meet
lao
p
11. 1 Tire Of :(check one) ❑Slrte Ownetl
Oviorva`
arenao'E
Pxbllc Ior z FamilyDevenm - No of bedrooms
✓
V
III. BUILDI USE: (If widnB im,ISr Chi a11thatappa) aTaxNiimbxh) A•watn1' d a9. /I iSAn
1 O Apartment I condo 49 a 0 — 139 —6kr)—jiti
2 ❑Assembly Hall 6❑ Metllcal Facility/Nursing Home 100 Outdoor Recreational Facility
3 ❑ Campgroural 7 0 MerchaMlseSales/Repairs II ❑ Raslawari Bari Dining
0❑Church/School 80 Mobile Home Park 120 Service 5btion/Cm Wash
S 0Hotel /Motel 9❑Office/Factury 130 Other theory
IV. TYPEOFPERMIT: (checkonlyoneboxonkini check box online 8, if applicable)
A)1 New 2 0 Replacement 30 Replacement of O O Reconnection of 50Repair of an
_ ___ystem _ Synem............. _Tank Only .............. n_g5ystem_ _Ex_uu_________I 5_N_n_QSystem
B) ❑ASanitary Permit was Previously iswed PermLLNm uber Date Issued
V. TYPE OF SYSTEM: (Crawk only one)
NomPreswnzMDl4rvbUM1on PreRunzMDrstnlwhan Experimental Other
I105eapage Betl 210 Mwnd 300Specify Type 410 Holding Tank
Irerragehench'�DILtOObM3l0ln-Ground Preuur 2 420 cot Privy
10sherapage Rl Ice ING/a/,CJ4OR 2.1i iS SL.iY 030 Vault Privy
140 System-In-FIII
VI. ABSORPTION SYSTEM INFORMATION:
i Gallons Per Day 2 Absory Area 3 Aboas Area a Loading Rate S Part Rate 6 System Else T FmlGmade
Regmretl(sq h) I ops, ly h) (GalLdey/p ft) IMin /mcM1l It elevation
VS6 Feet
.S <' Firectigglahe
VIL TANK
of
INFORMATION
in9allons
Tothaalto
Gallons
ianky
Tan#ofks
Manufacturer's Name
Pweb
Nit
seal
Fieg
Egce
New Exist in
Concrete
ed
pp
Too k
Septkiank k
❑
❑
❑
❑
❑
,mitm Tmkei ,dameer
❑
❑
❑
❑
❑
Vill. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the ormie sewage system shown on the attached plar0
Plumber's Name xi Mouthr Si9naWre t, 1
e
Na RSW xn
eu PM1,m Numbr
III ` E!—< <
-O
—soli'!
N a seats, o SNIZIve
U
I. COUNTY I DEPARTMENT S ONLY
❑Disappmirea n ye.rmilFee nmwnn
nVU
reN
mngnapys naWreenesempa
HAPprovetl
0pwnerG nlnind �/,Hv s0 `a'°r' re`i
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Ativese Delermnatlon irotaw
/
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X. ,C NDITIO cIDO AL/REASOfffWFO DISAPPROVAL:
CAce a. NfpLu+/.f
MILLER HOMES 386-2769 HOMESTEAD
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FOIL EVALUATION REPORT
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SP5345 tMe PJn Ca!
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Pi ,it al nnw polar biv]o 118M) n lard penaM elope,
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