HomeMy WebLinkAbout030-2127-10-000 - I
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
.Safelty and + Building Division
INSPECTION REPORT sanitary Permit No:
430091 0
(ATTACH TO PERMIT)
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 X Township Parcel Tax No:
Blake Builders, Inc. I St. Joseph Township U3o- 2 /Z7"/O - 000
CST BM Elev: /� jInsp.BMEIev: IBM D (( Section/Town /Range /Map No:
l • C_� escri s h�i4 — 25.30.20. a
TANK INFORMATION V ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic ' f Ben mar
o
Dosing AI 1 6 j
Aeration Bldg. Sewer
Jl.bo q2..
bolding St/Ht Inlet 12. Z•0 Q 2. Z O /
TANK STBACA INFORMATION
NFORMATION St/Ht Outlet tZ• 35 7 Z .OS
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic , / ` 3 <9' Dt Bottom
Dosing Header /Man.
13.4 1o. S-0
Aeration Dist. Pipe 14• 4 O ' Lint
ily
Holding Bot. System PAY- { :00 l d SS r
PUMP /SIPHON INFORMATION Final Grade , AZ 0 Jr
Manufacturer Demand St Cover V
GPM 7 !'1
Model Numb
TDH Lift on Loss System Head DH Ft
'
pef8emain Length Dia.
SOIL ABSORPTION SYSTEM
BED/TRENCH Width r Length ( foe ) f Trenc es PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS -3 QZ 04 ft
SETBACK SYSTEM TO OT 7 �� P/L JBLDG WELL LAKE /STREAM LEACHING Manuf ?c}yer-
INFORMATION CHAMBER OR AW
Type Of stem: c �a� UNIT Model Number: 7.1!-
. –.'
DISTRIBUTION SYSTEM R.C.w•
Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake
Pipe s)
Length Dia L ngt Dia Spacing
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
Bedrrrench Center Bed/Trench Edges Topsoil F Yes No Yes No
COnS (Ir lude screpencies, persons present, etc.) Inspection #1• � Inspection #2: T
�� 77** �3 �a 7
ocatio 1347 Birch Park Ridge Hudson, WI 54016 [IE 1/2 SW 1/4 25 T30N R20W) Birch Park o 31 P I No: 25.30.2
1.) Alt BM Description ip
2.) Bldg sewer length
- amount of cover = i
- -- - -- - - --
�-
Plan revision Required? - -- _
Use other side for additional Yes No
i
information.
SBD -6710 (R.3/97) Date Insepctor's Signature Cert. No.
Safety and Buildings Division County
® 201 W. Washington Ave., P.O. Box 7162
Madison,
iseons W1 53707 - 7162 Sanitary Permit Number (to be filled in by Co.)
in
(608)266 -3151 43 Qpr
Department of Commerce
Sanitary Permit Application State Plan I.D. Number
In accord with Comm 83.21, Wis. Aden Code, personal information you provide
may be used for secondary purposes Privacy Law, s15.04(l)(m) Project ' Brent than Mailing address)
10 go J4
1. Application Information - Please Print All Information �1 # J 3 L t - 5q 1 ( r_ / jQ{CJ
Property Owner's Name � Parcel #
Property Oww='s Address Property Leuonn
o �'J ' /., Section /
City, State Zip Code Ph e N € ? r
• , / � � ° �` (circle o
N - T N; R or
11. Type of Building (check all that apply) Y 7 or s 4) j j ubdivi ion Name -' CSM Number
�e` r -r
2 Family Dwelling - Number of Bedroom � /%►Iris .
❑ Pubfic/Commercial - Describe Use aQ w►t ,
❑ State Owned - Describe Use yV.S Z 0 N f N G 0 F F I �C� ❑City Village,�Township of � D�
111. Type of Permit: (Check only one box online A. Complete line B if applicable)
A. X New System ❑ Replacement System [I TreatmentlRolding Tank Replacement Only ❑ Other Modification to Existing System
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New list Previous Permit Number and Date Issued
Before Expiration Plumber Owner
IV. TVDC of POWTS System: JCheck all that appl
Non - Pressurized In- Ground 11 Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade [I Single Pass Sand Filter ❑
Constructed Wetland ❑ Pressu In -Gnxmd ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑
Recirculating Synthetic Media Filter ❑ Leaching Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (explain)
V. Dispersal/Treatment Area Information:
Design Flow (gpd) Design Soil Application Rate(gpdst) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation
vi. ark Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic
Gallons Gallons of Units Concrete Constructed Glass
New Existing
Talcs Talcs
Septic oeiieidrrrg" fink / Zoo
Aerobic Treatment Unit
Dosing Chamber
Vll. Responsibility Statement - 1, the under ed, ssu responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print) P III s MP)APRS Number Business Phone Number
Plumber Address (Street, City, Sta We � `7{ �y� T
Vlll. County/Department Use Onl
Approved Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Is sum gent Signattue ( o Stamps)
Surcharge )
❑ Owner Given Reason for Denial Z2-5 2et�
1X. C onditions of Approval/Reasons for Disapproval
Attach complete plans (to the County only) for the system on paper not lest than 81/2 111 lathes in size
94,, a
SBD -6398 (R. 01/3) / (}
T.L. Sinz Plumbing Inc.
E5609 708th Ave. f3LA Fv► LDI-14S TN L , Phone: (715) 235 -2644
Menomonie, W154751 (pi' tL s ki) Fax: (715) 235 -2592
www.tlsinzplumbing.com
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T.L. Sinz Plumbing Inc.
E5609 708th Ave. gv) LD -S TN L. Phone: (715) 235 -2644
Menomonie, WI 54751 (PWIL Sd k1) , Fax: (715) 235 -2592
FLo T !='t_►q+J w
ww.tlsinzplumbing.com
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Wisco� sin Department of Commerce SOIL EVALUATION REPORT P p age 1 of 3
Divisjon of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
' County St. Croix
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must
include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. 0 & 0 percent slope, scale or dimensions, north arrow, and location
and distance to nearest road. //
Please print all information Re 'wed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). -Z 3
Property Owner Property Location
Quest Development, Inc. Govt. Lot E 1/2 1/4 SW 1/4 S 25 T 30 ❑
N R 20 E(or)
Property Owner's Mailing Address Lot # Block # Subd. Name or CSM#
Suite 150 10700 Old County Road 15 31 Birch Park
City State Zip Code Phone Number oCity RVillage ■ Town Nearest Road
Plymouth MN 1 55441 ( 7¢3 -595 -9512 County Road E
Q New Construction Useo Residential / Number of bedrooms 3 to 4 Code derived design flow rate 450 id66Q I
Replacement Public or commercial - Describe: ' f
Parent material 1.oess over out wash sands Flood Plain elevation if applicable ern ft.
General comments stem t
for a conventional s
and recommendations: This site is suitable system
1 2w
. � ST CFtaX ..._
/ 11 Boring �>
Boring # > 110
0 pit Ground surface elev. 94.55 ft. Depth to limiting factor in.
imatt" ate
Horizon Depth Dominant Color Redox Descrip ' Texture Structure Consistence Boundary Roots GPD/ft°
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff41 *Eff#2
1 0 -8 10yr3 /2 sil 2msbk mfr cs 2f .5 .8
2 8 -110 10 r5/6 s Osg ml - - .3 1.2
0.
F 2 ] Boring # � Boring 90.95 >100
Q pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0 -12 10yr3/2 sil 2msbk mfr cs 2f .5 .8
2 12 -100 10 r5/6 s Osg ml - - .7 1.2
* Effluent #1 = BOD > 30 220 mg /L and TSS >30 < 150 mg /L * Effluen 0 mg /L and TSS < 30 mg /L
CST Name (Please Print) Signatu4e CST Number
Thomas C Nelson e— 227387
Address Date Evaluation Conducted Telephone Number
1432 120th Street, New Richmond, WI 11/23/01 715- 246 -2454
O r,71 AL
Quest Development.Inc Page 2 of 3
Property Owner Parcel ID # 9
3 Borin # Boring
g Pit Ground surface elev. 98.96 ft. Depth to limiting factor >105 in Soil - Applicabon Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0 -8 10yr3 /2 - sil 2msbk mfr cs 2f .5 .8
2 8 -36 10 r5/8 - sil 2msbk mfr cs if .5 .8
3 36 -105 10yr5/6 - s Osg ml - - •7 1.2
❑ Boring # ❑ Boring
a Pit Ground surface elev. ft. Depth to limiting factor in.
Soil lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fP
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
ED Boring
Boring # Ground surface elev. ft. Depth to limiting factor in.
❑ Pit Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
* Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg /L * Effluent #2 = BOD < 30 mg /L 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.
SBD- 8330Test (R07 /00)
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`' POWTS OWNER'S MANUAL ex MANAGEMENT PLAN rage of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner , L Septic Tank Capacity g al ❑ NA
Permit # 3101D Septic Tank Manufacturer iT ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA
Number of Bedrooms ❑ NA. Effluent Filter Model ❑ NA
Number of Commercial Units �'NA Pump Tank Capacity gal 13'AA
. -
Estimated flow (average) D gal /day Pump Tank Manufacturer .2-NA
Design flow (peak), (Estimated x 1.5) gal /day Pump Manufacturer �"pA
Soil Application Rate 7 gal /day /ft Pump Model .e'NA
Influent/Effluent Quality
Monthly average* Pretreatment Unit
s30 mg/L ❑Sand /Gravel Filter ❑Peat Filter
Fats, Oil at Grease (FOG) ❑ Mechanical Aeration ❑ Wetland
Biochemical Oxygen Demand (BODs) :_220 mg /L ❑ Disinfection ❑ Other:
Total Suspended Solids ( TSS) 5 150 mg /L Manufacturer
Pretreated Effluent Quality ' ❑ NA Monthly average* * Dispersal Cell(s)
Biochemical Oxygen Demand (BODs) :530 mg/L n- ground (gravity) ❑ In- ground (pressurized)
Total Suspended Solids (TSS) :530 mg/L ❑ At -grade ❑ Mound
Fecal Coliform (geometric mean) :510 cfu /100m1 ❑ Drip - line ❑ Other:
Maximum Effluent Particle Size % inch diameter * Values typical for domestic (non - commercial) wastewater and septic
tank effluent.
* * Values typical for pretreated wastewater.
MAINTENANCE SCHEDULE
Service Frequency
Service Event
Inspect condition of tank(s) At least once every j ❑ months 2ryear(s) (Maximum 3 yrs.)
Pump out contents of tank(s) When combined sludge and scum equals one -third ( of tank volume
At least once every
❑ months Eryear(s) (Maximum 3 yrs. )
Inspect dispersal cell(s) A -�
insp p
Clean effluent filter
At least once every ❑ months Lkyear(s) . f$
Inspect pump, pump controls at.alarm At least once every ❑ months ❑ year(s) ❑ NA
Flush laterals and pressure test At least once every ❑ months ❑ year(s) ❑ NA
Other- At least once every ❑ months ❑ year(s) ❑ NA
Other: At least once every ❑ months ❑ year(s) ❑ NA
MAINTENANCE INSTRUCTIONS
inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Mast
Plumber; Master Plumber Restricted Sewer; POWTS inspector, POWTS Maintainer; Septage Servicing Operator. Tank inspection
must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure tt
volume of combined 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. r more of
the entire
When the combined a aN be i e ed d a Septage Servicing Operat
or l and dis o
contents of the tank s f in accordance nce ch. 113, Wiscon!
h Y
Administrative Code. nents and
The servicing of effluent filters, mechanical 2 less shall r months orl P OWT S be performed by a certified POWTS Ma n�tainer.ny other
maintenance or monitoring at intervals c
A service report shall be provided to the local regulatory authority within 10 days of completion of any service event.
START Up AND OPERATION
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemic
that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the conter
^r rha rv%wir rarnovpd by i sentage servicing opera prior to use,
Page — of,_
System start up shall not occur when soil conditions are (roten at On Infiltrative surface.
During power outages pump tanks may fill above normal highwater levels. When power Is ratored the excess wastewater will be
discharged to the dispersal cell($) in one large dose, overloading the celt(s) and may result In the backup or surface discharge of
effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator -prior to restorint
power to the effluent pump or contact a Plumber or POWTS Maintainer to assist In manually operating the pump controls to
restore ncrmal levels within the pump tank.
Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area
within 15 feet down slope of any mound or at-trade soil absorption area.
Reduction or elimination of the following from the wastewater stream may Improve the performance and prolong the life of the
POWTS: antibiotics; baby wlpes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; (at;
foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbiddes; meat scraps; medications; oil;
paintlnst croducts: Desticide$: sanitary naokins: tamponsi and water softener brine.
A$AN DON EM ENT
When the POWTS fails and /or Is pemianently taken out of service the following sups shall be taken to Insure that the system is
property and safely abandoned In compliance with ch. Comm 83.33, Wisconsin Admintwative Code:
• All piping to tanks and pits shall be disconnected and the abandoned pipe opening$ sealed,
• The contents of all tanks and pits shall be removed and property . disposed of by a Septage Servicing Operator.
• Aher 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, W provide a code compliant
replace nt 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
required setbacks from existing and proposed svucwre, 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 rnust
comply with the rules In effect at that time.
O A suitable replacement area Is not available due to setback andlor soli limitations 6arrinl; advances In POWTS technology
a holding tank may be installed as a last resort to replace the failed POWTS-
0 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 W replace the failed POWTS.
D Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the
Inflltradve surface. Reconstructions of such systems awst.cornply 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 RESULi, RESCUE Of A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR
IMPn%%lRl F.
ADDITIONAL COMMENTS
I
POWTS INSTALLER POWTS MAINTAINER
Name �L Z 6� �tl�• Na me TL it/L b rVL-
Phone — Phone —
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Rhone ame AtCencY GIDYx
P hon e
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGR'E'* TENT
AND
OWNERSHIP CERTIFICATION FORM
9 U A C 01 o o D� s �
Mailing Address S a
Property Address
(Verification required from Planning Department for new construction)
City/State Parcel Identification Number _ 2( 27- — /o — c�( In
3S�
O 3 v J
�, sr DESCRIPTION 3p
P Location 5 0 '/,, Sec. 3-31 T N -R 9 W, Town of 5�
Lot # ._•
Subdivision
, Page #
Certified Survey Map # -
Volume
ZS X8(0 22T/ , Page # 2�{�
Warranty Deed # , Volume
Spec house 09 yes ❑ no It lines identifiable Q( yes ❑ no
�yS+ M MAIl�i�rE� em could result in its premature failure to handle wastes. Proper maintenance
per use and maintenanceof your septic cyst b a licensed per. What you put into the system
consists of pumping out the septic tank every three years or sooner,
if needed y
can affect the function of the septic tank as a treatment stage in the waste disposal system.
Department a certificat form, signed by the owner and by a
g that (1) the orHSite R ,astewaterdisposal system
The property owner agrees to submit to St. Croix Zoning
mastCrPlumber, jotaneymanPlr +restnctedplumberor, a licensed verifyin), the septic tank is less than 1/3 full of sludge.
is in proper operating condition and/or (2) after inspection and pumping C
vate sewage disposal system with the standards
the undersigned have read the above requirements and agree to maintain the pri S
th
of Natural Resources, State of Wisconsin- Certification
ent of Commerce and the Department offi within 30
set forth, herein, as set by the Department co mpleted and returned to the St. Croix County Zoning
septic system has been maintained must be
ys o:the expiration date.
/
DATE
SIGNATURE O APPLICANT
OWNER UM CATION ( our) knowled e I (we) am (are) the owne*) of
.I (we) certify that all statements on this form are true to the best of my
g
' pro d bed above, by virtue of a warranty deed recorded in Register of Deeds Office. / `�/ 0-:? _ DATE
SIGMA OF AP LICANT
« « « « «
i««0««
information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department .
warranty deed from the Register of Deeds office
•« include with this application: a stamped if reference is made in the warranty deed
a copy of the certified survey Map
r— -
j 2271 P 245
STATE BAR OF WISCONSIN FORM I - 1998
KATHLEEN H. VALSH
j WARRANTY DEED II REGISTER OF DEEDS
Document Number
ST. CROIX CO., VI
RECEIVED FOR RECORD
Birch Park, LLC 66/11/2003 11:36AH
This Deed, made between + _ j,
a Minnesota limited liability company WARRANTY DEED
EXEMPT 11
I ' Grantor,
REC FEES 11.00
and Blake Builders, I) TRANS FEE: 513.00
Inc.
i
1 COPFEE Y 2.00
f! PAGESs 1
Grantee.
Grantor, for a valuable consideration, conveys to Grantee the following I
i
Crox
described real estate in St. County, State of Wisconsin
(the 'Property'): j Recording Area
Name and Return Address - --- - -'--
—T^11
�GM►EC 1 � RG —Xy%su
i t Lot 31, Birch Park 5�{3q
#-o a I a — /0 0M j
25 - 30 - 20 - 1035
Parcel identification Number (PIN) j
This is not homestead property. j
I ) (is) (is not)
,I
I
i
Ij
�
j
I Together with all appurtenant rights, title and Interests. ;
I� Grantor warrants that the title to the Property Is good, indefeasible in fee simple and free and clear of encumbrances except
all easements, reservations and restrictions of record, if any.
Dated this 1 day of rn 0.Q G� 2003 i
i
BIRCH PA t LC
j (SEAL) (SEAL)
I .
By
Jj I s M. Water , s Chief Manager
II (SEAL) / (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
j Signature(s) Ij
State of %VJPV"J= FLORIDA
_ ss. q
SI RnSO l ti , County. j
authenticated this day of Personally came before me this 06' day of
March 2003 , the above named
James M. Waters. Chief Manager of Birch I
Park, LLC, a Minnesota limited liability I'
w company II
TITLE: MEMBER STATE BAR OF WISCONSIN
Of not, me known to be the person who executed the foregoing
authorized by §706.06, Wis. Slats.) instrument and acknowledge the as e.
THIS INSTRUMENT WAS GRAFTED BY a
902 =N
Wilkerson 6 Hegna, PLLP
'i
7300 Metro Boulevard, #300 Notary Public, State ofiWiscomttt kPles+
i Edina, MN 55439 My commission is permanent. (If not, state expiration date:
I' (Signatures may be authenticated or acknowledged. Both are not Ql —2 2Z_0 � )
necessary)
�' • Names of persom signing in any capacity must be typed or printed below their signature.
STATE BAR OF WISCONSIN Wisconsin Legal Blank Go., fro.
WARRANTY DEED FORM No. 1 - 1998 Milwaukee, Wis.
• c°"� OF: " BIRCH PARK
tAI.
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101 0 (SEE SflEET 1) � � UNPLATIED LANDS I �— — — �..•
/ , —\ { __ _� .•
aim. -MATCH LINE A-----/
_
LOT I " R AI
'! l LOT Sl ®` I "' ° "• �� { _±
LOT 21 „a,1
LOT�2 I r
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S LOT 15 I �` ' A
LOT 22
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LDT 29 . r LOT 14
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LOT 4 ...
Ck l LO ;,µ B r LOT 24 I 1 tr .•, -- --?ire
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w.caoena,.,a.coe
\\ (SEE SHEET 3) � � I ° � ' ry i WO r. "Y•"° �
-MATCH LINE B---
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`E� ,s
Jane Hansen
Subject: Sinz/ 430091/ Blake Builders ✓�
Location: St. Joseph Birch Park Lot 31
Start: Wed 09/10/2003 1:00 PM
End: Wed 09/10/2003 2:00 PM
Recurrence: (none)
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O'sconsin Department ' of Commerce PRIVATE SEWAGE SYSTEM Coun St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
(ATTACH TO PERMIT) 430091 0
GENERAL I N ORMATION 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 X Township Parcel Tax No:
Blake Builders, Inc. I St. Joseph Townshi 03 — S/ Z
CST BM Elev: Insp. BM Elev: BM Desc (( Section/Town /Range /Map No:
h 4 25.30.20. O
TANK INFORMATION V ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic ' f � Ben , phmar O lv5sS -
}•kt.� '•
Dosing AI •5
02 .
Aeration Bldg. Sewer 1
A (00 q2.&
Holding
g St/Ht Inlet `2• Z p ^ 2' 20 /
TANKS TBACK INFORMATION St/Ht Outlet (2 - 3 2.
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic ,L ` r Dt Bottom
Dosing 7` f Header /Man. � 1O. S
Aeration Dist. Pipe (� p Y
ty ke
Holding Bot. System 1500 r
qo.
Final Grade
PUMP /SIPHON INFORMATION
Manufacturer Demand St Cover
GPM
Model Numb
TDH Lift on Loss System Head DH Ft
F remain Length Dia.
SOIL ABSORPTION SYSTEM JL()
BEDITRENCH Width r Length ( No. f Trenc es PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 3 (2) S ETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manuf�c er.
INFORMATION Type Of stem: Z�` SOt CHAMBER OR - N
UNIT Model Number: 2 Il
DISTRIBUTION SYSTEM
Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake
Pipe s)
Length Dia L ngt Dia Spacin
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
Bed/Trench Center Bed /Trench Edges Topsoil
Yes No [ ]Yes F No
COnS (Ir lude �py�.�iScrepencies, persons present, etc.) Inspection # / �_? Inspection
ocatio 1347 Birch Park Ridge Hudson, WI 54016 iE 1/2 SW 1/4 25 T30N R20W) Birch Park Lot 331 7 Parcel No: 25.30.20.
1.) Alt BM Description p v� ��
2.) Bldg sewer length =
- amount of cover =
Plan revision Required? Yes �_] No I �
Use other side for additional information.
SBD -6710 (R.3/97) Date Insepctor's Signature Cert. No.
Safety and Buildings Division County -- --
201 W. Washington Ave., P.O. Box 7162
M adison, /Jl
���OA�I� on, W 1 53707 - 7162 Sanitary Permit Number (to be filled in by Co.)
(608) 266 -3151 #3 Q p C
Department of Commerce / ( �4 Sanitary Permit Application Plan I.D. Number
In accord with Comm 83.21, Wis. Aden. Code, personal information you provide
for Po Law s15.040)(m) Projecx s diilerent than mail address)
maybe used secondary purposes vary
1. Application Information - Please Print All information /l 4 ) 3. L t}
Property Owner's Name Parcel # Lot # l
Property Owner's Mailing Address Property Location
5?-5' aei oe�1f t section dPr
City, State Zip Code Ph mbop- Nu C E � �f E 4*!N A Sl/ _ _ 2 13� (ci o one
E o 11. Type of Buildin g (check all that apply) 7 z U or 2 Family Dwelling - Number of Bedrooms A � "/� ` Name CSM Number
❑ Public /Commercial - Describe Use a El StateOwned— Describe Use S ZONING OFFIC illage0ownshipof
Ill. Type of Permit: (Check only one box on line A. Complete line B if applicable)
A ' XNew System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System
B. El Permit Renewal ❑ Permit Revision ❑ Change of C1 Permit Transfer to New list Previous Permit Number and Date Issued
Before Expiration Plumber Owner
IV. Type of POW17S System: Check all that app F
Non - Pressurized In- Ground ❑ Mound ? 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑
Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑
Recirculating Synthetic Media Filter ❑ Leaching Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Otha (explain)
V. Dispe rsal/Treatment Area Information:
Design ow (gpd ) Design Soil Appli cation Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation
VI. 1 Into Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic
Gallons Gallons of Units Concrete Constructed Glass
Ncw Existing
Tanks I Talcs
Scptic ociieid01ll'T9nk �Jro /
Aerobic Treatment Unit yr
Dosing Chamber
Vll. Responsibility Statement - 1, the un ed, ss responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print) P 's MP RS Number B ,icinrcc Phone Number
�o L ;01ry
Plumber's Address (Street, City, State, ode
' Vlll. County/ artment Use Onl
Sanitary Permit Fee (includes Groundwater :Date Issued is uin gent Signature ( Stamps)
1K Approved ❑ Disapproved Surcharge Fee)
❑ Owner Given Reason for D enial 2zS�_ 23
1X. Conditions of Approval/Reasons for Disapproval
,
AA <,PAQCJL rre L.—
Attach complete plain (to the County only) for the system on paper not less than 81/2 111 inches in size
�. IJ c) 94pAa �j
SBD -6398 (R. 01/63) U
T-L. Sinz Plumbing Inc.
E5609 708th Ave. J�L -A FU) L-vf--4S TN e_. Phone: 715 35-
2 2644
Menomonie, WI 54751 (pq-,L So h1� Fax: (715) 235 -2592
vAvw.tlsinzplumbing.com
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