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HomeMy WebLinkAbout020-1447-15-000 (3)Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit NO SAN-2021-175 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No. Personal information you provide may be used for secondary purposes [Privacy Law, s 15.04 (1)(m)] Permit Holders Name: City Village Township Parcel Tax No MIKE ODONNELL TOWN OF HUDSON 020-1447-15-000 CST BM Elev Insp BM Elev BM Description Secl,onrrown/RangelMap No. 15.29.19.2846 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY Septic Dosing Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic Dosing Aeration Holding PUMP/SIPHON INFORMATION Manufacturer Demand GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia Dist to Well SOIL ABSORPTION SYSTEM STATION BS HI FS ELEV Benchmark AIL BM Bldg Sewer St/Ht Inlet SVHt Outlet DI Inlet Dt Bottom Header/Man. Dist Pipe Ent. System Final Grade St Cover BEDFrRENCH Width Length No Of Trenches PIT DIMENSIONS No. Of Pits Inside D,a Liquid Depth DIMENSIONS SETBACK SYSTEM TO PIL JBILDG IWELL LAKEISTREAM LEACHING Manufacturer INFORMATION CHAMBER OR UNIT Type Of System Model Number DISTRIBUTION SYSTEM Header/Manifold D,stnbution x Hale Size x Hole Spacing Vent to Air Intake Pipets) Length Dia Length DidSpacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xz Depth of xx Seeded/Sodded xx Mulched BedrTrench Center Bedr-rench Edges Topsoil ❑ Yes ❑ No Yes ❑ No COMMENTS: (Include code discrepenc,es, persons present, etc) Inspection #1: Location: 665 PINE TIMBER LN 1 ) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required? Yes LJ No — Use other side for additional information. SBD-6710(R 3/97) Date Insepctors Signature Inspection #2. -, Cert. No. 57ArJ - 2oz1 -I-75 nai County Sanitary Permit Application In accord with Chapert 12 St. Croix County Sanitary Ordinance ST. CROIX COUNTY WISCONSIN PLANNING & ZONING DEPARTMENT Personal information you provide may be used for secondary purposes Pa [Privacy Law. S. 15.04(1)(m)] ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016-7710 (715)386-4680 Fax(715)386-4686 Attach complete plans for the system on paper not less than 8-1/2 x 11 inches in size County Sanitary Permit # ❑ Check if revisiokp.p�Clgv���/� joq� ap 6lion .• I. Application Information- Please Print all Information Location,*.-, Property Owner Name 2021 '1 JJ 'C1,� l� t) e/ l ST. CR 1/4 "-1l4, Sec T r N, R E (o W Property Owner's Mailin ddress ,5 r , - %,� 1jb6,4 L HM Lot Number 15 Block Num r City, State �fser1j Zip Code Phone Numer Subdivision Name or CS Nu ber T of Building: (check one) ' / txity, ❑ illage o 1 or 2 Family Dwelling - No. of Bedrooms: !+ Public/Commercial (describe use): _Town \ :5C) lk J ❑ State-ownpd Nearest Road If. Type of P it: (Check only one box on line A. Check box on line B if applicable) Parcel Tax Number(s) 1. Repair 2. ❑ Reconnection 3.❑Nomplumbing 4. ❑ Rejuvenation A) Sanitation _ Uf-Io B) Permit Nu m r State Sanitary Permit was previously issued 3 0,5 Date I91 7 IV. TyGa of POWT System: (Check all that apply) ,17cp�x�/Non-pressurized In -ground ❑ Mound a 24 in. suitable soil ❑ Mound <- 24 in. suitable soil ❑ Mound A+0 Sand Filter ❑ Constructed Wetland ❑ Peat Filter ❑ Drip Line ❑ Pressurized In -ground ❑ Holding Tank ❑ Single Pass ❑ Other ❑ At -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 fan Required _ Pro sed (Gals./day/sq.ft.) (Min.Mch) �' - � �. Elevation VI. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic Gallons Tanks Concrete strutted glass New Existing Tanks I Tanks 1777 /.;2 67, 577 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ VII. Responsibility Statement I, the undersigned, assume responsibility for repair/reconnenction/refuvenalioNinstallabon of non -plumbing for the POWTS shown on the attached plans. A license is not required for terralift repair or the installation of non -plumbing sanitation system. Plumber's Name (print) � • M-fe I. /J6 s Plumb ignatur (no st p : r - ��- MP/MPRS No. L, Busness Phone Number 5- 73 -3 2.2) Plum�nber's Address Stre , ity, State, Zip C e) —7 ro � i � YI r i ,-It: ccici C/ �C�G �� �` � l - VIII. County Use Only Disapproved Approved Owner Given Initial Adverse Sanitary _yPermit Fee 04, • Gs C.o Dale / Is ueed� 9 Issuing Ag ignature (No stamps) Determination ( IX. Conditions of Approval/Reasons for Disapproval: 3 SYSTEM OWNER, r 7 1. Septic tank, effluent filter and dispersal cell most be -serviced / maintained as per management plan provided by plumber. 2 All setback requirements must be maintained as per applicable code/ordinances. Rev 8105 I 101 E=010 SM1n �fw4ilsj,eLFU County Safety and Buildings Division - �' ®� � MAY 25 2021 20 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.) \ P �, Madison, WI 53707-7162 St. Croix Count i 19 �AN —Do -(- 1 •7 Community Development , -4-4119 Sanitary Permit Applic State Transaction Number In accordance with SPS 383.21(2), Wis Adm Code, submission of this form to the appropriate governmental unit Project Address (if different than mailing address) is required prior to obtaining a sanitary permit Note: Application forms for state-owned POWTS are submitted to the Department of Safety and Professional Set -vies. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law, s 15.04(I) m , Slats I. Application Information— Please Print All Information Property Owner's Name Parcel # e C� rJr�neOAO - Iqq7-15- Coo Property Owner's Mail Address7 Property Location C b I IQ 1 u ✓%� h-r� Govt. Lot , Sect /.. /., ion City, St • Zip Code Phone Number `_ �C + T R 12ErW 11./Type of But •ng (check all that apply) Lot p 1 or 2 Family Uwe ' g-Number of Bedrooms _ Sub � sion Name Block # ❑ Public/Commercial - De theUse DCity of ❑State Owned - Describe Use % er ❑ Village of ,j Town of III. Type of Permit: (Check only olkbox on lindlA.Apnklete line B if app • ble) A ❑ New System y ❑ Replacement yytem ❑Treatment/Holding - Replacement Only Other Modification to Existing S ste explain�L Lf a,J B. ❑ Permit Renewal 71 Permit Revision ❑ Change of mbar ❑Permit Transfer to New Lis evi 5 P,ejmit Number and Dale Issued ) e ran 'dC/yDj"p-�� Before Expiration Owner IV. Type of POWTS S stemlCom onentlDevice: hec 11 that a 1 Non -Pressurized In -Ground ❑ Pressunzed In -Ground At -Grade ❑ Mound > 24 in. of suitable soil ❑ Mound <24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (expl ❑ Pretreatment Device (explain) V. Dis ersaUTreatment Area Information: Design Flow (gpd) Design Soil Application e(gpdsf) Dispers Area Required (sf) Dispersal Area Proposed (sf) System Elevation 2c' 7 � ) i �s' 7 7 VI. Tank Info Aacity in Total # of Manufacturer Gallons Gallons Units o ` u New Tanks Esisung Tanks c o y d U in y v: Septic or Holding Tank + , f �, I 1 iV 1� V Dosing Chamber VII. Responsibili tatement- 1, the undersigned, assume responsibility for installation Not POWTS shown on the attached plans. Plumber's Name nt) Piuig�i -'s Signature MP/MPRS Number Business Phone Number ti1z��Gs a' C3 Plumber's dress (Street, City, State, Zip Code) V1 . County/Department Use Only Approved ❑Disapproved Permit Fee Date Issued Issuing Agent Signature ❑ Owner Given Reason for Denial IX. Conditions of Approval/Reasons for Disapproval Attach to complete plans for the system and submit to the County only on paper not less than 8 12 x I I inches in size SBD-6398 (R. I I/11) N 97X B�. 13 ZZ 07 eh°°" Va.nta� �.✓`� - ,���'"""� fj��.� � x�'��' 9//�/may ST. CRO UNTY SANITARY SYSTEM File #: RECEINEDOffice use Only ! OWNERSHIP/ADDRESS FORM Created 10'a 2021 ST. CROIX Co0riTy CDD Community Development Department will utilize this information to provide the property owner with information regarding operation and maintenance of your new or replacement sanitary system! This information will be provided as part of our ongoing efforts to protect public health, your well, groundwater, surface water, property values, and county resources. Once approved, this completed form and educational information will be sent to you by email. If you would like to view your issued sanitary permit online, you can do so by using the Property Files Scanned weblink. OWNER/BUYER INFORMATION Owner/Buyer Mike Odonnell Mailing Address 665 Pine Timber lane city/state/zip Hudson WI 54016 Phone Number (required) 763-280-1963 Email Address (reouired) N/A Parcel Identification Number 020-1447-15-000 (found on the property tax bill) Property Location 1/a , 1i Subdivision Plat: Certified Survey Map #. NEW SYSTEM: LEGAL DESCRIPTION 15 T 29 N R 19 W, Town of Hudson Lot # Page # Warranty Deed # 1050 / 37 (before 2006)Volume Page # Number of bedrooms 4 Spec house 0 yes ■ no Lot lines identifiable ■ yes 0 no New Property Address (Staff Initials) (Date) OFFICE USE ONLY new add)Css required from Community Development Department for new construction.) This form must be submitted with all Private Onsite Water Treatment System (POWTS) applications. New System: Include with this form 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. Community Development Department - Land Use Division 715-386-4680 St. Croix County Government Center 715-245-4250 Fax cddCo)sccwi.ciov 1101 Carmichael Road, Hudson, WI 54016 www.sccwi.00v w8OCL A06MOCcOON HLQ) ARI @21HAP 9MYO M." I U XTM snDepa mentofComnece PRIVATE SEWAGE SYSTEM / and Building Division INSPECTION REPORT JENERAL INFORMATION (ATTACH TO PERMIT) Personal )Morineson yovke may ae used for semrdary purposes IPdvary Law, 6.15.04 (11(m)I 81 Permilm fame: City Village x Townft ri Bast, Kemon Hudson Township /o n. cio k TYPE MANUFACTURER CAPACITY Septic Dosing Aeration Holding TANK SETBACK INFORMATION YANK TO P/L WELL BLDG. Vent b Ali Intake ROAD Sepik ' aU r > J �1 ryzv _- y Dosing \ Aeration Holding PUMPISIPHON INFORMATION Ma rer Demand GPM Model Nu TDH Lift Friction System Head TDH —Ft Forco ra) Length Die. Dist lvlfwll*� 501L ABSORPTION SYSTEM St. Croix 430477 0 O 0-10 6%p No: 1 15.29.19.E STATION BS HI FS ELEV. Benchmark +1.3y AIL BM Bldg. Sewer 8.4i g6.SZ SVHt Inlet 9.7- gS.I-I SVHtOutlel I 9.q 4y.9 Of Intel Dl Bottom Header/Man. II.03 93. 3 / Dist. Pipe Got. System Final Grade��S/ S.YJ 98. St Cover -1 e- r S 1.20 SEWMENCH Width Lengln No Of TroryJrae PIT DMENSI-8 No Of Pas Inside Die liquid Depth OIMEN810N3 88 SETBACK SYSTEM TO Pll BLDGf- LAKE/STREAM LEACHING ManufaCrer WCHAMBER INFORMATION Type IX System > sod n.f-7 O � (M r N, ^ Fl OR UNIT Model Number Cur-aY4n.i...nYy W n1STti1RI ITVNd SVQTCaa Q Hesdx M/Manadd DRtnbu ion X Hole Sim Y Hob Spacing Vent toAe Ielaks LWVM-D--Die 'I / -..Spacy4 'J/ L Vth �- >to fJ� Die SOIL C:U V tK x Pressure Svafams Only va NI ar AflanAe Svatema nnty Depth Over ( Depth Over YY Depth of Yx saeded/Soddad xx MulchedBedlTrezh Gaoler ,•..- S BedRrench Edge$ "" Topaal - z Yea 1 ; No .� Yes No COMMFJITS: (Include code dlauepencies, persons present, etc.) Inspection k1:_1,&L_IQJL Inspection LoeM1 Hudson. WI 54016 (NW 1/4 SE 1/4 15 T79N R78W) '" %--^ Lot L Pall No: 15.29.19.11220 1.) Aft BM Description = 6% 1_S LVI L�l. - /06 -// d �(y,or lJSGt 2.) Bldg sewer length = ay N W42t Q TMiG✓ . amount of cover = 4 $ l% A Plan revision Required? Yes f f o ) C- ,/.IYn Lisa other side for additional Information. jy'/� ,i'Z f_°� - _ - - - 'I 4 / j j'^ S804710 (R."7) Dab MWpgtO%e Sipnalure Can. No. wiLMAr Safety will Buildings Division CMnty 201 W. Washington Ave., P.O. Box 7162 57- c:fI'&Y iSCO, Madison, WI 53707 - 7162 Sworary Perm/it Number (m be fill) d in by ) De artm8nt Df Commerce (608) 266-3151 Yf0 Q S Q - Own Sanitary Permit Application In ac brd wkW Conusl 113.21. Wu. Adm. Coe,, Information Stan p,rannal you prov' cony be a,af for scadaq' pennon Privacy law, sls.pt(I ��} Projm Addr6m (if nailing address) �� 1. Applicatton lnfermWit n - Phut Prim AN t n Kl=ys'' �— Pr�wsaR's Na� y C � 'J (j 15u Parcel / BIM-1 / Property Owav'a M ai1W Addma j i 1. � `s Progeny I.ocarioo a u• _ff.Seedon /-� �I Ciry, S e 'Lip Cade Rum Number T 2f N; R / f E li 0. Type of Buildlnt (tileek all that aDPIY) !n elL-�-tom. �2 Subdivuion Name CSM NLmher �u 0 I or 2 Featly Dwelfia6 - Niunber of Bedrooms " C PubliGCatnntercul -Describe Use p�C -----1 __ 0 Sine Owned - Describe Use /S% CiL` t4...t ( 77 f ��. �City� V I 8 owtNtip of �. -�1 111. Type of Permit: (Check only age boz an line A. Complete line f) It applicable) A A,New System U RePWAor S tom ❑ rreatnaenvliald" Tan\ n aatg Replacement only ❑Other Modification to Eaistitag Srifem B. y r-1 Pertni[ temwa! ,ryPermk Rnvuion C'haage o! Pesmn Tnnfrr to New I Lea Previous Pertnu Nruntw oral Dare knked I Before Fapiratlon Plumber Owrcr L,IV _TYpa of POVrrI'S System: (Check aR that ape&) MNon-Pressurized la,Orourd G Stated > 2a in, of suanswe sod '_. Mond < 24 in. of swtablt sod L Attrrde ❑ Single Pao Said Filter D ttucted Walsall C Presstdomil ln-Gniurd C holding I ank C Peat Filar Q Aerottic Tratnsem Unit _� Ftec'it ng Sand Pilm r 8ecfrcuistht{ Syndmic Media Filler Chao Drip Ltm _ Gravel less Pipe C Gdjw (*Plain) V. D[eoera.mur LTreata It Arras ea cA�Ge. r,-fv'i to ✓ (T / - = 19,*' 7 0 771-t— -� Duipa Plow (gpd} Desip Soil Applleauw f) 50MZI Arc. RM.T.M 6A Dispersal Armla-WeAd 0 tem � S�s� 7_F.Mvarseon VI. Tank Info Capauily in TW Number Matu twum I Prafab site Steel I Filar Ptaswi CNbss Galion of Units Continue Cownicted ' Uses Stpix or Holding Tatw r Asa Aerobic Trc.urcn�Utus -�. VII. Resporulbillty, Statement- I, the nidmipud, aalwe reapaslbYiU gar gglijiilon of the POWTS shown m the numbed PMU. V Plumber's Na see (Print) Plumber's St pants iP' PRS Numbe: &leans Phan Headier 1 ll' rcHG L z79 99(� �'Fd- 5V;M Plumber's Addrc ss (Sled, City, Stale. Lip Coda) tI-1V�IU. /De artment Use Od _ n Sutmry Permit Fee (Irrtude, Gruuna swr Dab kwad Wuma A ppuvad f� Disapproved �� -- t715 IL---� Q Owner Gwrn Reason for Dat.l i •o � /-2i IX. X. Conditions of Approval/Reasons for Disapproval � t � �' to nq-e (5) //'lR ¢ &'yl Side louy`ef5 A/ area aY, 6'0'��a4ot-- AUmb m ,plea pipes (rn ta. Caaoy aaly) air the ayum on paper ant Was law, gIR s 11 codas In an Gpt is -�- 0 s 7010 C 15 SBD-6398 (R. 01/03) ti ILevA✓o.✓ PLr6( For r.� �;voi c r v- .v�ars61.91 1 I OZrt-/ I Z, ,f S� Chi /JG, 6• 1/4�,e- -s->-e— 'a5p�sy bF� (Y WWcc„d,fD@pWWAntGIC=mywm EVALUATION REPORT Paps 1 or—.:2 atwmalSddvandtWkbXo ' TImB�K- - QQ �.p�a OD. AR AOR t.Co� C�" !t Audi a'omoo au plow emstaxtf Hilda.leR aalariadu ad�Nla N Pad ID. paroaraatope.aaabor a aM road prix ar 1n14�11. .�' M nse IawlHisws11m1eepa.Me .. tme, e. .044 Propaly0war D n 6� conk L Gort. Lot 1N F 1M S T Z9 N R E (t» pmpaly DwneftU OVAd"M Lots Bbcka mt.r fYiwneMC w �9 ba/ e 6 cillf um❑ Car O Vaape OTown Now AM µmod_c,,)r\ twi 1.5ft ,.c/ S aA pNwCaMYNdien lmPPAM1d1WdY/Nra16o0fteraoora — Codedaladdaaipolow raft yCa/�6� _ GPo !) ❑Rap4wnWd ❑ public, arawmvaW-tx.Qtm Paaarrwmbd rI , J SC^ -_ Flood PbtN eWatlon 11110 a3eb IvA, adismna mow,,: © BOelq x ®pit� Ground sunhat aim. ' 20 R Depth to W^" rao zt/1r In aw Rafe Nwow Depth Domkwn Cafor Red=Description 7tahra StnKlure Consistence Boundary Root GPDff -owl 'vw h ulmsel Ou. SL Cont. Color Gr.Sz.Sh 6'1 - 5,- Zm CS I v s- $, ' fyly, e- S — b-7Z V1 ,•� �/ � �-T s� O �w 51 Bwinp 1 ® px Gramd aurteca afw. "00, lob R Depth b Ip Hr1v � �� In. Sol Application Rae Depth DominantColor RadonDgedpawt Aab" Sbvdwo CondWnoe Boudory Root GPDW H.Mursel Ou. Sz CoatCobr Gr. Sc Sh. -12 3(Z - S, Z / l J Ll F 12 0 yr — 5.'G/ Zm C 0 W- 3. 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