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Home My WebLink About020-1100-40-100 (2)Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes (Privacy Law, s 15 04 (1)(m)] Pennd Holders Name City Village Township Lutheran Social Services I TOWN OF HUDSON CST BM Elev: Insp. BM Elev z B"scnphon. ,. TANK INFORMATION TANK SETBACK INFORMATION PUMPISIPHON INFORMATION j % Manufacturer Demand GPM Model Number TDH Lift Friction Lo System Head TDH Ft Forcemain Len Dia. o Well t SOIL ABSORPTION SYSTEM TION DATA Bldg, rSer �--_ Dist Pipe Bot System �A .r.91 f-' / � BEDITRENCH Width Length No Of Trenches PIT EN ONS No Of Pils Inside Dia. Liqui Depth DIMENSIONS SETBACK SYSTEM TO P)L BLDG WELL LAKE/STREAM LEACHING Manufacturer. INFORMATION Type Of System CHAMBER OR Model Number DISTRIBUTION SYSTEM "I" Header7Manifold Length Dia Distribution Pipes)) Length Dia Spacng x Hole Size x Hale Sp g Vent to Air Intake SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Bed/Trench Center Depth Over Bed/Trench Edges xx Depth of Topsoil zx Seeded75od d - zx Mulched COMMENTS: (Include code discrepancies, persons present, etc) Inspection #1: Inspection #2. Location: 9g BAKER RD it 6-nP�y�laGnq Cyst r�o� w�PU� �l 1.) Alt Description 2.) Bldg sewer length == y1r, h/�l'ti I V*,y, y o t - amount of cover = P I Plan revision Required? ]Yes � No 1A /j��(�/1 ' /) �jI 14y////// Use other side for additional information. 14� �W �I✓{ 1 ((IV Ir V�__ Datep is Signature Cert No. SBD-6710 (R 3197) iii �91ni- Goal — 3V 9 County Sanitary Permit Application ST. CROIX COUNTY WISCONSIN In accord with Chapter 12 St Croix County Sanitary Ordinance COMMUNITY DEVELOPMENT DEPARTMENT S information you provide may be used for secondary purposes ST. CROU(COUNTY GOVERNMENT CENTER F/J 30ral 1Pnvacy Law. S. 15.04(t)(m)] -7 X 1 , 1101 Carmichael Road Hudson, WI 54016-7710 lY (715)3864680 Fax (715)245-4250 lath complete plans for the system pe t 8-1 Ul1 inches in size. C0mmVnCrO4 Co only S fiery Permit # ❑ Check if o prevrous n 1. Application In Print all information Location, II// n Property Owner Name (G,4 8 R D 1, Q R d a. Ivr 114 5v 1/4, Sec 3 LU SrN C' I �1f\ ` ) (.Q T a9 N, R E Property Owners Mailing Address Lot Number Block Number 31a6 W C1�, mo►v" Su��e 3 _ City, Stale Wt Zip Code Phone Number 'CIS"'i41� Subdivmion Name or CSM Number rpu Clp,re 5`Ilbl 1ba3 CShn Vo . GF 11•�3 I Type of Building; (check one) []City ❑ Village own of ❑ 1 or 2 Family Dwelling - No. of Bedrooms: ❑ Public(Commercial (describe use): 1\ubS IJ "6 State-owned b Nearest Road �p� K II. Type of Permit (Check only one box online A. Check box online B it applicable) Parcel Tax Numbers) 1g Repair 2.0 Reconnection 3t] Non -plumbing 4.❑ Rejuvenation A O-Ao ` 1 1 0 I VO Sanitation / v B) Permit Number Date Is ad Slate Sanitary Permrt was previously issued IV. Type of POWT System: (Check all that apply) Non -pressurized In -ground ❑ Mound >_ 24 in. suitable soil ❑ Mound 5 24 m. suitable sal ❑ Mound A+0 ❑ Sand Filter ❑ Constricted Wetland ❑ Peat Filter ❑ Drip Line ❑ PressurizedIn-ground ❑ Holding Tank ❑ Single Pass ❑ Other ❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating V. Dispersallrraatment Area Information: 1. Design Flow (gpd) 2. Dispersal Area RequIired 3. Dispersal Area Prop 4. Sal Application Rate 5. Percolation Rate 6. System nyyElevation 7. Final Grad El �0� lsed� d (Gals. /daylsq.R.) (Min./in�) hl 8& 3 gory VI 4plas3bc VI. Tank Information Capacity in Gallons Total # of Manufacturer Prefab Site Con Steel Fiber- Gallons Tanks Concrete strutted glass New Existing Tanks Tanks aoa a Ir ❑ ❑ ❑ ❑ 7-1 ❑ ❑ ❑ ❑ ❑ VII. Responsibility Statement I, the undersigned, assume responsibility for repairlreconnecborVrejwenationlinstallatwn of nor -plumbing for the POWTS shown on the attached plans. A license is not required for teralitt repair or the installation of non -plumbing sanitation system anne,epnn Plyplber's,(lame (pnn P Sig t e (no stamps)' %fJi P/MPnRaS No. Bu Pho �tl�� l d� Plum o �ess (IStU t S to Winis)V vI /Tv\ ?S b VA ) U Vill. County Use Only Approved Disapproved Owner Given initial Adverse Sanitary Permit Fee 027 Date Is ued /7 Z Isswrg nl Signature (No stamps) /o/ Determination IX- Conditions of ApprovallReasons fw Disapproval:J II /1/ �e,r I r Q SYSTEM OWNER) �V S �lr2T 1 Sept:( tank, effluent filter and f e9 />J h fr Q , P14 te- -e-xl LA I.Jr M dLspersal Fell must be, servicedrmainnined // ,/J by V yt t& jALL a� our management plan provided plumber. 2 All smbsck icgdiremenis must be maintained as per aprAitable rodemnlittantef. Rev: 3/21 p'ESCW D ii�aflh� GONvef ONAL COMPONENT DESIGN r 99X AM T)i i_'c PAGE YgB I PW 2 hasmtamA* FW PIM PDW 3 Sin Sam $ .fit Pme9 paw (i Rbf SPEAM 1 PAS _ Mw,-gmrer*r'kn RRW 7 -%L QT& Ci l Tack MMomwil2ft T'ojM PA S vbn-M Dmd Paw 9 _ VSM a- F%21 FAM Paso,dm anew ins 9OMJFS thsFpnzosem-sme&_fMMjMt i�P� S ST. Ctzo UNTY SANITARY SYSTEM File #- OWNERSHIP/ADDRESS FORM �z�se �h 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. OWNER/BUYER INFORMATION � Owner/Buyer _ v -Rtrv,).. `` -5C U j I S_C r- Ce Mailing Address 31-, t3 W C b i 1LTn o N Sv 1 City/State/Zip 'L p\-� 1 1 l Phone Number (required) 1 S 7 9 G "r? 0 Email Address (required) i1 D Ih - 0 C S e IPA e)L Parcel Identification Number bU - q b-16 (found on the property tax bill) Property Location _ t/4 t 1/4 SS WIS. LEGAL DESCRIPTION FIRM T� 1 N R I r W, Town of 0 U D 1 I /J Subdivision Plat: C 5 1')'1 6' f� L I G I Lot # a. Certified Survey Map # q yb Z, /�i Volume is Page # /6 73 . Warranty Deed # �S� Zy"! (before 2006)Volume . Page # Number of bedrooms Spec house O yes M no Lot lines identifiable 0 yes O no OFFICE USE ONLY New Property Address �J�13� )( %� (venfi,:aW_nDLryKw address required from Community Development Deparmn nt for new construction) (Staff Initials) (Date) 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 cdd(asccwi.aov 1101 Carmichael Road, Hudson, WI 54016 wwwsccwiaov -plot MAP N[Am-e.: LuAeIZAM Sdc'jpl Smii(w5- `"CfffION , G9 b 14w- pop[) LICAPR5 aaagc7 �C7I ep \�i�l� CINq All cp rILGTl V Y -jr Q2 I act Mn, Vo�VY I FOGERTY PLUMBING & PERK TESTING 2473 Rolling Green Rd. Spooner, WI 54801 (715)468-7000 Cell (715) 416-0000 Z./'. 7 �q'd1y �1ic.Ff �//ices' ,oT K3 wrvc7-• Bw+./ 7y pc /trrOWI 1f•9r' C c QOr wEGL t;3� � pLyfE.rY6R w = WBLG yZ C=S ` ,lawy� ccaevf o-s I p/S strr teat I� '--_ __ • , tee. I c � jj:VErtILrL- VoLVE a'�r TAO- SOIL EVALUATION REPORT #2086 Depafhnent of Commerce in accordance with Comm 85, Wis. Adm. Code Page 1 of 3 Division of Safety and Buildings Steers 80H Service Attach complete site an on a County P plan paper not less than ref x 11 inches in size. Plan must St. Croix include, but not landed to: vertical and horizontal reference point (BM), direction and - - - -- -- -- - - - percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel i.D. _0_20-1100-40-100_ Please print all information. Reviewed By Date --- Personal information you provide may be used for secondary purposes (Prwacy Law. s 15 04 (1) (m)). Lutheran Social Services Govt. Lot na NEI/4, NE-1/4, S34, T29N, R19W Property Owner's Mailing Address Lot # r ---- -- — 3120 W Clairemont Rd Suite 200 Block a Subs. Name or cS67 — 3 na CSM Vol.6 PG 1673 City State Zip Code Phone Number .I City Village, ; Town Nearest Road Eau Claire I WI 1 54701 1 715-796-7023 1 Hudson i Baker Rd New Construction Use. Residential / Number of bedrooms 6 Code derived design flow rate 9D0 GPD Replacement _ Public or commercial - Describe na Flood plain elevation, if applicable _. nafl. Parent material otA_wash_ _ _ _ - - - General comments Conventional system, trnches spaced and depth to code. Sylsem elevation to be determined by designer and recommendabons. or at the time of installation. Boring # --' Ground 97.00 surface ekw. ft. Depth to Omfting facto 120 in. Soil Application Rate Horizon I Depth Dominant Color Redo: Description Texture Structure Consistenj Boundary Roots L_GPD/R' in. Munsell Qu Sz. Cont Color Gr. Sz Sh 'Eefa 'Ef1I2 1 0-24 1 r4 4 none sl fill na na — a lc 0 •8 2 24-41 3 41-48 10yr3/1 - none_-- 10yr4/4 none So sid 2msbk - mfr-- 2msbk i mfr � _ cs �— gw na —6 8 na .4 _.01 4 48-601 I -------- - -}- 7.5yr4/4 none -- � cos �r------------ osg mfr ----- i 9w --- - -- - - na � I .7 _t 1.6 5 68-1+/ 7.5yr4/6 none cos 1 059 i ml na na 7 1 1.6 There is 7.5yr5/6 staining of Iron in honzon 4. oBoring # I _ 97.20 Ground surface elev ft Depth to limiting factor 120 in. Soil Application Rate Horizon Depth Dominant Color 1 Redox Description Texture I Structure Consistences Boundary 1 Roots GPD/R' in- Munsell Qu. Sz Cont. Color Gr. Sz. Sh. •Efwl 'ERR2 1-- G-12 1 r4 4 none sl i_ OY / 2msbk mfr ' cs na i .6 1.0 2 12-32 10yr4/4 none sl r —i — 2msbk mfr cs�na 6 1.0 3 32-120' If 7.5yr4/6 none cos osg m' na na 7 1.6 I 1 1 ' Effluent Al = ROD? 3D < 220 mg/L and TSS >30 < 150 mgA- ' Effluent #2 = BOD5 < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signature, CST Number David J. Steel 248956 Address Steel's Soil Service Date Evaluation Conducted Telephone Number 1699 1501h St New Richmond, WI 54017 11/142007 715-760-0347 - SB68330fR 0]/001 Property Owner LutheranSodalServices _- - ParcellD#_020-110040-100 Page- 2_-of 3 Bonng # _ Ground wrlace elev. - 88.30 It Depth to limning factor120 in. - — Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure IConsistem el, Boundary Roots GPOM' in Munsell Ou Sz. Cont Color Gr Sz. Sh •ER#t •ERa2 1 0 12 10yr3/2 none sl fill na - na Cs if .0 0 2 1241 10yr3/1 none sit 2msbk mfr a na .6 .8 3 1- 9 ', 10yr4/4 none sid - - 2msbk mfr gw na .4 .6 4 none 69-120 7.5yr / 4 4--{- cos osg mgw na .7 1.6 - ---- -� -- - ---I - ------t------ I---- I i I I Baring # - Grou surface ft Depth to limiting factor in. nd sU ace elev. —_ Sal Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistences Boundary Roots GPDIR' in Munsell Qu Sz. Cont. Color _ Gr, Sz. Sh 'EMt 7E02 -7,l I S I I ❑ Bong # _ Ground surface elev. — It Depth to limiting fade _ in. Soil Application Rale Horizon Depth ! Dominant Color 'I, Redox Description Texture Structure Consistence Boundary Rotas G_PDIR' in. Munsell Ou. Sz. Cont. Color Gr Sz It I 'ER#t •ER#2 -- _1 I I I LgY -ow Effluent #1 = BODS> 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BODS < 30 mgR_ and TSS - 30 mi The Department of Commerce is an equal opportunity service provider and employer. If }ou 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, SBP8110 (R 07W) i,ld's $opt Se Am STEEL'S SOIL SERVICE 3ot3 David J. Steel Lutheran Social Services 1699 150th St. CST-POWTSM NEI/4,NE1/4,S34,T329,R19W New Richmond, WI 54017 I,ic. #248956 Town of Hudson, St. Croix Co. Direct 715-760-0347 CSM Lot 3 Fax 715-246-0318 Legend N 1"=40' j !G ♦ =Benchmark Ele. 100.00 ft Top of PVC pipe • = Alt Benchmark El 99.95 ft %jai /'6 op 0 E = Borings Boring Elevatioi is B1 = 97.00 ft "$2= 97.20 ft 6 e— B3 = 88.30 ft 1011cc B4 = 0.00 ft Cz �-j C 6 C '7s / C' C C Ff00o siDepartment of Commerce PRIVATE SEWAGE SYSTEM y and Building Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal mformation you provide maybe used for secondary purposes (Privacy Law, s 15.04 (1)(m)] Lutheran Social Services bM t TANK INFORMATION 1j , _ << TYPE MANUFACTURER CAPACITY Septic J , n.� ti. , CfrCti� F,•I � y / O 00 Aeration Holding TANK SETBACK INFORMATION TANKTO P/L �. WELL B��LD A ventlo Airmtake �� ROAD Septic .-, L5 Zy z7 -- Dosing Aeration Holding PUMPISIPHON INFORMATION Manufacturer Demand GPM Model NWober TDH ift Friction Loss System He TD Ft Forcemain ngth Di Dist to Well SOIL ABSORPTION SYSTEM 65-T ELEVATION DATA STATION BS HI FS ELEV. Benchmark 03 16).63 I GD AIL erne.; ` 3, b9 S�•3`i Bldg. Sewer 1 SUHt Inlet b L St/Ht Outlet S? Dt Inlet ` Dt Bottom Header/Man. Dist Pipe .n`7 f Sot. System Iby� Final Grade t I7 9 33 stc0N4.-, Co ?..U5 97, 3� 56oL1., T, I1.st $9,Y5 Iz, I Vs. 93 II 0J.r 9., 1 1+0�7 %P, /'(p BEDITRENCH Width Length r No Of Trenches PIT DIMENSIONS No. Of Pils Inside Diay Liq I Depth DIMENSIONS 3 W 3 lTew -k A I � SETBACK SYSTEMTO RIL eLDG WELL LAKE/STREAM LEACHING Manufacturer �� INFORMATION CHAMBER OR Y 6' Type Of System /V UNIT Model Number ^ ' [?y✓,ICJ¢-� ` ti DISTRIBUTION SYSTEM Afu'll,. 51 Header/Manifold ..' Distnbu0on x Hole Size x Hole Spacing Vent to Air of ke I Length ! Dia Length Dia Spacing C bLu' — SOIL COVER x Pressure Svstems Only xx Mound Or At -Grade Systems Only Depth Over / Depth Over xx Depth of xr SeedeNSodded xx Mulched Bedlrrench Center ! t� 7 Bed/Trench Edges Topsoil \ Yes " No +l, - yes COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1:_/. Location: 698A Baker Road Hudson, WI 54016 (NE 114 NE 1/4 34 T29N R19W) NA Lot 3 1.) Alt BM Description = ri 14, C. a m, - ) e— ' 2) Bldg sewer length - amount of cover = I) J Inspection #2:_!_/_ / Parcel No: 34.29.19.402i O v� #e .raeAAX4 3 O' Plan revision Required? ri Yes WrNo !y�il I {r Use other side for additional information l L- Date V Insepcto Stgnat SBD-6710 (R 3/97) Fir PAW e e commerce.wi.gov Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 _ isconsinMadison, WI 7-7162 Sam ary Permit Noumlbe�r o be filled in by Co ) Oepartmern of commerce �y p V CIO Sanitary Permit Application_ IIIR7aala State Transaction Number 'ey) In accordance with s. Comm. 83 21(2), W is. Adm. Code, submission of this form to the appropriate . unit is required prior to obtaining a sanitafy permit Now Application forms for state-owned POWCS are Project Address (if different thanmailmg address) submitted to the Department of Commence. Personal information you provide may be used for secondary DUrPOWSm accordance with the Privaz Law, s. 15. 1 m , SM s. AV 1. Application Information - Please Print All Informa . Property Owner's Nameparc/-iH fAfoira ✓�i--y Is li L - &7,2g Property Owner's Mailing Address NUV Zb ZUU1 Property Location 3 zo W. Govt. Let — -�� vh �f((` yti Section JUL City, Sure Zip Code P e ZONING OFFICE C ce rF' >' B (circle one1_ T N; R E o0h" r " 15-- Y — - Type of BsWdiug (check aD that apply) �t Subdivision Name _ _ _ .- __ ,111. Is>I oc2 Family Dwellinu— Number of Bedmorns 3 ULI re�p 'f Blmilk r ❑ City of ❑ Public/Commercial - Deacnbe Use ❑ State Owned - Describe Use ❑ Village of Town �!/DlD.1/ CSM Number 5 66 (, �tp� �� (_ ar 111. Type of Permit: (Check only one box on tine A. Complete tine B if a plioable) A. ❑New System Replacement System ❑Tmatment/Boldmg Tank Replacement Only (Other Madifiwtion to Existing System (explain) r--� s.T• i - I r� B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Ptmtrt Transferto New List Previous Permit Number and Dave Issued Before Expiration Owner T a of POWTS S tem/Com nen NDeviee•. Check all that apply) .IV. t7 Non -Pr' sunaed In -Ground ❑ Presswiaed In -Ground ❑ Al -Grade ❑ MouM>24 to ofsinmlhhe soil ❑ Mound< 24 in ofsuimble sill ❑ Holding Tank ❑ Other Dispersal Component (expl ❑ Pretreatment Device (explain) V. Dis ersal/Preatment Area Information: V ( 'nec Design Flow (gpd) Design Sod Application Rat squired (s0 Dispersal Area Proposed sf) System Ekvati?n C-I = 9 a--Q, VI. Tank Info Capacity in Total M of lituoulacneer Gallons Gallons Units v yy New Tanks Eautme Tanks Septic aeilaWra9Taak DearagC-Ferber � VII. Responsibility Statement- 1, the undersigned, assume respomibility, for butalh n of tke POWTS shorro ou the attached plain. Plumber's Name (Print) Plum 's Signature MP/MPRS Number Business Phone Number iv'- 6 - 7ocv Plumber's Address (Street. City, S flue. Zip Code) � 7� t/�`_eAeo � 3 vG Vlll. County/De utment Use Only 1�A/ bpproed E] Permit Fee Date issued Issuing A igna me, $ .4/51) zT o ven Reason for Denial •� ,r IX. Conti"TbOmmeasons for Disapproval 1. Septic tank, effluent fitter and dispersal can must all be*servh:es / maintained • as per management plan provided by plumber. 2. AN setback requirements must be maintained AIm i m emnple e p a s o be system and submit to the County only on paper not less than 81/2 a l l iaebes In size SBD-6398 (R. 01/07) Valid thin 01109