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Home My WebLink About004-1041-90-200 (2)Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County St. CFOIX Safetyand Building Division INSPECTION REPORT Sanitary Permit No GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No SAN-2021-373 Personal information you provide may be used for secondary purposes [Privacy Law, s.15 04 (1)(m)] Permit Holder's NameCity Village Township Parcel Tax No: Jeff Nelson I TOWN OF CADY 004-1041-90-200 CST BM Elev: Insp. BM Elev BM Description Sechon/TowmRangelMap No: 18.28.15.283B 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 Alt BM Bldg Sewer SUHt Inlet SUHt Outlet Dt Inlet Dt Bottom Header/Man Dist Pipe Bet System Final Grade St Cover BED/TRENCH Width Length No Of Trenches PIT DIMENSIONS No Of Pus Inside Dia Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer INFORMATION CHAMBER OR UNIT Type Of System Model Number. DISTRIBUTION SYSTEM Header/Manifold Distribution x Hole Size z Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length 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 Bed/Trench Center Bedrrrench Edges Topsoil Yes E] No � Yes �i Na COMMENTS: (Include code discrepancies, persons present, etc.) Location: 2748 CTY RD N 1 ) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Inspection #1 Inspection #2: Plan revision Required? ❑ Yes ❑ No Use other side for additional information Date SBD-6710 (R 3197) Insepctor's Signature Cert. No. our am ary Permit Applicatidn ST. CROIX COUNTY WISCONSIN C ter 12 St. Croix CountySanitary Ordinance COMMUNITY DEVELOPMENT DEPARTMENT C�rith ou provide may be used for secondary purposes ST. C R O NT P i orrposes ST. CROIX COUNTY GOVERNMENT CENTER [P acy Law. S. 15.04( ] 1101 Carmichael Road St, Crol% COuntY Hudson, WI 54016-7710 nmunity Development frni-Attach (715)386-4660 Fax(715)245-4250 complete plans for the System cimpaiRilILLo1jess than 8-1/2 x 11 inches in size. County Sanitary Permit # ❑ Check d re on to new bon I. Application Infomration - Please Print all Information Location: Property er Name 1/4 � 1/4, Sec 14 m T N, R E (or) Property Owners Mailing Address Lot Number Block Number (AvAl d, tJ I City, State Zip Code Phone Number Subdivision Name or CSM Number — 1 I GSW1 Z1 -52,35 I Type of Building: check one 13 1 or 2 Family Dwelling - No. of Bedrooms: ❑City ❑ Village [RTown of ❑ PublidCommeroial (describe use). Cap Nearest Road ❑ State-owned II. Type of Permit (Check only one box online A. Check box online B d applicable) Parcel Tax Number(s) zr1n A) 10 Repair 2.14 Reconnection 30 Non -plumbing 4 ❑ Rejuvenation � ` 11 t1 _/y ", j2h ,, kll—( V't �1V70r-1 Sanitation 8) Permit Number Lill Al 3 Date 1 �' z8 � State Sanitary Permit was previously issued IV. Type of POWT System: (Check all that apply) ❑ Non-prossunzed In -ground ❑ Mound z 24 in, suitable soil �' Mound s 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 R P sed (Gals. /day/ q.ft.) (MinAnch) Elevation LAGIO c Manufactu r VI. Tank Information Capacity in Gallons Total # of Prefab Site Con Steel Fiber- Plastic Gallons Tanks Concrete strutted glass New Fxistmg Tanks Tanks ( o00 ❑ ❑ ❑ ❑ 110001 ) 1 hhflf COAUde Q ❑ ❑ ❑ ❑ VIL Responsibility Statement I, the undersigned, assume responsibility for repair/reconnectionimluvenatioNmslallat n of non -plumbing for the POWTS shown on the attached plans. A license is not required for terrallft repair or the installation of -plumbing sanita em. Plumbers Name (p "n ) Plumber 'gn (no stamps). MP/MPRS No. Business Phone Number ,Lenk1S A Plumbers Address ( treet, City, State, Zip Cod Vill. County Use Only (� Disapprovedanitary Owner Given Initial Adverse [Determination Permit Fee Date Issu Issuing ent Signature (No stamps) RApproved 4 IX. Conditions of Approval/Reasons for Disapproval: SYSTEM Oink. of i`/-p eXl�7-!n mo ) 1. Sepfc tank, effluent filter and vtC VytO' dispersal cell must management p an pr edlma'by pud �1 � ,^ I O� /` esper �1 �xjg 7_L Jt�••U, etbkno,en,anp ustbebyptainedf 2. All setback regwren+.cots must bemaintained as per applicable code/ordmahtes Rev3121 —PRELIMINARY DRAWINGS ONLY- NOT FOR CONSTRUCTION USE— FINIS D. 1W885q Ft UNFINISHED I8935p Ft � I ill�•I ill rl:d Ell 9 l is wu e ._......-..._. �9L t5 Iv .'_ Q - aau:r ----- FOUNDATION SCALE, 1/8• = V' Wo .. w Q xaee�� J 9 _ � r W d DORMER i SCALE W16'=1'-I1' .i A Ell MAIN FLOOR e SCALE W= 1 L wQ M _ a SQ VW- v\kti ST. CKo LJNTY SANITARY SYSTEM File ce Office Use Only + OWNERSHIP/ADDRESS FORM Crated 212021 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 , )� t I\j'y \ -j l - 1 Mailing Address C( 1��/ �� City/State/Zip t�iordylu - uJ �AOD t Phone Number Email Address (required) +� Parcel Identification Number 00y - C)�\ - q 0-200 (found on the property tax bill) NEW SYSTEM: LEGAL DESCRIPTION Property Location 1,1A , 4 1A , Sec. IL T �J_N R__6W, Town of Subdivision Plat: Lot # Certified Survey Map # DgIZB!Ci -� 66 Volume z Page # �Z Warranty Deed # 6-� 029 3d3 (before 2006)Volume . Page # Number of bedrooms Spec house O yes O no Lot lines identifiable O yes O no OFFICE USE ONLY New Property Address Cht3�iYk (Verification of nolw address required from Community Development Department 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(sccwi.gov 1101 Carmichael Road, Hudson, WI 54016 www.sccwi.gov wrs•slrlsiri Id C«rvierce PRIVATE SEWAGE SYSTEM i Safety arM BuiNirg Division INSPECTION REPORT 'GENERAL INFORMATION (ATTACH TO PERMIT) Personal mformaton you provide may be used for secondary purposes [Privacy Law. s.15 06 (1)(m)] If I !ao•or TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic ( om A Dosing Aeration Holding TANK SETBACK INFORMATION ®M�_ ®' _-_a- PUM SIPHON INFORMATION MantAacbxer _ 6 L-��z- Dem2 , GPM I Number TDH lilt „cy �D Friction Loss 3-t4 System Head DH Ft S Y`f Forcemain Length I Da.Zq Dist. to Well • • ; J�I.1:F-l'd6'1+14,1. ELEVATION DATA ' St. Croix Saritary Pernvt No- 499143 0 /6.# Tax No IeaJ - /041- 9n 18.28.15. STATION BS HI FS ELEV. Benchmark Z/ r Alt BM Bldg Se SVHt Inlet Ix'� O2-r of St/Ht Outlet Dt inlet Ot Bottom �� O 3.0 1g r Dlsl. Pipe ij,� •O� BotL System 3.1- 3•1/ Final Grade St Cover A s.sr cr sf 9 , to Flo w�.vt Sl-i•. 1tdHf` 1a�bw NSI"O S Wgth / Length / . ZS No 01 Umehes I PIT DIMENSIONS No Of is Inside D,a SETBACK SYSTEM TO JPIL LDG ELL LAKE/STREAM LEACHIN anulacNrux RIFORMATION CHAMBER U Type Of System' " Mo Number nL4TRIRUTION SYSTEM NJ 1�t1e�rlr�I�ttttttttti `l��i�_�„ '„mar. ,l . Header/Manifold R rl Distributbn l Lengei D' Lerlglh paarg SOIL COVER Center 11 Pressure Sysl Depth Over Bed/Trench Edges x Mound Or At -Grade xx depth cf x :QMME NTS: �(jnclude ,"e dlscr pnc ies. persons pmseM. etc) tnspecton #1 / yalJji� W✓v U71sr. 1M Ion: pence Unknown (NE !4 SW 114 18 T28N R/5W) NA -),Lot I CAJ All BM Description = :u Ild"rt� �u ! A !) lio �•e� Iv�Q (,a Bldg sewer I ngth = M' �PP�tc m4 c` - amount of cover = d� l erosion for aidd? Yes y� No I % User sidea for additional nforms � 14( •. Dale Insepclors Signature 10 (R.3/97) Yes No I Yes : No I � Inspection 7F2. �y,•} Parael No: 18.28.15 iA YtT 4f_� j•.i� Cert No Safety and Buildings Division C-atty visconsin 201 W. Washington Ave., P.O. Box 7162 St. Croix Madison, WI 53707 - 7162 wy Permit Ntm w(m be r W m by Ca) De artment of Commerce (609)266-315) Sanitary Permit Application lfp Pt. fiber Trans. Id # 1310455 To cooed with comet 83.21, win. Aden. Code, peaood information Yon provide - Addsw (if thh a m.(iakg�ad a++�ra )p C�Q-tA �i%1%1i p" may be used for secoodo y purpose. L Applicatim Information- Please Print All lnfortos m Prapaty Onuses Name Pavel# # Bhp# y . Jeff Nelson Pru NTY 1 - 0 1 WA Property Ovmer'a Mailing Addmaa y 'm 420Johnson Court NE SW YS Saaim 18 vh City, State Zip Code Phone Numbs Woodville, W 1 54028 715/220-2618 28 rJ(�t me) N' R IL Type of Buildmg (check all that apply) �L bdivuim Name CSM Number ❑� (or2Family Dwelling ofBodmame 9 _ ,,, ,Sa ,-�-�/.. _f S-.,.L.�. 629156 ❑ Pnblia/Co s mmid - Dmanbc Use •� dYJ-t""`do �'°`Wd radY ❑State Otmed-Describe Use �- IIL Type of Permit: (Check only me box on A. Comp) B if applicabk) A- 0 New S)Vam ❑ Replaoemcnt Syatcm Trtatmmtflok1mg Tank Replao®mt Only ❑ oil=Mo35odim to Emu" syst® B. ❑ Pcvmil Renewal ❑ Permit Revision ❑ Change of O Pamlt T ansfer w New Lot Pmviem Pomrt Ntmbw and Del. knttd Bd'ore Expiration Plumber Owns l / IV. Type of POWTS S Check all that a S _ _ • O ❑ Non -Pree w=d In-Grormd ❑ Moutd> 24 k of suitable soil Mound <24 in. of suitable soil G At-omde ❑ S®gle Paw Sand Filler ❑ Conehuard wetland ❑ psasurind In-Grou td ❑ Iloldmg Teak Q Peat Filler ❑ Aeobw Trcawont Und ❑ Rmucu ding; Smd FiKm ❑ Ravuuktmg Synthd. Media Fier ❑ learLmg Cluaobe 0 Drip liix 13Gmve4ka pipe D Other ( ) V.Du naVFreatment Area Information: Deign flow (gpd) Design Soil Appbostim Rak(gpht) Dispersal Aces Required (d) Deposal Arta Pro"ad (sf) Systtm FJcvehm 450 1.0 450 450 96.53 VL Tank hdo C.paoityin Tow Nunsbe Mmju�fgal [w P.c�b Site SWO Fiber Plastic Gallons Gellcns ofUttik " "•"�' 1 jf.Q f,,,�tt'rr+a"h Cmade (.'onehoQed Glass Re. t} �0 Ts.b T.I. T.I. s.poeannBmgT.& 1000 1600 1 Wieser Concrete X A.rabc Trtm.eLL Unit m'ag °iaaba 600 600 1 Wieser Concrete X VIL Besponsibility Statement- L the aeivslpsd, aarase b for inwhilhiflaw efthe POWI'S shaws w Is. stmehel plea Ptumbda Name (Print) Plum 's ScgnaWre WWAS Number Business Phase Number Bennie Helgeson &0292 7151772-3278 Plumber's Addrea (Sheet, City, St" Zip ) W1229 770th Avenue, Spring Valley, WI 54767 V IIL gogEy/Department use Only AAP d ❑ Dkapprwed Sanitary Pemrit Fee Dat. hsued ent Is - AgSi Slurps) -Grutmdwaa>• surohalw Fee) 55CJ'— ❑ Reason id W IX. Cosdi4om of ApprovaURemom for Disapproval SYSTEM OWNER: 1 Septic tank, effluent filter and dispersal cell must all be serviced / maintained as per management plan provided by plumber. 2. All setback requirements must be maintained as per applicable codelordinances. Attack easpb pin. (tu do C..aty aly) forth• sy ear oar Peer nor hw this e111 x It tarkar Is arise SBD-6398 (R. 01/03) ,S MI Plot pl o s Er,go+- As s Km- o� 2 00 S:UaY" AIQ, -Pinti Trr� Pee G�p�l . REPAIR El ST, CIROIX COUNTY Nor STSArN —2oz f _ 373 RE&NNECTION NON -PLUMBING ❑ SA1 1 I TAR Y PERK SANITATION �YT REJUVENATION ❑ OWNER 74WISON1 PLUMBER �;t p%4 gke LIC. # ZZ Z 7148 C41 TOWN OF d LOCATED aiLE Xj is C,W 7zq SEC T N;R AND/OR LOT BLOCK CSVIA V- 57 3�S SUBDIVISION The purpose of the sanitary permit is to allow repair, reconnection, nation, or Installation of non -plumbing sanitation as described In the atlon for permit. The approval of the santlary permit Is based on regulations In force on date of Issue. (c) The sanitary permit Is valid for 2 years from original date of Issuance t may be renewed for similar periods thereafter. Application for renewal shall made through the county and shall comply with regulations In effect at the Inns. (d) Changed regulations will not Impair the validity of a sanitary permit until the time of renewal. (a) Renewal of the sanitary permit will be based on regulations In force at the time renewal Is sought. Changed regulations may Impede renewal. (f) The sanitary permit Is transferable. A sanitary permit transfer shall be obtained from the St. Croix County Zoning Department. If you wish to renew the permit, or transfer ownership of the permit, a cnnfacf th. Ff Crn]v n„h, 7...,1— 1--- ..___. VISIBLE FROM THE ROAD FRONTING THE LOT DURING CONSTRUCTION