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HomeMy WebLinkAbout006-1078-90-000Wisconsin 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)I. Permit Holders Name: City Ben Stack TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic Dosing Aarffro-n Hlin TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic r , Dosing Aeration Holding PUMPISIPHON INFORMATION MitS-f%7Iil,r ✓ q0 Manufacturer Demand GPM Model Number `; r TDH L' Friction Loss System Head �-- TDH Ft Forcemain Le Length Dia.d t I Dist. to Well r I f. —A"Jb� v 7 TOWN OF CYLON ELEVATION DATA County: St. Croix Sanitary Permit No: 642229 Slate Plan ID No: Parcel Tax No: 006-1078-90-000 SectionrFown/Range/Map No: 34.31.16.525A STATION BS HI FS ELEV. Benchmark OL �J d Alt. BM X -IrS Bldg. Sewer °j. 3 St/Ht Inlet C� 1Wutlet Dt Inlet Dt Bottom 11' r01 l (- Header/Man. 1v Dist. Pipe Bot. system 55 9 3 .7 5 Final Grade -�Coval -3.20 SOIL ABSORPTION SYSTEM + ,{- 19 BEDlTRENCH Width Length DIMENSIONS 3 L 7 6s No. Of T. nches s PIT DIMENSIONS No. Of Pits Inside Dia. Liqui Depth SETBACK SYSTEM TO PP/L BLDG W�ELL LAKE/STREAM I LEACHING f turer: INFORMATION Ty9f Of System: V r 3� 1 ' O :HA LINER OR umber: DISTRIBUTI SYS EM Header/Manifold Distribution x Hole pacing Vent to Air Intak e r � Pipes) Length Dia L Length Dia Spacing SOIL CbVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Bedfrrench Center 7 .) sr Depth Over Bed/Trench Edges rr th of Tops xx Seed dded :. No xx Mu d t_; es O No COMMENTS: (Include code dyMncies, persons present, etc.) Inspectia #1: t�3/�L( Inspection #2: Location: 2321 escHWY—V(&NV i /C��� / 1.) Alt BM Description = V�� �C_ 1 � 2.) Bldg sewer length = 301 7r I S •rp 5 3��(tofcover � I� 9 Plan revision Re redtl Yes n. No --�L %� � U ojfterpsitleforadditiona ' fo lion. �.,${@\ f0 a rJJ�Q/� r9� yv1e,,,,� bate n ors Signature Cert. No. SQD/6710 (R.3/97) � _a n _ _ A j /8Jkek �tiv^a"�i Industry Services Division County 4822 Madison Yards Way Madison, S-V C r61 Sanitary Permit Number (to be filled in by Co.) W 153705 P.O. Box 7162 Medicos WI 53707-71 '' 6 4 11a'' it Application State Transaction Number In accordance ith SPS 3 h (j4 v ode, submission of this form to the appr ' Project Address (if different than mailing address) is required pri to i itary permit. Note: Application forms for state -own dry to the Department a ety and Professional Services. Personal information you provide may be used for sec ry purposes in accordance with the Privacy Lase. s. 15.04(1)(m), Stats titian -Please Print All Into n®lu( f , , r Property Owner's Name Parcel A der. �4uc u, 0 o b- I o Property Location _ Property Owner's Mailing Address 23Z1 Govt. Lot 314. 31. 1 to . S 25.4 14N hi�tl 3L/ City, State Zip Code Phone Number 1Q4W W ( 6'-P0/7 7/6'• 977 V<. /a Section T 3 N R1 L E o eheck all that apply) Lot 4 I or2 Family Dwelling- Number of Bedroom. / Subdivision Name [Jublic/Commercial-Describe Use Block ft rb o e.' F-IState Owned- Describe Use U`tty village of CSM Number 51lygc Town of e�L✓% ' hermit: (Check either "New" or "Replacement" and other applicable on line A Chow one bo><9d;40, A. ❑New System ❑Replacement System athet \1011i lic.na'n 10 1 aistt ng System (eaplmn) .Additional Pretreamrent Unit (explain) B' 1^:1,�,,oldbt • Tank U'• b hrGrouttd � I''�k FGmde U^ Mound Individual Site Design ❑ ❑ bin Other Type (explain) (conventional) C. ❑ Renewal Before Revision ElChauge of Plumber ❑Transfer to New Owner List Previous Permit Number and Date Issued Expiration 3g Design Flow (gpd) Design Soil Application Ratc(gpd/st) Dispersal Area Required (s0 Dispersal Area Proposed (sf) System Llevauon r t3ao ot{ 1 7119,0 "1'l°L, taib Capacity in Total '1 of Manufacturer Tank Information Gallons Gallons Units o '� o New Tanks Existing Tanks Pply lol,- S2S v ? aU s n a %C7 m a Set or Holding Tank /000 tOpO 1 f�,y.-(f Dosing Chamber ire kgspotraibllitit for Installation of the POWTS shown on the a#tpOped plans. Plumber's Name (Print) Plumber's Signature MI'rMPRS Number Business Phone Number its 224W-7/ L7l5 -(v Plumbers Address (Street. City, State, Zip Code) 3s-z 14o4- St Aw)cew W l Sqa) j t Approved ❑ Disapproved Permit I ca Date Surd s Gl b Issuing Agcnt St rC ❑ Owner Given Reason fix Denial , C)O z �- Conditions of Approval/Reasons for Disapproval 3 • �1°v!S Ion A � Co►�,b Ih sysTEm OWNER: P� 1. Sefttic tang, efflitertfilter and imillertal m.anmust he aer.rtewdrmaintained y 1 m,L, oa per min,4 tatrdmt 1, nt plan ptovldod by plumber. 41 I �oy�d 1 ` !r 01..E 0 r`51 YIa tb mutt be tnaillal"W J 9, All srtbAk 100"i"110 a pot diwilgiiHM tdtlt4/Hrt11RAtICea, i h-e'�G�. Amen m complete plans tar the system and submit to the County only on paper not less than a tax 11 inches in size SBD-6398 (R. 03/21) Industry Services Division Coln v 4822 Madison Yards Way � Madison, WI 53%5 Vumbw filled in by Co.) Sanitary Pcmi- (robe P.O. Box7162 = OCT 22 2021' Madison WI 53, 16 ZZ rnit Application G stateT�nSa�'°��umbe In accordance with S o n� u el pMe :on of t}:s fotc to the zppropaate governmental unit -_ Pro'ect Address (if different tban mailing address) is required prioz to obtaining a sanitarypermi_ Vote: Application forts for state-owned PC WTS are submitted to the Department of Safety and Professional Services. Personal irformz$on you provide may be t:sed for secondary purposes in accordance with the Privacy Law, s. 15.04(-)(m), Stats. L Application Information - Please Print All Information Property Owner's Name Parce, cw sac P!operhOwner's Mailing Ad s P ope^y Location S'25A •?I.14.. 2 2 1 6Y& 9 Gov:. Lot City, State V Zip Code Pho_e \.rmber W Q Section „1 [VfW CSC 49cn � ✓l SVO17 577'Z70e., IL Type of Balding (check all apply) Lot -I V R /� Eo N+ Mxor2Family Dwelling-VumberofB -ooms__ Block�ublic/Commercial - DescnbeUse jubdivisionVame y o:❑State Owned -Describe Use CSM V,�mberllageof wn of CV /Oh ` M. Type of POWTS Permit: (Check either ` New or "Replacement" .d applicable on line A. Check one box on line B. Complete line C If A [aew System breplacem ystemE. M ca w xistg System ;explain) N ❑Add t onus P etreatment Unit (explain) LOOA r' B' aolding Tank "In-Groundi �^;'❑Vo Site Design.11 Ocher Type (explain) (convenrionzl) C. Ratawal Before ❑Revision mber 11_7arsfe: to New Owna;Qas' Expiration Previous Permit Vumbe, an Issued 3 s t > CAN ta w" IV. ent Area and Tank lion ✓l& Design Flow ) Design Soil Applicat: Ra, d nsperszl Area R wired (s D!s�ersz: Area Pro sed (s) System Elevation 3t� Sod D.'� S_0 7% 779.5 e1gd 93,4, `?3, I I Capacin n _-Total ;=Ofx Manufacnrc Gn_t Tanklnfornuman Gallons ons ::nks r 01ylo 5 v i v_ New Tanks xu gTA^" o= z r 4 or Holding Tank j 00(I/OOO ! Dosing Chambr. V. Responsdbtity Statement- 1, the 91dertigned. assame responsibility for installation of the P00V shown on the attached plans. Plumber's Name (Print) Plumber's Sicnat,.Lre -%,2 MPRS \umber Business Phone Numbe Plumber's Address (Street, City, S .e, Zip Code) 3sz / "s; h�7r.Jl L4_12 y4o I vL Connty/De artment only Approved ❑ Dis ved Permit Fee Dat Issued Issuing Agent ' n,* ❑ iven Reason for Denial '�ZS s o %1 Z 3 Z % /er Conditions of Approval/Reasons folTpis4—Ply" ca': SYSTEM OWNER: P t; 3 It`�%� D A d� 3 !hC pW 4fil 1. Septic tank, effluent filter and / J I L dispersal cell must be sarvlcrdbe lmahtainad /, T / as per management plan providedubbe h1' plu wal / "R-✓C S 2. All setback re le cod nts rnuat be malmaittad G lek- osperapplicabNcodelordinarltef, CC �jY� ter,,,/ 1 u �uumn we �)ounn otuy on paper nol*_less than a :n: 11 /incbq` r_a size �t 64vC Q J / !`i/qL f S! A�{�f e%i�N%7TT7 t S�SKY�s VS7` �C s/ 47L I)/ Z SBD-6398 (R. 03121) a y3 JCS/e lf`-' yQi 14 �321 O `' 3% IanK CB 14 ?022 Croixity p vefo me . cr L L, W �� 75 — 22 70 - 20 651 60 18 55 16 50 14 45 0 Q w T � 12 40 Q z 0 35 10 O 30 F— $ 25 6 — 20 15 — 4 10— 2 ` 5- 0 GALLONS LITERS 0 PUMP PERFORMANCE CURVE MODEL 140/4140/145/4145 jH[EC[mT'l1E� EB 2022 crois :-t j,Iiy ,ity Pe elcpment ! 14 41 4145 4140 10 20 30 40 50 60 70 80 so 80 160 240 320 -��vlrn > nlAti ITC '1 GIll1aR FEB 14 2022 Septic -Dose Tank Cross Section And Pump 1 erfotnance Spepi en Tank Manufacturer , Tank Model Number Total Tank Capacity /v e/'c<, c t' Max. Bury Depth Filter Manufacturer : / / e,e Filter Model Number G 3 ?.S`' Minimum Pump Performance Required 30 GPM1@1 top Ft TDH Outlet Manhole Min. 4" Above Grade With Locking Device. Inlet Manhole < 6" Below Grade Sealed Watertight ft, ► — . --/ " Finished Grade ' Pump Manufacturer zc 2 Pump Model Number JV/� Alarm Manufacturer z Ec .,. Alarm Model Number Switch Type Total Dynamic Head (TDH) - Feet Elevation Head Distal Pressure Network Loss �- Force Main Loss /• Jr Total 6.0 Manhole Min. 4" Above Grade Securely Mounted With Locking Device Weather-proof Junction Box o Depth of -IL Cover Vent Min. 12" Disconnect Ft Above Grade Means With Vent Cap > > > > > > ! • > k > > > > f Outlet , Outlet Filter Inlet Baffle - ------ ----- > > > > • > • f > > f f > > > > a • a • • • a • a < P A ` ' < '/`» < ` Weep ` >< a B >` ,< > < Hole ;< Off Elevation ' C ' Ft < > >< Bottom C >< D > Elevation GENERAL INSTALLATION: The septic/dose tank is bedded and back filled in accordance with the manufacturer's product approval specifications. Maximum depth of bury as specified by the manufacturer may not be exceeded without prior approval. Manhole covers exposed to grade have an effective locking device (padlock) installed. Piping at the inlet and outlet is of approved material, connected to the tank with watertight fittings, and laid on stable soil to prevent settling or sagging. The force main is sleeved with 4" Sch. 40 PVC to bridge the tank excavation and the sleeve is sealed watertight. Electrical service complies with NEC 300 and Comm 16.28 WAC. 02/05 LJ Page of 2£r N*14Ty11� — - /ee'sadU Pp+ W Apo 11WIO PAGE 1 OF 4 Pg1of4 Pg2of4 Pg3of4 Pg4of4 Attachments: In -Ground Gravity Plan Index & Cover Sheet Component Manual Design References: Version 2.0, SBD-10705-P (N.01/01, R. 10/12) Index & Cover Sheet Plot Plan Dispersal Area Cross -Section & Plan View Management Plan POWTS Application for Review Soil Evaluation Report & Site Map Project Name / Description Owner Name(s): h S%4c Phone: -21Y -477 - 22 9 Owner Address: a 3 1 w1 6.?A , Zip: 6-Y1 "7 Project Address: S�tti, r Govt. Lot: ' 1 /4 of 1 /4, Section 3 y T 3/ N-R 4 E❑ or W El Township: C 41oh County: STt Ci of y( Project Parcel ID #: 006 - >o b'- 7o o G Designer Information Designer Name: oeol7;s cldl-< Phone: 721f _241 -W7 Designer Address: '`�_CZ /"71 S 7- Zip: S-W r, I E-mail: License Number: Z z iy, / Remarks: Ir-s space 3 �sc-r -d foc approval sump. Signature: `-per Date:/0-22-zi Original signature required on each submitted copy. (D w-4It ed Mrod C1 RTs D' i SC u / e l�'� yoi ct�l ,aa ,A3z 1 r.. Cross Section of a Three Cell Inground Component$, Using Leaching Chambers Cell # 2 Typical Observation/Vent Pipes Original Grade Top of Chamber Ce11 # 1 System Elev. Fiaislied Grade = cg Cell # 3 ----� ,'I R Cell /f Finished Grade = 7 Z 3 Slope °/u = iseperation� ft. Cell ISeperafio - l Grade Ori =CIS, / �4' J — —_� w — Original Grade !! ., Top of Chamber = C/ , I .1 j • - • • V , t: �..,- , II' y' �!' + f' -, b� �::'� Top of Chamber ',SL/ system Elev. System $lev. 'gy/l Treatriendispeis:il one,. • : :+ •'. : ", • • 1 : + �•• ' 1vIL11141A1i �'NCfOf t ,� Obscrvation(Vent pipes to be co and pped approved materials for the particular use, Elsq , ,v�,�r/e ms,&, s.,•l her 'ro)� . y 710411 ,ar .�� 3oo 9f'� ©ter, low : , y sa•.� a "Atft 4, 2 o E/Sa s 39 <°,AcPAOe/S Y - _- - 77 isI An 4911 0 POWTS OWNER'S MMUAL & MANAGEMENT PLAN Pape•_or— RU M!&1B, MON SYSTHHf SPE�ICA7i OmerTank R7aqufacurer ❑ NA Fefmi#;� 3apbc ❑ Dosa ❑ Holding Vdrrt a /cue) toss NimlberafBedroonls: ------------ Number of Publto Faa7iiy Units: SFUM*d (cage) Row. - Design (psak) Rouen (esffmatad x 1.5): In shu Sd ApplICEEM fM Stapdard (DOmeattc) hlfluafyEtuamt Fvts, oa &GYMa (FOG High Preheated Effluent i+liinam MOM ftildte Sze Z- NA ( Tank Manuf Wrar. r LT Septic II Dace Q Hol ft Vdume: ❑ NA (Sao HA I Vadoal Distance Tank Sototn(s) to Set= Pact: 2d9 t; Wday) Horizontal DMenceTa Ks) to SwAce Pad OQ {9 eY) -p-8�emv W9ranchmbemwtba0row"dNwffowis ]efeaor if hwf;untel TO yi t54 l9st VPIg11D tl OW W by PnRgdOd on bfidL y waydayz : EntlentFiltermwufa aw. cr/yLoK Mon�itdyaverege Effluent FllterModel: �� 5 Z)� ❑iA Pump MBnu Mrer. D NA s'i6a nmrL Piltnf3 Model: ❑ NA I Monthly e"age >Sa MOIL >2W mgiL 0 NA Morrtirly avrwe s5o m_WL in dia MwhanfaerAemffim 13PeafMw ©NA Dwrrrartlon Q WOU and II (VA SM AbMrpgort Spstefn ni� <a-f3roand ) 1 DfNbs ate. ❑NA Mourld ogfec 0 NA I DNA I MAnnrEWANCF INTRUMONS Npe one of tithe mld eci alieorp3on %dams shall be made by an in Mdual Wrft one of #te Wft f or MECd= Maser F urnbw plumber Re9wded sewer, powrS inepeotor, PolNi'S Marriainer or Septage SwAft OPe f tar OLWMS i- Tank iropecliona must Include a viaual Impaction of the tanks) to k Y arty missing or hroWn hw*W% iderffy any'aafckc or leeks, mamm the volume of combined sludge and scum and a che& for any back up or ponddng of egiuent on the F w1d WrIh e. the sOIi absorption sydem snail be ftegy Inspected to dx&fhe effluent levels in the observation pipes and to deoicforwW pwtdbV of OTUWA or the around surfaces Ths ponding of effluent on the ground satiate may kepats a felling condition end mquGec the unmed fete nodlIcEdon of the loot regulatory authority. When the combined eaumMon of sludge and scum in any treatment tank equals one ild (.ire) or mars of H* tank VOfUMA #ire en5re cmt M of the MM shag be removed by a Septage Servicing Operator (Pmnper) and deposw of In acemdam wHh dopier lR 113, Wiscormin A mblafraHve Cede . AD other servtees, rndL&v twt not lirnit ed to #ifs awvh M of effluent JUM mechantcai or p ametaed companenwh pmeamimant w*c, arar WW aerWI%at RIKVIft of S'12 motmrs, sty be perMn ned by a cerOed POVTM ➢eernts'ner_ A. srnvlec input MW bs p vj*d to the focal reguislory aufhorf{y wifbin W days of ctimpl&n of arlyselti46a avant . ws—of— aTAR ir ESP AND OPERATION ot fie prr Of Pain"nlirt9 p��, or other For near =Wtrudion, prior fn use of the POWi72 shack irealrrtent tank(s} s" ohemimic or cadenert OmE may impede the bsaiment ptvicess mugor damage the soil sbcorplion sysbion- if tdgh conoa6rafiorta aro detected have the cordents of the WAR) removed by a saptage semoing opsrarar (pumpar) pdOrtc use pump tanks may 21 above normal highwater levels priorto startup or due to pump Mhffw - start up or restoration ai tinder these condilivna is rat moormrtanded, as the excess waasie s Will be disdtarged 10 the WO absorption system in one W99, dose C"rlg an overload that may resttit in the backup or suiaca discharge of eflitteni and d�rtage to $re sysm to or oextWa Plumber cmttettis of the pimp tank removed by a Sepiage SetpAdrig Opet&r ({ UMW prior fa pump or FOWTS yWntaiM to aWlst in menu* opera5ng ihs pump controls ant, normal of ug it Weis are rertibiad ta>i M to PUMP t9nit System shirt up shall not occur when soli condrifons are frozen "a lnfilit'8iive sunem Do not drive or park vehldes over bents or the soil absOTHOn syeterrl. Do riot drive or park over, or Wier vdw dMob or rtflmpaak fits. aMe Within 15 test down slope of any mound or at -grade sort absorption area. I�rrC� aridthe fife Of the treatrttent Reduction or edmina6an of the *AovAng from Me v�tt:vunter stream may bril"Ve to Perm tams and sail absorption syetam; acid:, entiblOVAG, b2by wipes. atsaratte buds, a0001134 aoitan s AD% % s Ctarilaiue mA diapers, &ir&ctwft, fats, foundation drain {sump pump} discharge, frL t and vegabble padIn9r, ! hwbWdscraps, mediations, ads, painting products, pwffddes, Unitary napkins. solvents, tampons, and wafer sob%nair brine ABANDOWENT shall betataert to insure t118tttte sy11 Is property Vlliten the POWTS fells a�OYIs ifant:e wtih�Ctmm 83.33, ViTiaeo(en out of r AdministrsYve Godm'w1 and s1Y abandoned P o All piping to tanks. plls and other gall absatp"uon systems shall be disconnected and the abandoned pipe ope(tln� Spied a The contenis of ail banks and pSia shall bB removed and proP9dy disposed of by a 5e*90 OP per}. e Airw pump!M all tanks and pits shall be WIstad and removed or their Carters MMOVed and the VOID apace =ad VA soli, grave( or ert*w inert solid mlaMrW. CONTH4GENCYPLAl3 of must He teKert, to pravtdo n coda carp if'the poWM falls and cannot be repaired 4ma following measures nave been, replacenenf syd=: a A suitabis replacement area has been svaluaied and may be vim for the [ � should � s The roacemea area Nnouid bs protected from distwbarlce and c ompacao rTWcolent area wig UPORt in the hued fora now sod and site �izallon too fistosed s abUsh aisultabie r0aacemer>'C� � ertt dY�s mt�E mmply W�1 f� ricks ht enact atme time of their petnit issuance A stye repiwAmerrt area Is not available due iD st rback an�m it �Q O7 8Y cannot be rehabilitated and barring advances in PolA7C toohnolegy. a holding batik mw Le Inetdlod ew $ kci rot art l[ The site has not been eVeluaied to identilyt a suft=e rapiacesnent area upon f0ure of the PfWir(S a sou go SW wWuaflan must be perRnmed to brats a s{n'fable replacement area. If no rMIMMMt area Is weave a hdit tanx may to mataded as a last resort to replace the felled POWT-S p Mound and at -!Fade sod absorptton systems may be reconMolad In PACO £oUmnar� of the btonr� a ths +Q surface Reconstructions of such s_vsiems must comply wRh the rules in~ et fWlkne- tMMATMENF TANKS, I°tNIP A,*M, AAID HOLDING TANKS MAY CONTAIN poWNOUS GMW OR LACK SLIFPICIENY 0,.YG24 TO TAfid LIFE 't MVI R M79R ANY YANK LWM ANY MW1.1111WANCIL DEATH MAY RESULT, ESCAPE OR R13GLiE FROM AS IN"i €RIOR OFA TAr4KwAY wOT zw P0891E1.a. A1301TIONAL INSTRUCTIOPI,5: POYM INSTALLER_ y POWiS IaAA�ifAWgR Name r �! %7 �' Name % 5 Phone aEPTAGE SIMMONQ OPERATOR IPLMPMI, . Nine t Phone . LOCALTDRYAUTHOR[TY NGne c- Il L"T� ZO/71nr' Phone % . cr Z7 7 TO aestMW W29 toMW ny ate salts 11 ate Green l ei Vl queb and WMIA8ra CM* POM rrrgllfW Oub pt COMM101 i21 setaans 9WW and 88. I){ (2) £ C4, INbcensrn Ae irikhaFrve Code. ST CRO UNTY SANITARY SYSTEM File t%raf f:usir, ._ Office Use Only OWNERSHIP/ADDRESS FORM ueored2/2o2t 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 Sell S.-/C-tc r Mailing Address OWNER/BUYER INFORMATION q v City/State/Zip Mcv Qrc/iYY![tn j W-{• i Phone Number (required) 7/4= S77 _ .2Z�/G Email Address (required) -Low. Parcel Identification Number (found on the property tax bill) NEW SYSTEM: LEGAL DESCRIPTION Property Location l=v"'/4 , r� " '/s , Sec.. '/ . T 3 / N R 14 W, Town of V /os-7 Subdivision Plat: Lot # �. Certified Survey Map # 5- 1 L}W."! Lo-t 357866, Volume 5' Page # I 1 Warranty Deed # 915 p %o (before 2006)Volume , Page # Number of bedrooms -Z--_ Spec house O yes no Lot lines identifiable O yes O no OFFICE USE ONLY New Property Address .54 ija (Verification of new 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 wwwsccwi.aov y�M�� «' ;��-5�� �ST D s. Dept. of Safe Proles Tonal Services ATION REPORT Page of D' ' S eiA, VlsIRM 0 uddings 1�U � in accordance with SPS 385, Wis. Adm. Code e�r �nty County v Atta cgT0*&� er not less than 8 1/2 x 11 inches in size. Plan must inclu 'Ut "61 o. vertical and horizontal reference point (BM), direction and Parcel. D. pe, scale or dimensions, north arrow, and location and distance to nearest road. n 0 to - 10 72- 90-000 Please print all information. Red by / Date Personal in`,orma'ion you provide may be used for secondary purposes (Privacy Law, s. 1E.04 (1) (m)), Z Z! Property Owner Property Location C Q V Y I Govt. Lot 1/4 114 Sj T N R (. E (or Property Owner's Mailing Address Lot # Block # Subd. lame orCSM# d al -9w-_(.a)1w I I I cSroliit 5//q-gq —w �=.v .�P wue nlune Ivumoer achy uVillage Ajfown Nearest Road C-6 S'(0/7 LZIS) y C-I #L4y (a3%ay New Construction Useg Residential / Number of tedrooms Code derived design f )w rate 3 60 GPD ® Replacement ❑ Public or commercial'- Describe: Parent material 1 D ! S 3 0-1111trr�A in G Flood Plain elevation if appl able k- General comments and recommendations: = S �Jg C-S-} 3 - Tr Cv��1g �,y� f f- + k1 S r tt T. % 9y,l0' T.a 93.Vo' I -r z 4 M r ., 1-11 R Boring # Boring Pit Ground surface elev. 95, Lo ft. Depth to limiting factor _%7_ in. Soil Application Rate Horizon Depth n. Dominant Color Munsell Redox Description Cu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Ionsister a oundary Roots GPD/ft ff#1 ff#2 •A4 11>18SL S:L .sb� _3o RY L Jr6 6V mf r F . 43 S _7 - s Syvf/to 7`IAA/ S L L S h kM f t�FV- c w — - q . V T� 0-7 i 7 `ilfSbk ® Boring # Boring r� Pit Ground surface elev. IL, k43 ft. Depth to limiting factor OJ in. Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. onsister :e Boundary Roots ovn mpljatlun Kffie GPD/ft ' 21 ff#2 I - d o m- -- )-� /aY - SQL 'SbK SFrr WF rca ►- 8 YfRyl -_.�._.� �. a b►t SFr- � �F 8- S`�i2 `► L Sbk ►nfr LJ SIG - 01 •u 5 JV IIIy/L 611U I JJ I JU mg/L CST Name (Please Print) (�j� Signature ` CST Number mil_\! iN , 1-7 y Io Address a 00* h S}r Date Evaluation Conoicted Telephone Number 4;0L S+Xr Pm:r;t ws Saoab %-�7-jr p1DcZt (flSl-a38-YbIS SBD-9330 fRl 1/11) �1 e,.,j sk"iv-\ OC- �'" t Lc�f�S%kt C"' Property Owner g 1 r Parcel ID # N Boring # Boring Pit Ground surface elev. _�ft. Depth to limiting factor_ .85 in Page -of-3— Snil Annlinofinn D.fc Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. onsister ce Boundary Roots v GPD/ft ' ff#1 ff#2 o-Q - -Va LA) F 15. W, s s I ,S? 3 A-V -70/4 r C LAJ VjF a9 -?5 Sy pY �----- SL jjf6jDV- hfr C w Iq, 7 ❑ Boring # Boring Pit Ground surface elev. ft. Depth to limiting factor_. in. Soil Application Rate Horizon Depth in. Dominant Color Munsell Redox Description Ou. Sz. Cont. Color Texture Structure Gr. Sz. Sh. onsistence Boundary Roots GPD/ft ' ff#1 '�ff#2 ❑ Boring # ED Boring 11 Pit Ground surface elev. ft. Depth to limiting factor_, in Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh, onsister;e Boundary Roots oun MPPIlUduun mate I GPDIft 3 ff#1 ff#2 Effluent #1 = BOO 5 > 30 < 220 mg/L and TSS >30 < 150 mg/L ^ Effluent #2 = B(,D 5 < 30 mg/L and TSS < 30 mg/L The Dept. of Safety and Professional Services is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, contact the department at n08-266-3151 or TTY through Relay. SBD-8330Tcst (Rt ti l p 73101 P-16W TonAA csgr Aoloq6 Z5+6'-14 Lo 6,3710 —TT- 4 it 1� -A r-� EuLpol t oc + if - OW I5W\ I Do, as /-JGr-v, t 60'r-I % " ro C Po 94,93 ?!f wz^ i- Sa..CM�t couNn NO. 642229 STATE SANITA Y PERMIT Z3Z ! flu,,/ G3 6 Y OWNER `a `h PLUMBER &nrlt%-5 &dk LIC.# ZZI TOWN OF A, SECYq ,T!_3LN, AND/OR LOT / or R_A E,' BLOCK ---- SUBDIVISION Zokcx CHAPTER 145.135 (2) WISCONSIN STATUTES (a) The purpose of the sanitary permit is to allow installation of the private sewage system described in the permit. (b) The approval of the sanitary permit is based on regulations in force on the date of approval. (c) The sanitary permit is valid and may be renewed for a specified period. to) Changed regulations will not impair the validity of a sanitary permit. (e) Renewal of the sanitary permit will be based on regulations in force at the time renewal is sought, and that changed regulations may impede renewal. (f) The sanitary permit is transferable. History: 1977 c.168;1979 c. 34,221; 1981 c. 314 Note: If you wish to renew the permit, or transfer ownership of the permit, please contact the county authority. //tlfte / AUTHORIZ D ISSUING OFFICER —DATE /Z3 2% THIS ftERMIT EXPIRES ftZ Z4Z 3 UNLESS RENEWED BFIORYTHAT DATE POS I PLAIN VIEW VISIBLE FROM THE ROAD FRONTING THE LOT DURING CONSTRUCTION SBD-06499 (R11/20)