HomeMy WebLinkAbout020-1181-60-000 (2)Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and Building Division
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMITi
Personal information you provide may be used for secondary purposes [Privacy Law, s.115.04 (1)(m)I
Peril Holder's Name: City Village Township
IRA II ISLAND TOWN OF HUDSON
TANK INFORMATION
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
OVIL AC30vrcr 11UN bTb I t:M
ELEVATION DATA
Inlet
Bot.
Cover
BS
BED/TRENCH
DIMENSIONS
Width
Length
No. Of Trenches
PIT DIMENSIONS
No. Of Pits
Inside Dia.
Liquid Depth
SETBACK
INFORMATION
SYSTEM TO
I P!L
JBLDG
IWELL
LAKE/STREAM
LEACHING
CHAMBER OR
UNIT
Manufacturer:
Type OF System:
Model Number:
UIOI MIDU I IVN OTOI tlVI
H eader;Manifold
Distribution
x Hole Size
x Hole Spacing
Vent to Air intake
Pipes)
Length Dia
Length Dia Spacing
V W lL l W v l V i n.l. — M.......1 n. �. !_....J.. n-....
Depth Over
Depth Over
xx Depth of
xx Seeded/Sodded
Mulched
Bed/trench Center
Bed/Trench Edges
Topsoil
Yes
7No
I, .Yes Q No
COMMENTS: (Include code discrepancies, persons present.. etc) Inspection #1 Inspection #2.
Location: No Address Available
1.) Alt BM Description =
2.) Bldg sewer length =
- amount of cover =
Plan revision Required? D Yes E No
Use other side for additional information.
Date Insepctor's Signature Cart. No.
-
— ✓/ J I v CK v v f
Industry Services Division County
�22
4822 Madison Yards Way ST. CROIX
_
Madison. WI 53705 Sanitary Permit Number (to be filled in by Co.)
county
P.O. kJ 7 16 6��i3
Madison, 141 53
.Croix nt
GOmrrtUfli! 1 Permit Applleatl0 Sate Transaction Number
In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the app c governmental unit NA
is required prior to obtammg a sanitary permit. Note Application forms for state-oweP POW'TS are submitted to Project Address (if dit%rent than mailing address)
the Deparnnem of Safety and Professional Services. Personal information you provide may be used for secondary - -
purposes in ac ordance with the Privacy Law, s. I5.04(I Xm), Stats+ �
. 1 ft q
I
1. Application Information -Please Print All Information
Property Owner's Name
Parcel k
IRA If & MICHALE A. ISLAND �p�E
020 - 1181 - 60 - 000
Property Owner's Mailing Address
property Location
18 WINDSOR WOOD PATH
Govi. Lot NA
City. State
Zip Code
Phone Number
HUDSON, WI
54016
NW ,, SE , Section 28
T 29 N R 19 E or
D. Type of Building (check all that apply)
Lot it
zI or 2 Family Dwelling - Number mlBedrooms
I Subdivision Name
as P« h°"' - S
[Itlblic/Cormnercial- Describe Use
CEDAR HILLS ESTATES II
Block
_
NA
Oalymf
_
illage of
Dtate Owned - Desenbe Use
CSM Number
CSM 1124069
31- 6933) 12
Town of HUDSON
111. Type of POWTS Permit: (Check either "New" or "Replacement" and other applicable on line A. Check one box on line B. Complete line C i
applicable.
A.
ew S stem
y
r—�,
I fceplacement System
L�/JIn-Ground
❑Other Modification to Existing System (explain)
[]Additional pretreatment Unit (explain)
B'
8
[ jZd,n Tank
134t-Grade1sylound
Individual Site lksign
Other Type (explain)
tons
18 Ez
Flows
C-
❑ Renewal Before
❑Revision
hange of Plum
ransfer to New Owner
List Previous Permit Number and Date Issued
Expiration
(3) 3'
60' Trenche
NA
tV.
DispersaV17reatment Area and Tank Information:
Design Flow (gpd)
Design Soil Application Rute(gpolstl
Dispersal Area Required (at) Dispersal Area Proposed (st)
System Elevation
450
0.5
900 900
94.54 FT.
Capacity in
Total
N of
Manufacturer
Tank Information
Gallons
Gallons
Units
New Tanks
Existing Tanks
POLYLOK 525
z
N 2
-E v
u`
Septic or Holding Tank
1000
1000
1
WIESER
Dosing Chamber
V. Responsibility Statement- 1, the undersigned,
assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print) IPlumber's Signature MP/MPRS Number Business Phone Number
MICHAEL RODEWALD 931384 715-425-6200
Plumber's Address (Street, City, State, Zip Code)
285 C.T.H. SS, RIVER FALLS, WI 54022
VI. CountytDcpartment Use Only
IgApffINL2!!�
sapproved
$crmit Fee
Date s ued
iss ing Agent Sign ore
n for Denial-
Conditions Approv rs forBisapprpl ` ; ^
'STEMOWN 3/ t"'y lily yet,.�dl
Septic tank, effluent filter and 4.dY)
dispersal cell must be serviced /maintained n 1
_ _
xA-^ Ste AQG- 11Z,p6c/`
n+
as per management plan provided by plumber. 1
II setback requirements must be maintained Roe.er
4t) 6"W- C—a lyrtg�"S 544C 4
as per app!i e�'z cDdz/ordinances-
neo-r 6Z S,t; ( l e Q It g 2-
-7) r, • .4 tbrh ro eo®pk1e, br Me avaten a d avbm a ty a on paper mat lees 16aa 8 I/S s 11 ioa6o in S¢e
ZZ
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PAGE 1 OF 4
In -Ground Gravity Plan
Index & Cover Sheet
Component Manual Design References:
Version 2.0, SBD-10705-P (N.01/01, R. 10/12)
Pg 1 of 4
Index & Cover Sheet
Pg 2 of 4
Plot Plan
Pg 3 of 4
Dispersal Area Cross -Section & Plan View
Pg 4 of 4
Management Plan
Attachments:
Enclosures:
SYSTEM CALLS
POWTS Application for Review
GRADING PLANS
Soil Evaluation Report & Site Map
SANITARY OWNERSHIP
TANK ,SMC.5
HOUSE PLANS
WARRANTY DEED A7 SidFTE Mp
Project Name / Description
Owner Name(s): IRA II & MICHELE A. ISLAND Phone:
Owner Address: 18 WINDSOR WOOD PATH, HUDSON, WI
Project Address:
Govt Lot: NA
751 ALDRO ROAD, HUDSON
NW 1/4 of SE
Township: HUDSON
Project Parcel ID #:
1/4, Section 28 , T
_ County: _
020 - 1181 - 60 - 000
Designer Information
Zip: 54016
29 N-R 19 E ❑ or W
ST. CROIX
Designer Name: MARY JO HUPPERT Phone: 715 _ 426 _ 1775
Designer Address: 25720 FIREFLY LANE, WEBSTER, WI Zip: 54893
E-mail: hollisterdesign@outlook.com
License Number: 1859 - 007
Remarks: a
Signature: per,,; ' 0 0; 2022
04gmI tune Auirea "ch submitted copy.
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PROPERTY LINE
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of NE $ NW of .5C,
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