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HomeMy WebLinkAbout020-1311-30-000Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT sanitary Permit No: (ATTACH TO PERMIT) 641960 GENERAL INFORMATION State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village Township Paroel Tax No: Raymond Kowski TOWN OF HUDSON 020-1311-30-000 CST BM Elev: Insp. BM Elev: BM Description: SectionrTown/Range/Map No: It*-v� I loo-0 f CSTBT+-* 1 12.29.19.1566 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY Septic c �z i 2so Dos' b ,Aaration Ho ' TANK SETBACK INFORMATION ®�MIRPMEMEL",9"- PUMP/SIPHON INFORMATION Manufacturer Demand GPM Model Number TDH Lift Fri n s System Head TDH Ft Forcemain 4r gth Dia. SOIL ABSORPTION SYSTEM (2Z)e"(y�sf{�p STATION BS HI FS ELEV. Benchmark 1-30 P101. Alt. BM Bldg. Sewer 4.0 ct i r ,3,0t T SUHt Inlet 2-0. 1 to St/Ht Outlet b C Q .�, 1 Dt Inlet Dt Bottom Header/Man. 1.30 ai-co( Dist. Pipe Bot. System Final Grade St C veLP�1 49— BEDlTRENCH DIMENSIONS Width t Length( o. ? Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth Q i. SETBACK SYSTEM TO P/L G WELL LAKE/STREAM LEACHING Man tur INFORMATION CHAMBER OR Type Of System: y r01 UNIT Model Number: DISTRIBUtTION SYSTEM Header/Mani Distribution x Hole Size x Hole Spa (( Pipe(s) Lengt Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Onl Spacing Vent to it I�kes T. J Mu the as k8 No M Yes . No Depth Over Depth Over m Depth of xx Seeded/Sod d BedlTrench Center BedrTrench Edges Topsoil C3 ❑ ❑ ❑ A00C pIIMF, NTS; (I`clude I crg epencies, pgrsons presgnt etc.) Inspection #1: S� Inspection #2: tip atl�on:1094TANNE LN lLfera`t.. ly�Ial- 1.) Alt BM Description = 2.) Bldg sewer length = Lf Ot,. v.✓ '�"� W `�� . - amount of cover = 4Z N t Plan revision Required? [ Yes � No S1 1 22, ^t Use other side for additional informati n. / YG SBD-6710 (3/97) Date Insepctoes Signature Cert. No. 0.07 rya &., M,.. & . s�-�'wp:1 / 6, rt ek. 1 -%' eil . eti. o ��"�-� IMD+ti1�rQ2 �� is C�ial.rt43/ 4lbcw <Aht , -%., -N1 — 12,A Industry Services Division ounty ��r;= �D 4822 Madison Yards Way ,;.� �J ST. CROIX Sanitary Permit Number (to be filled in by Co.) j:f \_! Madison, W153705 = P.O. Box 7162 \ !; 2022 Madison 53707-7if / t' q�0 21 1an� Per t Applicat State Transaction Number [n accordance S.3$: 655101n of this form to the aprtunlit NA Project Address (if different than mailing address) .�Et1 is required prior ote: Application forms for slat are submitted to the Department of Safety and Professional Services. Personal information you provide may be used for secondary 1094 TAN N EY LANE purposes in accordance with the Privacy Law, s. 15.04(l )(m), Stats. L Application Information - Please Print All Information Property Owner's Name Parcel # RAYMOND KOWSKI 020 - 1311 - 30 - 000 Property Owner's Mailing Address Property Location 1079 TAN N EY LANE NA Govt. Lot City, State Zip Code Phone Number HUDSON, WI 54016 651-955-8314 "w �,-sw y, Minn 12 T 29 N R 19 E mrW tT. Type of Building (check all that apply) Lot # Subdivision Name TANNEY RIDGE SPECIAL ADDN. F1711or2Family Dwelling -Number �y ,,,s Pe! o�� s) 30 Block .ra7 ablic/Commercial - Describe Use NA []City Of late Owned - Describe Use Elvillgeof CSM Number NA WITownof HUDSON M. Type of POWTS Permit: (Check either "New" or "Replacement' and other applicable on One A. Cheek one box on line B. Complete line C i a liable)l� A. j ew System I pceplacement System Sher Modification to Existing System (explain) DAddittional Pretreatment Unit (explain) B. ❑holding Tank s/ In -Ground E34t-Grade Mound Individual Site Design Other Type (explain) ven C. ❑ Renewal Before Revision hange of Plumber 1:117ransfer to New Owner nst Previous Permit Number and Date Issued Expiration 1 I IV. DispersWFreatment Area and Tank Information: Design Flow (gpd) Design Soil Application Rate(gpd/st) Dispersal Area Required (st) Dispersal (sf) eviction it 600 0.7 857.15 892 g y3, z 89.50; 89.00 ft. Capacity in Total # of Manufadtater o $ Tank Information Gallons Gallons Units I New Tanks Etisting Tanks Z (I 0. U W w Septic or holding Tank 1250 1250 1 W IESER Dosing Chamber V. Responsibility Statement- I, the smilersignedAjeme responsibility for installation of the POWTS siown oar the attacied plans. Plumber's Name (Print) I pli ignature WINIPRS Number Business Phone Number THOMAS A. WANG , 227469 715 - 425 - 9958 Plumber's Address (Street, City, State, Zip Code) W9672 770TH AVENUE, RIVER FALLS, WI 022 VI. County/Department Use Only lull! ______ pproved ❑ Disapp a Permit F $ Date Iss ���Gr' I Agent Si ❑ Owr even Reason f Denial ,, ZZ ip Conditions o A v traerrs #efl3isappreral ' STEM OWNE f eptic tank, effluent filter and o n - _- • . - e t QQ�' �sP ispersal cell must be serviced I maintained 4) rm,, 11v`^ "" -V '9 - _ , n ) n s per management plan provided by plumber. G� � � - ©.� 61PP/d =- : 1 S°"'�..i—�/ II setback requirements be must maintained �t' o ! s per applicable code/ordinances. ,7"" � oln>za¢ < Attach to complete plans for mdsys add submit to the County epply m paper mot less than 8 1121 it 'dam sae SBD-6398 (R. 0321) 'Plot Plan Page Ik of I PROPERTY OWNER: �KAVMQN D KoWSK► Legal Description, b-r 3010 TAMMEN Rl OGE SPEe, SAL AIZ�W1 AbDA) Lbe A ED im "r= NEVY W IM SW`/�f i NW`A CfTtW SWEI SEC. lz, Ta", S(Ivj Town) OF 4ivz5oul 5T 6fOIX CO AEY \ Wt5CDN5FN. logy Tatntntq time OQ� t`'f 't.� 1 .s 1• 0 m 1R WFU ' i ZS Ft ss:ir e- THAN( >,SAf PRDmn ©xAt*FIst.P-> Site E t- I'� = 40 Ff. (except where noted) G = backhoe pit 2•0 Aemcs / North Mi �r 303t4- „SdAt, tic 0 OPY N i AU 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: Tank specs POWTS Application for Review Filter specs Soil Evaluation Report & Site Map Sanitary Ownership Form Warranty Deed Owner Name(s): Owner Address: Project Address: Govt. Lot: NA Township: Project Name I Description RAYMOND KOWSKI Phone: 651 _ 955 : 8314 Zip: 1094 TANNEY LANE, HUDSON / NW 1 /4 of SW 1 /4, Section 12 T 29 N-R 19 E ❑ or W Q HUDSON County: ST. CROIX Project Parcel ID #: 020 - 1311 - 30 - 000 Designer Information Designer Name: MARY JO HUPPERT Phone: 715 - 426 - 1775 Designer Address: 25720 FIREFLY LANE, WEBSTER, WI Zip: 54893 E-mail: hollisterdesign@outiook.com ett ror a ,!Oval star:,. 1859 - 007 License Number: -,'��• Remarks: aa• a a + �J'fi"'=�Wi,"`2()22 Signature: Date: o ' sig tune required on ea copy. Plot Plan Page 16 of I PROPERTY OWNER: -: AVMVN D KOWSKi Legal Description: LO-( 300 TA NM -9IQC�:E SPET•IAL {itO(7rj. I St IQLW A-mz it4 TiiE NEVLI of /stE SW'/LLq � MWA oFT}tE sW' SSC.. Izr TzgA, Az(jvj_ T9vwn3 DF 4AVZ50NF ST, CAy1)c COkkgy lNi5CDN5(N. IOgy jf1n1NEY LANE 13 W a 16 Site oeation: fI 1" = 40 FT. (except where noted) = backhoe pit z.ob North © S o - Yd 'Ct,3 �Pj o 1 wDD VJGLL 3 CII � > Zj. Ft^CM 56Pfrrz TRAiI(' pn -;>St' PROM ©RArr.1FrF-LL> 2