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HomeMy WebLinkAbout020-1349-11-000 (2)Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: 641978 Personal information you provide may be used for secondary purposes (Privacy Law, s.15.04 (1)(m)] Permit Holders Name: city Village Township Parcel Tax No: Steven K. & Cari A. Vierck TOWN OF HUDSON 020-1349-11-000 CST BM Elev jInsp, BM Elev: B escription: Sectionfrown/Range/Map No: $� 26.29.19.1887 TYPE MANUFACTURER CAPACITY Septic Dosing A%cai Holding :.`� L ditaki0 TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic ve t Dosing AgisTo—n coil —7 t 1 alding PLIMP/SIPHO INFORIOIATION anufacturer Demand GPM odel Numbe Tr Lift Friction Loss Sysle Head TDH Ft Folli Length Dia. Dist. to Well A 3- R r 6 I SOIL ABSORPTION SYSTEM/ \ BEDfTRENCH Width Length 1 No. Of Tenches PIT DIMENSIONS No. Of Pits Inside ia, iq e DIMENSIONS SETBACK SYSTEM TO I P/L JBLDG IWELL LAKE/STREAM I LEACHING M df c r INFORMATION CHAMBER OR Tr,�']e ^Of System: \i\1\�l �] t 7 T UNIT . .. Ide j DISTRIB Header/Manifold IlDistribution x Hole Size x Hole Spacing Vent to Air Intake I 1 Pipe(s) Length Dia Length Dia Spacing SOIL COVER x Pressure Svstems Only xy Mound Or At -Grade Svstems Only Depth Over Bed/Trench Center / �/ I �• r� t Depth Over Bad/Trench Edges %j /� xx epth of Top oil xx ded/Sodde Mulch d " v l Yes O No 0 Yes 0 No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: 1 ] Inssp�ectiion�#2}:} Location: 743 BLUE JAY LN R\ I�✓ro�, ]���.L �1 H/n �� nC,LJTI' Oli 1�� 1�`'� ` " 1.) Alt BM Description = �a ���AAV 2.) Bldg sewer length = Nltlll � - amount of cover = Plan revision Required? H] Yes �* No j Use other side for additional information. jo�& Y L I ( e tors Signature Cert. Nc. SBD-6710 (R.3/97) I a �—A `6 Il )l 1 S;U, Jew 1 / /14-7 ` Industry Services Division 4822 Madison Yards Way County t S1 C r-0 q = MA 1 Madison, W153705 P.O. • � Sanitary Permit Number (to befilledin by Co.) k o` 162 Box 707 Madison, WI 5307-7162 6 1' 1 -T County e ennit Application State Transaction Number Qom In accordance wi 83.21(2), Wis. Adm. Code, submission of this form to the appropri unit �— Project Address (if different than mailing address) is required prior to obtaining a sanitary permit Note: Application forms for stateown are submitted to the Department of Safety and Professional Services. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law, s. 15.04(I)(m), Stats. L Application Information - Please Print All Information Property Owner's Name ` �PW ��� ��° a Y11 t I1 $?� V IRKQ Property Owner's Mailing Address lVi't TAlA Ub Property Location m Govt. Lot l j 5 fya5 LJ y4, Section at 10 City, Sta'tee1� t " Code % 1� s 1 Phone Number —� Vlr/S �� \� V T ;k1q N R E or W H. Type of Building (cheek allthat apply) Lot # Subdivision Name ®I or 2 Family Dwelling -Number of Bedrooms I abtic/Commercial - Descn'be Use ( t Block# ity of Dvillageof fate Owned -Describe Use CSMNumber to , _(Check 6Q-4: ®Town of Hubsah4 ULType of PO P ." either "Nei r" or "Replacer t" and other applicable on Mae A. Check olte box or Use B. Complete Use C if applicable.) A. y E]Nm System epl [vent System ❑Other Modification to Existing System (explain) Additional Pretreatment Unit (explain) B' ❑Holding Tank t round ❑4t-Grade Mound Individual Site Design Other Type (explain) nventional) C. ❑ Renewal Before Expiration ❑ Revision ge of Plumber ❑transfer to New Owner ist Previous Permit Number and Date Issued 12M 353 Z9 3 0 IV. Dispersal/Treatment Area and Tank Information: Design Flow V Design Soil Ap lication Rate(gpd/sf) Area RWuired (sf) f(0 3 Dispersal r Propo. (sf) (�Q System. Elevation 7 s. Tank Information Capacity in Gallons Total Gallons # of Units M a °o Ti New Tanks Existing Tanks r J u o a U Septic or Holding Tank ^., / / 00O mo $d I A N 1 S -Q le - i PSti M I] EJ V. Responsib7ity Statement- 1, the anderdgved, assume respeasibllity for ostaYatioo of the POWIS mown on floe altacMed plaos. Plumber's Name (Print) �� B��t, P , i MP/MPR.S Number � 9 4Y Business Phone N I �S 3 $��aap �K Plumber's Address (Street, City, Stateip Code) 1616 Aw 7� ii4JA A � -Syul VI. County/Department rse Only Approved 1 Permit Fee Date Issu Issu Agent Signature ❑ nfor Denial Conditions Appro) /1 �� . 1` STEM OW 3/ lJ�'S44^ a7,-_ M Septic tank, �1/J• t filter and M (b� &., 5 � �a►la MT►or�S a . dC l MUst dispersal [;ell must be t plan as per management plan provided by plumbt3G , provided bytained �� � � $ All setback requirements must be maintained as per applicable code/ordinances. `j Attach to couplete plus for'Mrsystean aN submit M the 6ointy only u papa not lass rise 114 it It iaebes in sloe SBD-6398 (R. 03121) f l©t NrA m-e.7 15-t-kv e CAR VA , 1� Rim Sy p Q ; < "0 Gok��p ��t(I ug, v gq a o` �,b ► Jvg- to t��L wlu Pol 1, DV- Q f —� It �tV =1U0.0 a ��n.eroc�5 3x �� N T� UcAPR5 aaa9a, 51Stem Per: 9s.(o i i,,fn (66o 0) -W( Ruw Ublvc COPY