HomeMy WebLinkAbout020-1353-22-000 (2)Wisconsin 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)]
Permit Holder's Name: City Village Township
Mark & Kim Romness I TOWN OF HUDSON
TANK INFORMATION
TANK SETBACK INFORMATION
TANK TO
P!L
WELL
BLDG.
Vent to Air Intake
ROAD
Septic
Dosing
Aeration
Holding-
PUMP/SIPHON INFORMATION �1
Man
facturer
ll
Demand
GPM
Mod
I Number
TDH
Lift
Friction Lass
Syst Head
TDH Ft
Force ain
Length
Dia.
Dist. to Well
w&ir-i•A a rai i rLvw rya.
ELEVATION DATA
County: St. Croix
Sanitary Permit No:
644716
State Plan ID No:
Parcel Tax No:
020-1353-22-000
Sectionlrown/Range/Map No:
36.29.19.2022
•
Wwm®
BED/TRENCH
DIMENSIONS
Width I
Le9th
No. Of Tres
PIT DIMENSIONS
No. Of Pits
Ins de ia.
Li ui Dept li
SETBACK
INFORMATION
SYSTEM TO
Tyr OfSystem:
1, ,n
,'IFt�tni11
IP/Lf,,
/f
GJ
IBEDG
,
WELL
/te r
`W/)
LAKE/STREAM
LEACHING
CHAMBER OR
UNIT
r
I u bar.
111611 N 1=11111 06IM&YI&I I :I J,
Header/Manifold (1
Distgbution
x Hole Size
x Hole Spacing
Vent to Air Intake
Pipe
Length Dia
Length Dia Spacing
SOIL COVER v PreSSrlr& Svstems Anly vy Mnllnd Or At.Grarlp Systems only
Depth Over , /
Bed/Trench Center V
Depth Over g rf ]
Bedrrrench Ed es 2]
xx th of
Topso
xx See
'�
xx Mulched
L o
Yes 0 No
at Yes Q No
COMMENTS: (Include code discrepancies, persons present, etc.)
Location: 664 HILLARY FARM RD
1.) Alt BM Description
2.) Bldg sewer length =
- amount of cover
Inspection #1: Inspection #2:
Plan revision Required? 0 Yes [ No
Use other side for additional information. I Off' O f. -iv'A"A"wi IL l
SBD-6710 (R.3/97) Date 41nsCert. No.
epctor's Signature
�4N-2o22 !jfy
r
R E C E� M E
industry Services Division
4822 Madison Yards Way
County
2
Madison, W153705
uqmber (�to7 be led in by Co.)
Permi6!t
21 2022
P.O. Bx7162JUN
Madison,153707-
/
T� 1P
Saftita Permit Application 'd
Trsasacxion Number
In accordance with U- -. Ff,; tic U ^ � eg'on of this form to the appropriate governmental unit
Project Address (if different than mailing address)
is requited prior to obtaining a sanitary permit. Note: Application forms for state-owned POW TS are sub,,ttod 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(1)(m), Stats.
�^
L Application ]Information - Please Print AN Information
Property Owner's Name
Parcel #
m6k ,- )M ZOMMSS
o 0 -1 - 4.000
Property 'Owner's Mailing ddress �//�
, J V
Property Location
�p A N it M o p
Govt. Lot
Q F Y. / V W '/a Section 3
City, State Zr
1^
Code
d
Phase Number
y,
K rls 1i
T a 9 N R E or W
Ill. Type of Building that
Lot #
check all apply)
Subdivision Name
or 2 Family Dwelling -Number ofBedrooms
��ff
[jublicfiCommercial - Describe Use
1� 1 �
Q i UN W U
Block #
sty of
late Owned - Describe Use
'illage of
CSM Number
La-jq�
+ 1
RTownof 1J1A i,��N
11L Type of PO WTS Permit: (Check either "New" or "Replecemeu" and other applicable on Use A. Check one box on tine B. Complete tine C if
applicable-)
A-
[:]New System
lacementSyst
Other Modification to Existing System (explain)
dditional Pretreatment Unit (explain)
B.
aoldmg Tank
n-Grormd
at -Grade
Mound
individual Site Design POther Type (explain)
C.
❑ Renewal Before
Revision
ge of Plumber
Transfer to New Owner
ist Previous Permit Number and Date Issued
�i/2't�/'��
Expiration�p
II 11 •• Z
1V. DispersaVTreatment Area and Tank Information: 2 0
Des(gpd)
G��
Design Soit Application Rate(gpd/s
Dispers4LAra$egrtind (st)
j((��JJ
Dispersal Area (sf)
System evation
8
t
+
Capacity in
Gallons
Total
Gallons
# of
Units
Manufacturcr
a 79
Tank Information
too
"
N
.�
New Tanks
Existing Tanks
^•��b�'C
c
n.
•1
Vl �
u
Vl
.a
W C7
is
LL
iL,`
Septic or Hoktag Tank
^
f
V
0
4 r
Dmmg Chamber
V. Responsibility Statement- 1, the undersign9drMonijilie responsibility for imataaation of the POWIS dhown on the attached plans.
Plumber's N
lumber's
MPAIPRS Number
Business Phope Number
1117-
V
Plumber's Address (Street, City, State, Zip Code)
b� ?�
N
Vt. County/Department/Use Only
AApproved
0 Di ppm
Permit Fee
S
-DIssued
Issug Agent Signaturg
'��ate
fo
❑ Owner Given Reason Denial
5z
Conditions Of pprova 13) n' 1 _ ,yizrT 4 �B �D{ I time l
SYSTEM OWN J f tt}y�N�Q� 1M�^'� 1
k
1. Septic tank, effluent filter and _ tom � 5 t
dispersal cell must be serviced / Maintained
as per management plan provided by plumber.
2.All setback requirements must be maintain ec�� `' p_ u�y`��� yam{ 1 +WMAG.d a�cL
as per applicable codelordinances. �[� `]cave i/IOx Qax I /
r
Z'DOC v� fie tit d.,a AZf-2t-t�OC c+y.LLM'!',
Atluh to eos,plete pl s for m W ssbmit to the Cssnty only " paper not thm a 1/2 111 inch" is size e
�%�(w.t�b * -}a Prove st t Inca:-, Ko.ic e try► 1"io
SBD-6398 (R. 03121) -kt> p taMQ j
NC-i j'r1-E' : C1 P12 � Kom !v-e S
S
LOT 41.,coPY
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14
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UIC rtxtmi eta-a9o'
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