HomeMy WebLinkAbout016-1046-90-000 (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 11 )(m)l
Permit Holder's Name City Village Township
Morgan & Lisa Krueger TOWN OF GLENWOOD
CST BM Elev Insp BM Elev IBM Descnpbon
TANK INFORMATION ELEVATION DATA
TYPE
MANUFACTURER
CAPACITY
Septic
Dosing
Aeration
Holding
TANK SETBACK INFORMATION
TANK TO
PIL
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 FI
Forcemain
Length
Dia
Dist to Well
JUIL Ab,UKY I IUN SYS I tM
STATION
BS
HI
FS
ELEV.
Benchmark
Alt BM
Bldg. Sewer
SUHt Inlet
SUHt Outlet
Dt Inlet
Ft Bottom
Header/Man.
Dist Pipe
Bot System
Final Grade
St Cover
BED/TRENCH
DIMENSIONS
Width
Length
No Of Trerches
PIT DIMENSIONS
No Of Pits
Inside Dia
Ligwtl Depth
SETBACK
INFORMATION
SYSTEM TO
JPIL
BLDG
WELL
LAKE/STREAM
LEACHING
CHAMBER OR
UNIT
Manufacturer
Type Of System
Model Number
UI5IKIbUIIUN SYSTEM
Header/Manrfold
Distribution
x Hole Size
x Hole Spacing
Vent to Air Intake
Pipes)
Length Da
Length Dia Spacing
SOIL COVER v Praesura Svatama Aril. rx Mnund rlr A}-Qrado Sve}ame r]nly
Depth Over
Depth Over
zz Depth of
m Seede4'Sodded
xx Mulched
BedrTrench Center
Bed/Trench Edges
Topsoil
-
Yes No
Yes No
COMMENTS: (Include code discrepancies, persons present. etc)
Location: 1467 290TH ST
1.) All BM Description =
2.) Bldg sewer length =
- amount of cover =
Plan revision Required? Yes No
Use other side for additional information
SBD-6710 (R 3/97) Date
Inspection #1 Inspection #2
Insepctor s Signature
Gan No
44#V- )any- i'7Q
County Sanitary Permit Application
ST. CROIX COUNTY WISCONSIN
In accord with Chapter 12 St. Croix County Sanitary Ordinance
COMMUNITY DEVELOPMENT DEPARTMENT
®17 % ersonal information you provide may be used for secondary purposes
ST, CROIX COUNTY GOVERNMENT CENTER
/ul [Privacy Law. S. �t(1)( J
i
1101 Carmichael Road
ilb
Hudson, WI 54016-7710
Z
(715)3864680 Fax(715)245-4250
Attach complete plans forthe sys
1/2 x 11 inches in size.
n i n ary Permit' # ❑ Check if revision to previous application
Cio e
e\0 ry— Z 2—
I. Ap icy ation - Please Print all Information
Location:
Prope ner Name
A�\� r
L�Ln
SL+"J 1/4 N(,A/ 1/4, Sec 2
I v\ 1 !0111E�
T 3<5) N#r R E (or
Property rs Mailing Address
Lot Number
Block Number
City, State
ZipCodePhone
Number
Subdivision Name or CSM Number
—1 q
II Type of Building: (check one) d S w w,:
❑City ❑ Village OTown of
1 or 2 Family Dwelling - No. of Bedrooms:
❑ Public/Commercial (describe use):
❑ State-owned
Nearest Road
µ
It. Type Permit:
of (Check only one box online A. Check box online B if applicable)
Parcel Tax Number(s)
1.❑ Repair 2. Reconnection 3J] Non -plumbing 4.0 Rejuvenation
A)
/ ? Lam?
d� -lG �4 - Q-
Sanitation
B) Permit Number p p
Ix
Dat� I sued
12? IZooip
State Sanitary Permit was previously issued O 0
IV. Type of POWs S stem: (Check all that apply)
Non -pressurized In-groun ❑ Mound 2 24 in. suitable soil ❑ Mound 5 24 in. suitable soil ❑ Mound A+O
❑ Sand Fitter ❑ Constructed Wetland ❑ Peat Filter ❑ Drip Line
❑ Pressurized In -ground ❑ Holding Tank ❑ Single Pass ❑ Other
❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating
V. DispersaUTreatment Area Information:
1. Design Flow (gpd)
2. Dispersal Area
3. Dispersal Area
4. Soil Application Rate
5. Percolation Rate
6. System Elevation
7. Final Grade
�50
Required
Proposed
(Gals. /day/sq.ft.)
(Min./inch)
Elevation
VI. Tank Information
Capacity in Gallons
Total
# of
Manufacturer
Prefab
Site Con
Steel
Fiber-
Plastic
Gallons
Tanks
Concrete
structed
glass
New
Existing
Tanks
Tanks
oo�
❑ 1
❑
❑
1 ❑
❑
❑
❑
❑
❑
VII. Responsibility Statement
I, the undersigned, assume responsibility for repair/reconnectionlrejuvenationfinstallation of non -plumbing for the POWTS shown on the attached plans. A
license is not required for teralift repair or the installation of non -plumbing sanitation system.
Plumbers Name (print)
%�rchatl J. A
P hers S at ire ps):
MP/MPRS No.
s
Business Phone Number
el
2ec7Fc
1-2do _
Plumbers Address (Street City, State Zip Code)
291/3 1_?P2d4
VIII. County Use Only
Approved
Disapproved
Ow en Initial Adverse��
Sanitary Permit Fee
ate Issued
Issuing Agent Signature (No stamps)
Dete ation
c - Conditions f Approv
OWN .l 'Rp Maabger ual: z _ ,�S f ler_ / - t5 a ntrLCo�+'trW� ek 'Q-�
SYSTEM
1. Septlt tank, effluent filter and -b -to
dispersal cell must be serviced /maintained r� �� �S ifIIs T 0wx
as per management plan provided by plumber. `i
2. All setback requirements must be maintained ��
�
as per applicable code/ordinances.
.t6,4
Rev: 3/21
d,ikv&�k" 'its S iko p¢ e+n
CHECK BOX AS APPLICABLE.
CHECK BOX AS APPLICABLE.
❑ SOIL EVALUATION
Scale: 1°=40'
❑ SYSTEM PAGE 2 OF
SITE MAP o
ao Bo
so
PLOT PLAN
PROJECT NAME:
Morgan Krueger
(ton,ara)
10
DESIGN FLOW: GPD
Attach design flow calculations for commercial plans.
/
PROJECT ADDRESS. 1467 290th St, Glenwood City WI
Pipe Material / ASTM Standard (Tables 384,30-3 $ 384.30-5)
BM Symbol: $ BM Elevabom I/O�O.O FT
NSanitary
Sewer /
BM Descrlp0on:
Force Main:
Slope Gradient (%)
of Tested Area: Well Symbol ("applicable): appNcabk): Q
Indicate north by
dp an rnav
IMPORTANT:
Show ground elevation contours at suitable intervals.
the a
on the pproghe are
2Yq' f
O pal
G
r l we w'`l
— — g3.so-
'iZ' .e P lac. n..y C►+. b, flit Ff/o.�-- C3 FsDRnt� ,A>;!-L
a, tCO P
CHECK BOX AS APPIJCABIE CHECK BOX AS APPLICABLE.
❑ SOIL EVALUATION D Scale: " 40' ❑ SYSTEM PAGE 2 OF
SITE MAP PLOT PLAN
PROJECT NAME: (iongrid) 102 DESIGN FLOW: GPD
Morgan Krueger Attach design flow calculations for commercial plans.
PROJECT ADDRESS. 1467 290th St, Glenwood City, W N Sanitary Sewer.
I Pipe Material / ASTM Standard (Tables UW.30,3 & 3M.345)
BM Symbol: BM Elevation: �DO.O /
FT � Farce Man: /
BM Descrlpdon: F'J/a1+nr ia. rldv— �i� c4 oaf e.. knuf r,c
Slope Gm&W (16) k4cam north by IMPORTANT:
of Tested Aron: Well Symbol IN applicable): (, drewkq an arrow Show ground elevation conburs at BWtable Intervals.
on ft epproprits it
2'/o' (
177::�rr��
„uetl
St��b
Re P let, �"7 [if,b. (i Ff//o+r�s-
(3E,69AC) Mom/✓l f� NU �.,,,�
/UP z�79�s
JUN 14 2022 I
NMNIAndPl y��St. Croix County
29431300
mmunrty Developn
I �yNppd C— VA 54013
Busimn (7is) 265-4115
Fax(715)2W 4120
mrm�i g aMuMEI nr
LOCATION:
SCOPE: Septic Inspection
SEPTIC SYSTEM VISUAL INSPECTION
INSPECTION DATE_ f�2
TYPE OF SYSTEM
X Conventional At Grade Other.
Mound Holding Tank
OBSERVATIONS
„/1 visual inspection Indicates that the septic system and all components are
located the proper distances from the dwelling's foundation, well, and property lines.
The tank(s) were pumped but not physically entered and were completely
inspected and Is/are free of any structural defects and are functioning properly.
X The tank(s) were not pumped, but from readily obsevable feature, it
appears to be functioning properly.
DETERMINATIONS
A visual inspection indicates no evidence of system failure at this time. The
system is adequately sized and is not disapproved for current use as per WI Admin.
Code, SPS 383.
CERTIFICATION
The undersigned cannot guarantee the continued acceptability of the private
sewage disposal system due to unpredictable factors, which could later determine
toe life or code c mpliance of the system.
267985 MP/CST
inspector's Signature License # Type of License held.
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF EXISTING SEPTIC TANK(S)
This is to certify that I have inspected the existing septic and/or dose tank
presently serving the following residence:
(Street address) /yG? zg,011 f . �! •,sue„�ii , located
at: suj '/a, Nltd '/a, Section �, Town 3 o N. ange—L�--W,
Town of clen�a.d , St. Croix County Wisconsin.
Upon inspection, I certify that I have found the tank(s), to the best of my
knowledge, will conform to the requirements of SPS. 384.25, and it (they)
appear(s) to be functioning properly.
Most recent date of inspection or service 6 -2-- 2 n z 2-.
Did flow back occur from absorption system? Yes No K
(if no, skip next line.)
Approximate volume or length of time: gallons minutes
Tank Capacity: /000 eiso
Construction: Prefab Concrete X Steel Other
Manufacturer (if known): 14)j,-s cr &~z c hcO&r-
Age of Tank (if known): /6 ye+.-y-
Permit number (if known) yfq/x p
/Zr.,elms /%%► -rrs
(Licensed Plumber Signature) (Print Name)
/1?/r-21
(Title)
!P - / 5! 2o a- z-
(Date)
2,G7Pao 5
(License Number) MP/MPRS
Form to be completed by licensed plumber (Dept of Safety and Professional
Services Chapter 305 and s. 145.06, Wisconsin Statutes) or licensed disposer
(NR 113 Wisconsin Administrative Code)
Rev. 2/2012
File #:
ST. I V,.NTY SANITARY SYSTEM Office Use Only
OWNERSHIP/ADDRESS FORM
crcored 212021
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. If you would like to view your issued sanitary permit online, you can
do so by using the Property Files Scanned weblink.
OWNER/BUYER INFORMATION
Owner/Buyer
Mailing Address /` 67 2f0 �' g'/
City/State/Zip 6 /inwae/" -s`1d/3
Phone Number (required) ?15 3e 9- ?99
Email Address
Parcel Identification Number G/lr /o yG fo ood
(found on the property tax bill)
NEW SYSTEM: LEGAL DESCRIPTION
Property Location Y&J t/4 ,tic✓ t/4 , Sec. 21T 3o N R15W, Town of Vic-, WOO
Subdivision Plat: Lot # .
Certified Survey Map # Volume . Page #
Warranty Deed # 73Y-530 (before 2006)Volume Page #
Number of bedrooms s3 Spec house O yes,d.no Lot lines identifiable O yes O no
New Property Address
(Staff Initials)
OFFICE USE ONLY
(Verification of new address required from Community Development Department for new construction.)
(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 worronty deed.
Community Development Department - Land Use Division
715-386-4680 St. Croix County Government Center 715-245-4250 Fax
cdd@sccwi.g_ov 1101 Carmichael Road, Hudson, WI 54016 www.sccwi.gov
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1 Wisconv00epanmentofComnwce PRIVATE SEWAGE SYSTEM
Safety and Building Division
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT)
Personal information you provide maybe used forsewndary purposes [Privacy Law, s.15 04 (1)(mll
TANK INFORMATION ELEVATION DATA
TYPE
MANUFACTURER
w. S
CAPACITY
Septic
g '
Iwo
Dosing
Lo,4„�
bra
Aeration
Z /U�
Holding
TANK SETBACK INFORMATION
TANK TO
P/L
/J ru.
WELL
BLDG.
Vent to Air Intake
ROAD
Septic
710
/
> /3o
Z /
Z /
Dosing
`.-l7 /
/56
/
Z.1
/
Z1
Aeration
Holding
PUMP/SIPHON INFORMATION - 1
Manufacturer
Demand
Model Number
ii:��
TDH
Lift
z
Friction Loss
System H d
TD2o 3 Ft
/r z
Forcemain
Length /
Dia. //
Orsl. towel]
90
Z
CY.1I a1111F.\-L9a1-1.1 dra1JL Ski y!.
STATION
BS
HI
FS
ELEV.
Benchmark
/� /6
/0/•/
/ 6b
Alt. Q�
iv1 4_ �
/3. i_.
77• ai
Bldg. Sewer
'1.4
T/ $1,
SVHt Inlet
SVHt Outlet
`
Dt Inlel
Dt Bottom
ZS.cz
75. y�
Header/Man.gy-
Dist. Pipe
{O•
% • fi
9;.5
Bot. System
6
Final Grade
St cover 1Al it 60,J19
Z
77 . `T
j
7.s5
9s. SS
BEDRRENCH
Width
Length /
No 01 Trenches
PIT DIMENSIONS
No Ot Pits
Inside Oia
Liquid Depth
DIMENSIONS
3
A
a
I �� 1 r�
Y-�
`
SETBACK
SYSTEM TO
P/L
BLDG
WCELLLL
LAKE/STREAM
LEACHING
Manufacturer ' I
al
INFORMATION
CHAMBER OR
�T
Type Of System: /
2 r
(( q /
1 !
Model Number
Q✓. 4
UNIT
7
/J
I e1 Ritl rl lcl IN 9 I9UL'V&-t9 =1!.I
17 •h 17 = -W %%46J
Header/Mand d
Length C Die_ _
IDistribution
Pipe(s)
Length
\
Oa \
spat;' \
x Hole Size
x Hde Spacing
\
Vgn1 to r Intj119
3 r
!.^d
cnu rnvFv -- M. ers..d Sa.eama nnh.
Deem tTx
h Over _ _ , _ - _ _
xx Depth of
xx SeedeNSodded
xx Mulched
/
Bed/Trench Center 3.
):of
BeNTrench Edges \
TopstNl \
\es
Ayes No
COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1:_/_/_ Inspection #2:_/_/_
Location: 1467 290th Street Knapp. WI 54749 (SW 1/4 NW 1/4 21 T30N R15W) NA Lot / Parcel No: 21-30-15.339
1.) Alt BM Description = 1"y' k�" ��+� G�w:.•.-S 4- r-o cjC,S a�
2.) Bldg sewer length = 75 M
- amount of cover = r QG�` (�� I ( I I O v
Plan revision Required? Yes %/No !� I Z b1 -
Use other side for additional information. _ �0 PS
Dale In Cert. No.
SBO-6710 (R.3A7)
Safety and Buildisills;
Wisconsin
201 w.
Madison. WI 51707 - 7162
sunny Pctrnn NwVw ro be m la eo— i
De artmant of Commerce
(60) 2662131171
!
Sanitary Permit Application
Saint Plan 1. D Number
In accord with Comm $3.21, Wis. Adm. Cade. Personal Wama6on you prorrdt
' may be used for secondary purpdaa Pnvrq law, s I5.01(IXm)
Protect Address(of different than anae7ress) 1
—7
--
2 'T
1. Application Il tanasatia - Please Print AD Wermadoe
I
_
Property Ow,r*s No me
Parcel I Lac Jr Work I
APA 6RAI
(!'tC%11LcJ
i Properry Owner's M ailing
Property Location
-foe C..durG
Sw %-AJWie-seemn 2/
City.Sese Ip Code Pliant Number
p
f7tJA?P1 GtJ T. CROIX 7 ! ?�5-G45-295
circle t
T V N. R1,�E or�+
Type of Builder ( tU that apply)
r11.
,.^
rt7 1 a 2 Family Dwelling - Number of Wrooms -nm ttL ttD
.J PubiwJCetanercial - Describe Use
Sutdi-ision Name CSM Number
�4 r
J Site Owned - Desenbe Use —� -
I
]Gty_`-vrlla fc Xowrabip of G(e4z"Wi.
III. 7ype of Permll: (Cheek oolr oee box ae Inc A. Complete Doe B If applicable)
A. New S iern
ys
❑ Rtplarement Systm ❑ Traanent/HOWigr Tank Rcp4ccmcnr O� y
Other Modiriaiion n Earetly System
B. ! _, Permit Renewal
Permit Revision Q r. ...
Qnm�e 0f O Permit .. ant.'r , •tw
un Previous Permit Number said Dee Issued
Before Expiration
Plumber Owner
I von _Pressurised In -Ground ❑ Mooted >.)A in of suiaMe soil ❑ Mound < 2e :n of iulu-lc so.. G At -Grade W Single Pass Sand Filer
i Cauuvcied Wetland _i PrwurlaM Io-G�r wtM Holding Tank G Pat Film! ._ • t' t)rc---cslmta Vogt� Recirculating Sad Faster
u RaUCda S rchebc Media Filter 0 Lcoclung
Clumbcr
U Drip Lice Q Gra.a-less P: a
Other re mi
V. DiapensalirTreatiment Ara ImfarlmaUoto
_
I]csijn Flow Opel)
Desipl Sod Appliatioo
Ditpasa) Ate Required cant Otsperssi circa Proposed rant rem
v
r -7 4
to Z.90 G6A&I
e�So' c1�,3�
i V(. Tank info Gpaeiry m Tod
Number
Manufacturer
Prefab Sat 1 text Fiber plastic
Gallon Gallon
of Ultw
;oru:rttt j ComwerN G1au
Mew Existing
f
- Twits Tawas
'
SCVK or Molding Tilt J Q-6
J\
CJC- A/CtGG7E
_
J '
Y~
Atr Utiir
� �"
Oetieg Clrinaer
� ,SMMihililY Cffl,fnfnl• 1 •Ac .nA-..t�J ..-.�_ -.-_- _.cr..._ �__ ._�_..-... ......-��
. Plumber's Na rrie (Prim mber't S' psture Business Phone Ntmrber
/j 'ers o
Plurow's Addre is (Strem City. Suit. Zip Code) f {6-y ��-%
/SSG Sf�f� R) 44. $04eaw�Gce, rN i S��z S 7
.Y Appro.ea DuApproYm Sartiury Permit Fee,(irskrd/esyGrou:to.urn a:e bsuae ' ulna +�Ri SSJ, atu o Stempel
C Ownes Given Reason for Denial streaaK Fee) llJJYY// �f�i• GL I d 7 D 1� L�L�%'txYfL l�C�f•L�Y.. r 1
IX. Coadkloas of ApproyaURasoos for Usapproya)
SYSTEM OWNER: d �� AW t f ! !
i t Septic tank. efffuent filter and
dispersal cell must all be serviced !be serviced maintall
as per management plan provided by plumber. ?. i7 .
! 2. All setback requirements must be maintained U L�Ae �. ,r7jm ���yl yt Q��� 461
as per applicable code(ordinances. G/ /� 5Y' P G,fir
as iat :fan ar, a 11 imcbm 4 , r
ya.s' B2 3 delaw�
5d64 92 Ja2 l w
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ST, CROIX COUNTY No. s*C-9v4—�-H9
SANITAI? Y PERMIT
OWNER
PLUMBER
■■
i.a < la
TOWN OF r lowwwtol LOCATED
I� Iy SEC T N;R157W
AND/OR LOT -�' BLOCK
SUBDIVISION
REPAIR ❑
REG'bNNECTION 10
NON -PLUMBING ❑
SANITATION
REJUVENATION ❑
The purpose of the sanitary permit is to allow repair, reconnectlon,
nation, or Installation of non -plumbing sanitation as described In the
allon for permit.
The sanitary permit Is valid for 2 years from original date of Issuance E
be renewed for similar periods thereafter. Application for renewal shall
a through the county and shall comply with regulations In effect at the
I(d) Changed regulations will not Impair the validity of a sanitary permit until
the time of renewal.
Renewal of the sanitary permit will be based on regulations In force at
time renewal Is sought. Changed regulations may Impede renewal.
(o The sanitary permit Is transferable. A sanitary permit transfer shall be
obtained from the St. Croix County Zoning Department.
If you wish to renew the permit, or transfer ownership of the permit,
contact the St. Croix County Zoning Department.
AUTHORIZED ISSUING OFFICER - DATE
AM Z 22
THIS PERMIT EXPIRES &2 UNLESS RENEWED BEFORE THAT DATE
TWO YEARS ROM oRidffl7rfflIrrE F ISSUANCE
OST IN LAIN V1 W
VISIBLE FROM THE ROAD FRONTING THE LOT
DURING CONSTRUCTION