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HomeMy WebLinkAbout020-1339-30-000 CDo ?&A, Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count $T. CROIX ` Safety and Buildings Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanita&Ze0i9l7o.: Personal information you provice may be used for secondary purposes [Privacy LRw, s.15.04 (1)(m)). EISE)�der xft Tillage ❑ Town of: State Plan ID No.: CST M Elev.: W AYly Insp. BM Elev.: BM Descrip n: M Parcel c — �y �K TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. S ptic L t , la Benchmark g,H 1139 /-11 " Dosing atn , - 75J 21 ?ZAP - SPO /o,£ Aeration Bldg. Sewer Holding St /Afi Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Air I to n ROAD Dt Inlet Air NA Dt Bottom 45 4 Dosing „ Z7 NA Headed �' Aeration NA Dist. Pipe �3' Holding Bot. System gWi" 3 �' /a PH INFORMATIO F ina l Grade PUMP/ SIPHON IN ORMA ON I a / Manufacturer Demand �1./ 6 /� 10S Z-34 Model Number GPM < �iA bS 7 ' r°� , Wr u.« a ✓ TDH Lift Friction S TDH Ft L r1 L Forcemain Length,,., � i � Dia., ' Dist. To Well 1r SOIL ABSORPTION SYSTEM BED /TRENCH Width 5 Length 80 No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth D IMENSION S DIMEN SYSTEM TO P/ L BLDG WELL LAKE /STREAM L anufacturer: SETBACK CH BER INFORMATION Type of ✓lei _ Mo el Number: System: 124414; R UNIT DISTRIBUTION SYSTEM Header / Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length — Ll� Dia. Length Dia. Y—L Spacing / SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Syste 1 Depth Over Depth Over xx Depth Of xx eded / Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS (Include code discrepancies, persons present, etc.) LOCATION: HUDSON 33.29.19,SW,SE 605 SUMMERFIELI� LOT 7 1 fN►` 0 4i'b*4 C-r 0 ; 1 - T 4 7 j (lit ll ��' 2 1�tF7,�o il'io- a,(�'``i�� Plan revision required? [:]Yes ❑ No p. Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. _/ Vi s ' cons i n Safety and Buildings Division SANITARY PERMIT APPLICATION 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Department of Commerce Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x 11 inches in size. ( m% • See reverse side for instructions for completing this application State Sanitar Permit Number zo 0 - 7 The information you provide maybe used b other government agency / ❑ Check if revision to previous application (Privacy Law, s. 15.04(1)(m)]. N5 SI�{mii a - h6I 61 e c e/ f /� State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION Property Owner Name Property Location A- -� -c / 5 ­- S4j 1/4 ST �1/4, S 23 T : , N, R / E (orYW Property,Owner Mailing Address r'/ t /� ,Q / Lot Number Block Number / A 4110 - e 11QA , C% City, State Zip Code Phone Number Subdivision Name or CSM Number CUl II. TYPE OF BUILDING: (check one) ❑ State Owned 0 cit '' LL Nearest Road Villae Public 0 1 or 2 Family Dwelling - No. of bedrooms r rK Town OF 7�V SL/�ii',eiQ ��� eR III. BUILDING USE (If building type is public, check all that apply) Parcel TaxNumber(s� O/s/1 �•'�j9 1 ❑ Apartment/ Condo g3,, A. !//��llll 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant /Bar /Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash 5 ❑ Hotel /Motel 9 ❑ Office/Factory 13 ❑ Other: specify IV. TYPE OF PERMIT (Check only one box on line A. Check box on line B, if applicable) A) 1. V3 New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12� Seepage Trench 22 E] /7/t L In-Ground Pressure 42 [] Pit Privy 13 Seepage Pit w / �'r 43 ❑ Vault Privy -14 ❑ System -In -Fill S� VL ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade J Required (sq. ft.) Proposed (sq. ft.) (Gals/da /sq. ft.) (Min. /inch) Elevation b © p 7-6-Q ( J- / j0 Feet 7. Feet Capacit VII. TANK in Ca allon Total # of r Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existing structed Tanks Tanks eptic Tank f+k IdrngiatMr if /<Z ❑ 1 ❑ ❑ ❑ ❑ Lift Pump Tank i0".44,.ber Q/1p 6 O ❑ 1 01 ❑ ❑ ❑ VIII. RE PONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Sig atur : (No tamps MP /MPRSW No.: Business Phone Number: e,4 R / 5 L / �l�h t- s G ��s �Py -z3 ?3a Plumber's Address (Street, City, State, Zip Code): g 7 - �, 3 T� s ,� z ram SS ® o IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved S itary Permit Fee (Includes Groundwater D ate Issued Issuing Agent Signature (No Stamps) Surcharge Fee) (B7 Approved []Owner Given Initial � /�/O 049 Adverse Determination / 0 AP X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SOD-630 (R.1 1196) DISTRIBUTION: Original to County. One copy To: Safety 8 Buildings Division, Owner, Plurnber T. �,n 6h CJ� • J r 'C� ,vs i \Ali � r � /lI P'� 1 7 Ld Co e f'os� S � f - - ��rJ ms`s r.►,� - I 4 cy — y"cT �11`EPtPC*S y y'`,�vc �L'RFolxAfil� PIpR S' 1 FoR� G�2.�SS S�CI�ON 4 "cs \JeKm \>>�,,� w1 PrpPnu� CAP AT LAST \Z 1= +�utS!{LD 6R -h'PE �ctST�NG GCtJ1'3X' �� ✓� -- - - ---- -_ 1 — � �„� 141t LO G RAC FILL eLoJ :T,4, 76 V G C� "nf I �Z"1v Z IIZ4 AGGR�t�-e O� -cup., a�g1�Lt Bv'1701�! 'Pt PC' C'lrup Z pF HGGRfi' GA'TL' � AOV t pt PE DISTRIBUTIOU PIPE TO BE AT LEAST IUCHES BELDw ORIGINAL GRADE AUD AT LEAST 2!O IUCHES BUT HO MORE THAM y2 IUCHES ESELOW FINAL GRADE MAXIMUM DEPTH OF EXCAVATIOU FROM ORIGIWAL GRADE WILL t3E - IUCHES MINIMUM DEPTH OF EXCAVATIOU FROM ORIGILlAL GRAOE WILL BC =4 =— INCHES SIGtJED: �— LIG E U SE UUMBE R: UAT C - -`--�- - -� -- I � - Combination Sep4c'Tank and PLl-MPCHAMBER CROSS SECTION AND SPECIFICATIONS' PAGE OF -VEIJT CAP WEATHER PKOOf — JU)JCTIOU 90X . 4'C.I. VENT PIPC APPROVED LOCKING 10' FROM DOOR. 10, COVER kJIV ohKiDOW OR FRESH wARa111.1G L-�BEL ALP, t corauutT 6 R-R . �� -I I r el3 Q : 11� PROVIDE L I t'�i1oN . IAILE T 7 AIRTIGHT SEAL I I I A I ! � I .APPROVED JOIfJT�: APPROVED JO UT I I ( W /C.I. PIPEFuc W /C.I. PIPEaR Tank construction I' II ALARM I shall comply with I I ILHR (83.15 and 33.20 e I I I I ow C ! I LLCM. g7�D OFT PUMPS __J OFF D CONCRETE 9LOLK 8 � 3" APPROVE. K15EK EXIT PERMITTED OULy IF TAWK MAMUFACTURE =R HAS SUCH APPROVAL BEDUtN� SEPTIC F SPEGIFICATIC)US DOSE T AMKJ MANUFACTURER: IJUMBER OF DOSES: PER DAy TAWK :AZE: IAJol7s0 GALLOWS DOSE VOLUME ALARM MANUFACTURER: SJ �z -elf d IfJCLUDIiJG 6ACKfL�OW: ` 7 � GALLONS MODEL WUMBER: Q CAPACITIES: A= �"��� I CHES OR 36 / ' 11 GALLOW5 ��t 3 a SWITCH TUPE: /�( e R C UR y B = d2 INCHES OR ��'� tl kJ5 PUMP MAIJUFACTURCK: — -2 o C- " /2 1UCHES OR � � $ D LLOIJ S MODEL MUMBER: D- °' INCHES OR GALLOWS SWITCH TYPE: MOTE: PUMP AND ALARM ARE TO 5E MIM11ALIM DISCHARGE RATE 2 GPM INSTALLED OW SEPARATE CIRCUITS VERTICAL DIFFERENCE DETWEEU PUMP OFF AIJD..DISTRIBUTION PIPE.. FEET + MIu1MUM uETWORK SUPPLY PRESSURE , . . . . .. . . . . FLET + F E E T OF FORCE MAIN X - -I�YOrr.FKICTIOU FACTOR.. 2 " FEET ._ TOTAL OylJAMIC HEAD FEET Pump chamber DIAMETER {� z IIJTE AL � MENSt01JJ OF TAWK: LEAIGTH .WIDTH ;LIQUID DEPTH J `� BOTTOM AREA 231= GAL /INCH z / C/ AS PER MhNUFACTURER C_� GAL /INCH U W W HEAD CAPACITY CURVE 4're 61/4 W 66 53 -55" SERIES 45ra 25 TOTAL DYNAMIC HEAD/ m 4'/e \ FLOW PER MINUTE ` EFFLUENT AND DEWATERING m �' HEAD UNI SCMIN \ —1 - LU 6 FEET METERS GAL LT 5 1.52 43 163 3 m 10 3.05 34 129 15 4.57 19 72 15 19.25 5.V 0 0 z 4 J 10 I H O ~ 2 5 9' S /,s I 0 1 1 US 10 20 30 40 50 3 GALLONS LITERS 0 60 160 FLOW PER MINUTE CONSULT FAC FOR SPECIAL APPLICATIONS • Piggyback Mercury Float Switches • Available with special cord lengths of 15 available. 25', 35' and 50'. • Variable level long cycle systems • Alarm systems available. available. • Duplex systems available. Standard cord length - automatic 9 ft. Standard cord length - non - automatic 15 ft. - -'— SELECTION GUIDE M53/55 SER - Control Sel ection 1 Integral float operated mechanical switch, no external control required. Model I Volts M ode A mps Si mplex Duplex 2. Singlepiggyback wide angle mercury float switch or double piggyback mercury float M53/55 1 11 1 Auto 8.0 1 or 1_ &_7 — switch. Refer to FM0477. N53/55 115 1 Non 8.0 2 or 2 & 6 3 or 4 & 5 3. Mechanical alternator 10 -0072 or 10 -0075. D53/55 230 1 A uto 4 .0 1 or 1 & 7 4, See FM -712 for correct model of Electrical Alternator, "E- Pak ". E53/55 1230 1 N 4.0 2_o_ 2 & 3 or 4 & 5 5. Sensor mercury float switch 10 -0225 used as a control activator, with E -Pak (3) or (4) float system. 53 Series - Wt. 23 Ibs. - .3 H.P. 55 Series - Wt. 25 lbs. - .3 H.P. 6. Four (4) hole "J Pak", junction box, for watertight connection or wired - in simplex or duplex operation. P/N 10 -0002. 7. Two (2) hole "J- Pak', junction box, for watertight connection orsplice, P/N 10 -0003. For information on additional Zoeller products referto catalog on Combination Starter, FM0514; CAUTION Piggyback Mercury Float Switches, FM0477; Electrical Alternator, FM0486; Mechanical Alterna- All installation of controfs, protection devices and wiring should be done by a qualified nator, FM0495; Alarm Package, FM0513; Stimp /Sewage Basins, FM0487; and Simplex Control licensed electrician All electrical and safety codes should be followed In addition to the Box, FM0732. most scent FlectnC Code (NEC) and the Occupational Safety and Health Act (OSHA) RESERVE POWERED DESIGN For unusual conditions a reserve safety factor is engineered into the design of every Zoeller pump. rte, Q 3280 Old Millers Lane Manufacturers of ... Z OE��E/T rZ7. P. 0. Box 16347 • Louisville, Kentucky 40216 (502) 778 -2731 • FAX (502) 774 -3624 /J UAUrr p ,W PUMPS �NCE ���J l _ r V•J sconsin'Qepartment of Industry SOIL AND SITE EVALUATION Page 1 of 3 Labor and Human Relations Division of Safety and Buildings in with S. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less th x 11 in es m s must County include, but not limited to: vertical and horiz fererA), di and St. C ro i X percent slope, scale or dimensions, north a nd loc tance a rest road. Parcel I.D. # t� 1i0p0o77 - 0'2 Q APPLICANT INFORMATION - PI prjf all'Uora��tfon. � _.- Reviewed by Date Personal information you provide may be used for a ary piny Law, s.,t (t) (m))• Property Owner /P roperty Location Dick St out Govt. Lot SW 1/4 SE 1 /4,S 3 3 T 29 N,R 19 E (or) V Property Owner's Mailing Address Lot It Block# Subd. Name or CSM# 1 352 Awatukee Trail 7 1 C$ ry, �/p/- 1 3.2 IF City State Zip Code Phone Number Nearest Road Hudson Wi 54016 715 549 -673 ❑ City Village Town ( ) High Ridge Rd ❑ New Construction Use: [3 Residential / Number of bedrooms 3-4 Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow 600 gp d Recommended design loading rate • 7 bed, gpd /ft • 8 trench, gpd /ft Absorption area required 8 5 8 bed, ft2 7 5 0 trench, it 2 Maximum design loading rate * bed, gpd /ft - 8 trench, gpd /ft Recommended infiltration surface elevations) A l B2 B3 92.90 _ ft (as referred to site plan benchmark) Additional design /site considerations Parent material Glacial Depo sit Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system KI s U KI S ❑ U ®S ❑ U I NIS ❑ U I ❑ S E ❑ S )D U SOIL DESCRIPTION REPORT Boring Horizon Depth Dominant Color Mottles Structure GPD /ft 9 Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 1 1 0 -14 10yr3/2 none L 2mabk mfr cs 2f .5 -.6 2 14 -41 10yr3/3 none sl lmabk mvfr Cs if .4 '.5 Ground 3 41 -9 7 .5 yr5/ 6 1gune ms Osg ml -- -- . 7 elev. 9 6. */ Qt. Depth to limiting factor 9 in. Remarks: Boring # 1 0 -10 10yr3/2 none sl 1mabk mvfr cs 2f .4 ..5 2 2 10-93 7.5yr5/6 none ms osg all cs if .7 .8 Ground elev. 97 - 4 1. Depth to J limiting factor 9 0 — in. Remarks: CST Name (Please Print) Signature Telephone No. ' /l. .4- S� u/r e _ �/� • - ,?/.;?/ Address Date CST Number 'YfTG ? TY OWNER SOIL DESCRIPTION REPORT PROPER Ill P4 :Gk k 9# 9131=. Page 2 of 3 PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Structure 2 in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed , Trench 3 1 0 -10 10 r3 2 none L 2mabk mfr CS 2f -S 2 1 10-30 10 r3/3 none sl 1mabk mv Ground 3 30 -110 7.5yr5/5 none ms os ml Cs -- .7 .8 elev. 99 -Ln ft Depth to limiting ; factor 1 1 O in. Remarks: Boring # 1mabk mvfr Cs 2f .7 , .8 2 8 -9 7.5yr5/6 none ms osq ml Cs if .7 :.8 Ground elev. 99 �Qt• Depth to limiting factor 9 Q_ in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring# 1 -38 10 r3 2 none is 1mabk mvfr 5 2 8 -9 7.5yr5/6 none ms osg 1.11 Cs if .7 .8 Ground elev. 9 9 - r; Oft. Depth to , limiting factor 90 in. Remarks: Boring # ..................... Ground elev. ft. ' Depth to limiting factor in. Remarks: SBDW -8330 (R. 08/95) i ` i W } i GrJ 1 ^I.�Y2 � 33 ��1✓ �� 6,31 r > �z I k Y , � h i i ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerlIIuycr A 4 ►'1 E k 1 s� Mailing Address _ _ 5 8o Property Address 66 S (Verification required from Planning Department for new construction) Cit estate 14L) DS-0 n. c c_�Z. Parcel Identification Number ©� D • l �1 9 J,EGAL DESCRIMON Property Location J'Uj ,, SC; y S T �q N -R��W, Town of Wc/'OSo•z Subdivision Urh ire �' f'1 Lot it fxxt fed Smvcy Map # _ � Volume . Page # Witt ranty Deed # 5 V -7 5 9 Volume 3 ? Pag i ff Slsoe h0u$0 IN yes ❑ no Lot Imes identifiable ® yes ❑. no t§"TI!C�IANCE � tsp�aataa�cla�ucetolandlcwastr .s.Pivpermamtcnan� as of out Bae sepeic tank cvaY thane yeaas or soonct; if needed by a Tknscd pamper. 'VA=t you put into tie system can afrod.&Cf of tier xvdc taak in ffie waste sage disposal.systcm. Me PmPcEty' 0'r ag= to submit to St tic ?,owing Dgiarftacat it eradication four, signed by >be Qwnet and b9' a P QO Pbmbe4 =Micta pkmtb roritIk=scdpa gxrver yingffl t( 1) g,, eoa�dtcwastewater(lssposdsysticm is is pamper op=tting cmdition and/or (2) after inspection and pampiag mocuy), &C =ptic.t mk kss .than 1/3'full of d edge. hm cad Mc abm =qqk==ts and agree to asaiataia dtc private sewage diq*W systam wi& fb,- td &rds • h=in at bytie Dq>sztned of 0au==e and the Dqui catofkatud Rasoarocs State of Wisconsin.. twn zft tigg 6 d y = septic syrtenn leas bom— intainedmastbe eompIdedand ncdan0d to the St Qoix.County Zoning Office within 30 da of true der =_ ne3" cxpimfim date. SltrfiiA:R= OP APPIJC NT_ � DATE OWNER. C Ek'I CA.U0N I (we) ca ify that all stn =cats on this form tro true to the best of nay (our) lmowledge. I (aft) am (ace) the ow=(s) of PMkxtydmdibed above,, by vktw of a waanaty deed racoaded in Register of Deeds Offic S,a'NX OF APPLICANT DATE ««s «ss AV iof that is n'k rx=Wma - y rcautt is the sanitary Permit being revoked by the Zoning Depaatmeat *« Ifndude WI(h this application: a tramp d wanuty decd from the Register of Dexds office a copy of the certified survey rup if trfcrcace is made in the warranty dcod ^ ^ - VOL _ ^� K7 ma��^�^» ~ ������& o�sBAR opW/ycowawmnmz-1*� "�`�-�v"w~° WARRANTY DEED DOCUMENT NO. RTCHARD- 0 - AUG 1 U 1998 � tic conveys and warrants to ------------- ---------------� .HIS SPACE RESERVED FOR ncCo°o.°so"r'. ~^"�^=u"�mn°�9nas — ��,/ the following described real estate 'n ��__�coi�- _____-___c��� /'}���c� --- -- uu'eoJx\aonsip- l Lot 7, plat of Sommerfield, Town of Hudson, Gt. Croix County, wi000uoin' TRAN SFER FEE This h=m=a"'apror'«y .."` (~"w) Exception m"^"°mns easements, restrictions, rights-of-way and covenants of record, if any' om"u,h* ��a -»»/9-4�-� �s�� "^~^ ^ Q�L�� ^ ------------- ------------------ 'ss^u (SEA'` AUTHENTICATION acIINovvcsos/mswc [ � ^'u""/""`") �u�^� o ���**�*�. � *`ov`x"^xuax�uu/o(___-__-��9____ ur^r�y>um'/v�o'n,.�e--l���__-__u --___----- /*-0-&. the above mm/u ////c mcur-n�rAIcoaxvrm`c^wax o/n^t,___---__-_-_-_-____ b m."^',^"uit°,x'p"*n--�*h the :v*`"g THIS wornuwEwrNAS DRAFTED n, Janet P. 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