HomeMy WebLinkAbout032-1000-60-025PRIVATE SEWAGE SYSTEM
INSPECTION REPORT
(ATTACH TO PERMIT)
Wisconsin Department of Commerce
Safety and Building Division
GENERAL INFORMATION
TANK INFORMATION
TANK SETBACK INFORMATION
PUMP/SIPHON INFORMATION
SOIL ABSORPTION SYSTEM
DISTRIBUTION SYSTEM
SOIL COVER
COMMENTS:
ELEVATION DATA
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name:
CST BM Elev:Insp. BM Elev:BM Description:
County:
Sanitary Permit No:
State Plan ID No:
Parcel Tax No:
TYPE MANUFACTURER CAPACITY
Septic
Dosing
Aeration
Holding
TANK TO P/L WELL BLDG.Vent to Air Intake ROAD
Septic
Dosing
Aeration
Holding
Manufacturer
Model Number
TDH Lift Friction Loss System Head TDH Ft
Forcemain Length Dia.Dist. to Well
Demand
GPM
STATION BS HI FS ELEV.
Benchmark
Alt. BM
Bldg. Sewer
St/Ht Inlet
St/Ht Outlet
Dt Inlet
Dt Bottom
Header/Man.
Dist. Pipe
Bot. System
Final Grade
St Cover
BED/TRENCH
DIMENSIONS
Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia.Liquid Depth
SETBACK
INFORMATION
SYSTEM TO P/L BLDG WELL
Type Of System:
LAKE/STREAM LEACHING
CHAMBER OR
UNIT
Manufacturer:
Model Number:
Header/Manifold
Length________ Dia________
Distribution
Pipe(s)
Length_________ Dia_________ Spacing_________
x Hole Size x Hole Spacing Vent to Air Intake
x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over
Bed/Trench Center
Depth Over
Bed/Trench Edges
xx Depth of
Topsoil
xx Seeded/Sodded xx Mulched
Yes No NoYes
(Include code discrepencies, persons present, etc.)
Location:
1.) Alt BM Description =
2.) Bldg sewer length =
- amount of cover =
Inspection #1: Inspection #2:
City Village Township
Section/Town/Range/Map No:
Plan revision Required?Yes No
Use other side for additional information.
Date Insepctor's Signature Cert. No.SBD-6710 (R.3/97)
Community Development Department – Land Use Division
715-386-4680 St. Croix County Government Center 715-245-4250 Fax
cdd@sccwi.gov 1101 Carmichael Road, Hudson, WI 54016 www.sccwi.gov
SANITARY SYSTEM
OWNERSHIP/ADDRESS FORM
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
Mailing Address
City/State/Zip
Phone Number (required)
Email Address (required)
Parcel Identification Number
(found on the property tax bill)
Property Location _____ ¼ , _____ ¼ , Sec. _____, T _____N R_____W, Town of .
Subdivision Plat: , Lot # _____.
Certified Survey Map # , Volume , Page # .
Warranty Deed # (before 2006)Volume , Page # .
Number of bedrooms Spec house yes no Lot lines identifiable yes no
New Property Address
(Verification of new address required from Community Development Department for new construction.)
/ /
(Staff Initials) (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 warranty deed.
NEW SYSTEM: LEGAL DESCRIPTION
File #: ______________
Office Use Only
Created 2/2021
OFFICE USE ONLY
OWNER/BUYER INFORMATION