Loading...
HomeMy WebLinkAbout040-1214-50-000 (2)LWA= PC a rW4PYf I 4Astr?,8 - 19 -* 10 2 9 P PRIVATE SEWAGE SYSTEM Labor and Human Relations Safety and Buildings Division INSPECTION REPORT GENERAL I?4FORMATION (ATTACH TO PERMIT) Permit Holder's Name: 0 City [I Village Town of: IHOMAS I PAX TROY CST BM Elev.: Insp. BM Elev.: BM Description-:-- 100' ;7 _? < TANK INFORMATION TYPE MANUFACTURER CAPACITY Septi c 41- Aeration Holding.. TANK SETBACK INFORMATION TANK TO PI L WELL BLDG. Ventto Air Intake ROAD Septic NA Dosing NA Aeration . ...................... Holding . ...... . PUMP/ SIPHON INFORMATION Manufacturer Demand Model Number GPM TDH Lift Friction 5yste > FDTt-- Ft Head7, Forcemain Length IDI-a.tl Dist. To Well SOIL ABSORPTION SYSTEM ELEVATION DATA County: RT outclix 'Sanitary Me Fm 1 tMM" State PT -a an IT) Iq Parcel Tax No,: QAA-110�1 A9300280 ��//� /g S STATION BS HI FS ELEV. Benchmark 16ide 60 /6, Ild "5 ■ Z42-go Bldg. Sewer St W Inlet 75 St. / YV Outlet 77 Dt Inlet .......................... .... ........ Dt Bottom Header Dist. Pipe Bot. System Final Grade TRENCH Width Length No Of Trenches PIT,-- No. Of Pits inside Dia. Liquid Depth D MEN S 10 DIMENSIONS SETBACK SYSTEM TO P L BLDG WELL LAKE STREAM LEACHING Manufa ct ur INFORMATION Model Number: TypeOf.�,�, 1 System: 1 OR UNIT DISTRIBUTION SYSTEM Header/ A XPAIL SaA 8 4 6 Distri I I Distribution P pe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia- Len gth7 Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade S yst Sonly Depth Over # Depth Over ,, 7 xx Depth Of --0 `5eeded /Sodded xx Mulched Yes No B e d /qfy!gf_c-enter � Bed /dges Topsoil ❑ Yes ❑ No E] D COMMENTS: (include code discrepancies, persons present, etc.) LOCATION :,TROY 16,28*19.1029 Af 711 Plan revision required? ❑ Yes [D--No Use other side for additional information. SBD-6710(R 05/91) Date Inspect , or's SignatLle Cert No- S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER C�A ADDRESS Fo2 5 q I 'I SUBDIVISION CSM# ��v�/E/� LO T 24 �o4 7Y CK) SECTION T 2j� N-R /I W, Town of 0-% 1(p0q. lei. /0 bl ST. ICROIX COUN . WISCONSIN Provide setback and elevation information on reverse of this form. tankmanhole Cover P i ovIde 2 dimensions to center of septic BENCHMARK: �''"� AAr O.-Ai ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING _.TANK INFORMATION Manufacturer: ZA►�S Liquid capacity: a.?,-5�aa.14 Setback from: Well S-" House 1f - Other ---� Pump: Manufacturer 'Ai A Model # AJII Size /lJtl Float seperation AIA Gallons/.cycle: AIA Alarm Location) ': SGIts ABSORPTION SYSTEM Width : Length Number of trenches .� Distance & Direction to nearest prop. line: /'� Setback from: well: �� ` House .� � other ErEvATioxs Building Sewer_ ' ST Inlet. cj5.3� ST outlet PC inlet PC bottom A/4 Pump Off A/1 Header/Manifold 951-67� Bottom of system Existing Grade�� Final grade DATE OF INSTALLATION: �s/S PLUMBER ON JOB: LICENSE NUMBER: �%�iPj INSPECTOR: 3/93:3t - IMI I RANITARV PFRUIT APPI MATUIN CW In accord with ILHR 83.05, Wis. Adm. Code COUNTY 45�� Lllz:�Ql k00001 STATE SA TA 7 P MIT # —Attach complete plans (to the county copy only) for the system, on paper not less than 8% 11 inches in ❑ x size. vision C .9if vision to Previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER I. APPLICANT INFORMATION — PLEASE PRINT ALL INFORMATION. PROP OWNER PROPERTY LOCATION '00� e :5 4,6- -7 1/4 AJZ'O' 1/4, S T WS79 N , R E PROPERTY OWNER'S. MAILING ADDRESS LOT # BLOCK# CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 11. TYPE OF BUILDING: (Check one) ❑0 CITY NEAREST ROAD State Owned 0 VILLAGE of TOWN E]Public X1 41 OF. 2 Fam. Dwelling-# bedrooms PARCEL TAX NUMBE'R(S)' or of 111111. BUILDING USE: (if building type is public, check all that apply) 0 LID _AZI 1 El Apt/Condo 2 El Assembly Hall 6 F-1 Medical Facility/Nursing Home 100 Outdoor Recreational Facility 3 El Campground 7 0 Merchandise: Sales/Repairs 11 El Restaurant/Bar/Dining 4 1:1 Church/School 8 1:1 Mobile Home Park 12 El Service Station/Car Wash 5 El Hotel/Motel 90 office/Factory 13 El Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1 New 2. El Replacement 3. ❑E]Replacement of 4. ElReconnection of 5.0 Repair of an System System Tank Only Existing System Existing System 13) A Sanitary Permit was previously issued. Permit # Date Issued V. TYPE OF SYSTEM: (Check only one) Non -Pressurized Distribution Pressurized Distribution Experimental Other 11 1:1 Seepage Bed 21 ElMound 300 Specify Type 41 El Holding Tank 12 K, Seepage Trench 22 0 In -Ground 42E] Pit Privy 13 1:1 Seepage Pit Pressure 43 El Vault Privy 140 System-ln-Fill V1. A ABSORPTION SYSTEM INFORMATION: -GALLONSPERDAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5.PERC.RATE 6-SYSTEM ELEV. 7.17INALGRADE 1 GALLONS G REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION 1-' 01 4 Fel-1, 0 a ao 1 7 1ro -5 C?. $:F. 977 1 Feet 0 Feet 11. TANK V V11. T� INFORMATION CAPACITY in gallons Total Gallons # of Tanks Manufacturer's Name Prefab. Concrete Site Con- Steel Fiber- glass Plastic Exper. App. New xisting Tanks Tanks structed Septic Tank or Holding Tank L1 I I Ll Lift Pump Tank/Sip on Chamber F-1 Vill. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber'oigna ure: (No Stamps) MP/MPRSW No.: Business Phone Number: 3 2rfo - Plumber's Address (Street, City, State, Zip Codg) 2/5 00ov, -Vc 7x. OOUNTY/DEPARTMENT USE ONLY / f Approved Disapproved F-1 owner Given initial Sanitary Permit Fee (includes Groundwater 1, Surcharge Fee) Date Issued issuing Aifen 0 ps) 70TIX Adverse Determination X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVA 4, e(700. SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. it 2. Your sanitary parmit may be renewed before the expir-ati-.)n date-:, and at the tinne of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit 4 ransfer/ Renewal Form (SBD 633g9; to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 5. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. ll. Type of building being served. Check only one and complete ## of bedrooms if 1 or 2 Family Dwelling. Ill. Building -use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in #1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIIl. Responsibility statement. Installing plumber is to fill in name;, license number with appropriate prefix 'e.g. NIP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8� x 11 ink, hes gnus} be submitted to the county. The plans must include the following: Aa plot plan, drawn to scale or �Prith complete dinnension�q iocalion of holding tanks : septic tank(S) or other treaty;den' tanks- Jm,_,� �' ra�7 ���.��.�w,� ;=4 s�'`" 4'jaI � i�"a�i� "��,-'��=���?� i-4 ervire; tr 5 d pump orp opt tanks; tr outs bar , .) S= q i ► er.1 e- am �t s v +� r-i ­� re -is and the ',,xation _-f the building ding served. 1; horizon � ,a =��� ... �� ��' °�� 4 eev-a o,po;.., a C) complete specific,, tions for pumps and contrals, dos-4s volUPIe= ��le ��� �y�= �s er:�� ax;�� tr ��'.i,�.� 3 �;=� pLfr-n,p performance curve; purnp € odel and pump manutfacturer, D} cross sect. -1 C_ t the Soil absorptio syc_tern if required by the county; E} soil test data on a 115 form; and ::i siring lrformatoE. GROUNDWATER SURCHARGE 198. Wisconsin Act 410 in%cbaded thle creation of surcharges e r ,4A nL;pf Si� regulated practices which can effect groundwater. T'he� inonies collectewl through these surcharges are used fo �f`�4�a€���-3�'�f ��� �E= :s�.�i"i�-i&���t��r --of (Pm:d.. water contan--tination investigations and establishment of "; andi ard�:,_ SRD-6398 (R.11188) 0 T-f I V. 63 A6 ------- 4 1 aAl tJ17-Y 15C,4 ly/O PVC AT Cc4T,44T A�J,0 L �e- N Vv 4 / A) PLB 67 PLOT & CROSS SECTION PLANS t-APPA k3hQ5. tXCAVAfIN(A INC L—,PLUMBING UNIT PROJECT 4 f &--- / - I - . FAP-S-HAIR INLET AND OBSERVATI MAXIMUM 12" ABOVE FINAL GRADE 1-71777 JP 7,7 7-r .7 7- MAXIMUM OF 42" ABOVE PIPE TO FINAL GRADE # I I MARSH HAY OR SYN-THETIC COVERING I I MINIMUM 2" AGGREGATE O'l E R PIPE DISTRIBUTION PIPE 'Wow 40 so 40 ELEVATION BED 6" AGGREGATE BOTTOM PER SOIL BENT NTH PIPE TEST IS "I, FT. APPROVED VENT CAP 4* CAST IRON VE14T PIPE SIGNEU:/ LICENSE". lq&l 33 96- DATE: /�1'-3 f TEE SOIL TESTING BY: PERFORATED PIPE BELOW COUPLING TERMINATING AT BOTTOM CIF SYSTEM DEPARTMENT OF SOIL BORINGS AND SAFETY &BUILDINGS RE -PORT ON DIVISION INDUSTRY, ` LABOR AND ` N TESTS(115)P�O• Box 7g69 PERCOLAT � MADISON, WI 53707 HUMAN RELATIONS SILHR 83.09(1) &Chapter 145) LOCATION: SECTION: TOWNSHIP/MUNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION N E: / %-.0001 36 6L0\j&-g_ Isw 1/4 N L 1/4, / 4, /TzV N/R 19 E (or) W pny C NTY: O ER'S/BUYER'S NAME: MAILIN UG ADDRESS: o 4 DATES OBSERVATIONS MADE USEPROFILE DESCRI T,1,ONS: PE OLATION TE,TS: N0.8EDRMS.: COMMERCIAL DESCRIPTION:'�� Residence N �—XNew ❑ Replace MAy /S O /7 �► ILA �-. "� � � 1 cs �c�� RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: iN-GROUND-PRESSURE: SYSTEM -IN -FILL HOLDING TANK: REC MENDED SYSTEM:(op nal) J [� h/ A l S CCU S Elu S ElU Z S E U EAZIL ©► -� If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate:Floodplain, indicate Floodplain elevation: AIA V--r PROFILE DESCRIPTIONS WATER INCHES CHARACT NUMBER DEPTH 1pil ELEVATION OBSERVED EST_ HIGHEST ER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH T TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) A -7 0. L 0 A-7 1-7$c L-t s f 3" 8kP lS FL k4 '*R6 9 w AS 594 E Q 1,j TOTAL 14 *'IRL LTv> 2 6"6,e,,j �S j L A " &B Rry A5 4'9' 6A rj M-5 if' &1-rS 72� 89to-iS, L reie h&n, rhs N i'1S 44-&-urs zveaos, L. 46"gowm--s TEST NUMBER L DEPTH �`� WATER IN HOLE AFTER SWELLING IS.70 PERCOLATION TESTS TEST TIME DROP IN WATER LEVEL -INCHES INTERVAL -MIN. PERIOD 1 PERIOD 2 > � > PERIOD 3 > RATE MINUTES PER INCH P- ) P'T X1fi i to d P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. i SYSTEM ELEVATION 36 1 -� e 2- 70 P \1\0 . r�.. y / (1-3 f El ......... . 4 AUV- I c._ I, the undersigned hereby cent' icy thai'tT1e"1;vi�—tests reported on this form were made by me in edures and meths Administrative Code, and that the dat ecorded and the location of the tests are correct to the best of my knowledge and belief. Low ied in the Wisconsin NAME print): TESTS WERE COMPLETED ON: 36WSO-0i a 1 9-1 ADD RIS: CERTIFICATION NUMBER: PHONE NUMBER (optional): sAa 1 4 f:ST SIG TURE: 1 DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) — OVER — INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 To be a comOilete and accurate Oil tem4 , 'Vout _epot must, Indude, 1, cornplet� legal desc�'iptlon; 2. The use sc..act ion rnust clearly in(licate whether this r's a, residence oi- corrm-ierc­ial projo,t; 3, MAX IMUM numbor, c.J bedroorns or use plann,-�d, 4, Is this d tleVV ()�' feplacement 5, Complete the suitability r-atrnq I axes. A SITE IS SUFFABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMIS ARE RULED 01k.jl- BASED ON SOIL CONDITIONS; 6. PLEASE use the ,,ihbrevia-!JonS Shown here foi, vvd.ting F).1ofile de�3c� 4)tiont , and, completing the plot plan; 7. MAKE A LEGIBLE diaq1'aM9 W'11<11ui'vatply locming your test locat'K-,ns, Drawing to scat ei is preferred', A separate sheet may used H: dere(J; 8. Make ure you; hennchr-Aark and vf.-�r-tical ek,-3vwjon �-Rknt afeclearly shown,and are pei,rnanent; 9- Complete all appropriate boxes as 'to da?es, names, �iddre�se,,, fl000 " L C . I - Plain data, percolation test exemp- tio$-), if appropriate; 10. If the inforrriation fsudh� a,� floocl Oain,, eieva-tion, ds,Oes rlot apply, place N�i,%. in fl)e 9 i , pprog)r�al:e 11. Sign the forn) PIIIC, YOW� cui -�t ad(-Ilress and your �rl:ificat-Jon numbbox;cL,�r; 12, Make legible (x-)plend dist'ribute as requ6red, ALL SOIL TEST,3 MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS 01-r" GOIVIPILE ­TL (ON, ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols CA"IR �.Wllffir BR iadock cob Co6ble� (3 , 10") SS Sands-Lorie Gavel Ljndei- 3"', LS [_irnestorli�,, S I I IV`, Hig'h CS o a Sand latim, Raie 'U'M, 'Z3,"7i 'San�J T11 nan B k y vv sc; &,ndy Clav Lo;)m L�icl SHW Clay I sc sandly Cay V' h s i C Silty Clay ff -f fewe� fine, faint .K_ I C Clay c c corn�,non, coarse in a W!6 n C t ri VV I., High water llevt.,$J, &x general vvatc4 -for hqud �v,?,aste d'spos,fl , BA4 M1�2 Bench ark VRP V o, ca I R\ e This soil test report is the first step In securim ,j a Sanitary peri-nit. The county or -the Department may request verification of This soil test in the field prior to perniij� ' erl I issuance. A complete set of plans for the private sewage system and a Permit application must be submitted to the appropriate local authority in order to obtain a parmit, The sans-taty permit must be Obtained and posted Prior to the start of any construction, /,i '� "{,.r ,i .'�' � j 1 .. ',, f. � t' ,�. 'i S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT Ste Croix County OWNER/BUYER—Z gel 9 S a 7.11e, te� Ar ADDRESS 7- FIRE NUMBER___,J CITY/STATE / L/t;zz- LIS ZIP PROPERTY LOCATION: 1/4,r 1/4 SECTION /4*7 T 5 W TOWN OF 1/ —1 Ste croix,Count y, SUBDIVISION LOT NUMB ER­z?G: Improper use and maintenance of your septic system could result in its 0 premature failure to handle wastes. Proper maintenance consists Of Pumping out the septic tank every three years or sooner, if needed by a licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal' system. ! St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to july 1, 1978. Ste Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix zoning a certif ication 'form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (I). the on -site wastewater disposal system is in proper operating condition and (2) after 'inspection and pumping (if necessary), the septic tank 'is less than 1/3 full of sludge and SCUM. I/Ile, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR0 Certification stating that your septic has been maintained must be completed and returned to the St. Croix co. Zoning Officer within 30 days of the three year expiration date SIGNED: DATE: St. Croix co. zoning Office 911 4 t h St. Hudson, WI 54016 S T C - l o o This application form is to be cOmpleted in •full and signed •by �the owner(s) Of thc Property being developed. Any Inadequacies will only result in delays of the POrrftit issuance. . IShould this development be intended for resale by owner/coht' house), thenla second form should'be ractor,(spec the property' is retained and completed when sold and submitted to appropriate deed recording. this office with the -------- Mr. ------- ........... Owner of property 7,; ele-- k- - Location of'property5,cR-.)l/4 A/4<7,1/41 Section T N-R W "O� _;,v Township Mailing address Address of site Zrl � Subdivision name WA o t no. Other homes on property? -yes- No 2 Previous owner of property � �VIS Total, size of parcel 2- Date parcelwascreated 'Are all corners ers and lot lines identifiable? >(-..—Yes No Is this,., perty being developed for (spec. house)? --Yes No Volum iffand, Pa I ge . Number 1`1 - of Deeds,, as recorded with the Register 4f/ ----------------------- INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER & THE SEAL OF THE REGISTER OF DEEDS. In addition, a Certified survey, if available, would be delays of helpful so as to avoid the reviewing process. if the deed description .references to a Certified Survey Map, the Certified SuryMa shall also be required. ey p PROPERTY OWNER CERTIFICATION I(we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner ) of the Property described in this information form, by virtue of a warranty deed recorded in the office of the County Register of Deeds as Document No. , and that I (we) presently own the Proposed site for the sewage disposal system, or I (we) obtdined an easement, to run the above described property, for the construction of said systemandand the same has been duly recorded in the office of County Register of deeds as Document No. Signatu'fe of applicant Date of signature Cd-applicant Date of Signature