HomeMy WebLinkAboutSAN-2018-394 032-1065-50-165Wisconsin 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
Kelly Stover I TOWN OF SOMERSET
CST BM Elev linsp. BM Elev: IBM Description:
TANK INFORMATION
TYPE
MANUFACTURER
CAPACITY
Septic
Dosing
Aeration
Holding
TANK cFTRArK INFORMATION
TANK TO
P/L
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 Ft
Forcemain Length Dia. Dist. to Well
SOIL ABSORPTION SYSTEM
ELEVATION DATA
County: St. Croix
Sanitary Permit No:
SAN-2018-394
State Plan ID No:
Parcel Tax No:
032-1065-50-165
Section/Town/Range/Map No:
24.31.19.325B-31
STATION BS HI FS ELEV.
Benchmark
Alt. BM
Bldg, Sewer
SVHt Inlet
SVHt Outlet
Dt Inlet
Dt Bottom
Header/Man.
Dist. Pipe
Bot. System
Final Grade
St Cover
BED/TRENCH
Width
Length
No. Of Trenches
PIT DIMENSIONS
No, Of Pits
Inside Dia.
Liquid Depth
DIMENSIONS
SETBACK
INFORMATION
SYSTEM TO
P/L
BLDG
WELL
LAKE/STREAM
LEACHING
CHAMBER OR
UNIT
Manufacturer
Type Of System:
Model Number:
DISTRIBUTION SYSTEM
Header/Manifold IlDistribl.
Pipe(s)
Length Dia I Length.
IHole Size x Hole Spacing (Vent to Air
Spacing
JUIL %,U V CR
x rressure JyaLrr•Ia —11y
^- •-•-- •-
xx Depth of
- -• -
xx Seeded/Sodded
xx Mulched
Depth Over
p
Bed/Trench Center
Depth Over
Bed/Trench Edges
g
Topsoil T
opsoo
�] Yes �_� N
Yes No ��
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1
Location: 714 205TH AVE
1.) Alt BM Description =
2.) Bldg sewer length =
- amount of cover =
Plan revision Required? n Yes ] No
Use other side for additional information. 1 Date I Insepctor's Signature
SBD-6710 (R.3197)
Inspeuuui 1 xc.
Cert. No.
'n01s
County Sanitary Permit Application
ST. CROIX COUNTY WISCONSIN
nrj
Gp_
In accord with Chapert 12 St. Croix County Sanitary Ordinance
PLANNING & ZONING DEPARTMENT
onal information you provide may be used for secondary purposes
ST. CROIX COUNTY GOVERNMENT CENTER
\� \
[Privacy Law. S. 15.04(1)(m)]
1101 Carmichael Road
$�'' . -`l i� �\ ,-•
Hudson, WI 54016-7710
(715)386-4680 Fax(715)385-4686
A ch complete plans for the system on paper not less than 8-1/2 x 11 inches in size.
a Permit# [3Check if revision to previous application
e
e�oP� S�A1 -Zb 18"- 394
L
1. Application I - Please Print all Lqformation
Location:
Property _ e AL
1/4 1/4, Sec
N, R E (or
IF'ropeoOwners
Mailing Address
Lot Number
Block Number
City, Stale
Zip Code
Phone Numer
Subdivision Name or CSM Number
11 Type of Building: (check one) C5
amity nVillage JgTown of
1 or 2 Family Dwelling - No. of Bedrooms:
❑ Public/Commercial (describe use):
'1yearest Road
''tt `` AE�
❑ State-owned r
11. Type of Permit: (Check only one box on line A. Check box on line B if applicable)
Parcel Tax Number s)
a� Vf •
Rejuvenation
1.❑ Repair Reconnection 3. Non -plumbing ❑
A)
Sanitation
Permit Number
Date Issue
B)
❑ State Sanitary Permit was previously issued (p3 5
% f /3
IV.Type of POWT System: (Check all that apply)
p� Non -pressurized in-group ❑ Mound z 24 in. suitable soil ❑ Mound s 24 in. suitable soil ❑ Mound A+0
❑ Sand Filter ❑ Constructed Wetland ❑ Peat Filter ❑ Drip Line
❑ Pressurized in -ground ❑ Holding Tank ❑ Single Pass ❑ Other
❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating
V. Dispersal/Treatment 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
Required
Proposed
(Gals./day/sq.ft.)
(Min.lnch)
Elevation
:56 b
'y 29
` o
o . -7
NA-
17-0
V. Tank Information
Capaicty in Gallons
Total
# of
Manufacturer
Prefab
Site Con-
Steel
Fiber-
Plastic
Gallons
Tanks
Concrete
strutted
glass
New
Existing
Tanks
Tanks
pab
/voo
�
❑
❑
❑
❑
❑
❑
❑
❑
❑
11. Responsibility Statement
1, the undersigned, assume responsibility for repair/reconnenction/re venation[installation of non -plumbing for the POWTS shown on the attached plans. A
license is r>6t required for terralift repair or the installs ion of non- birig sanitatipp system.
Plum s Nam (pr
Plumbers Si a no ): '
MP/MPRS No.
Business Phone Number
✓
.1
Z
Plumber's Address ( treet, City Sta , Zip C
Ili. County Use Only
pi �
Sanitary Permit Fee
Date Issued
Issuin gent Signat a (N tamps)
Approved
even Inr hAdverse
$ S , ap
12/Z9 I/T
Determination
/
IX. Con itions of Ap roval/Reasons for Disapproval
�) Pei j-
� 0"6 (::�_
Rev: 8105