HomeMy WebLinkAbout010-1077-40-110
IQ,gATTR#~rtAIWW ,y 32.30.16 •PRtVA-1 S'EWT~►GE~SYS 0T AVE, county:
Labor and Human Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No-:
GENERAL INFORMATION 149028-T
Permit Holder's Name: ❑ City ❑ Village ❑gown of: State Plan ID No.:
EMERALD
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
010-1077-20-110
TANK INFORMATION ELEVATION DATA A9200427
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosi ng
Aeration Bldg. Sewer
Holding St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
Verit
irito ntake ROAD Dt Inlet
TANK TO P/ L WELL BLDG. A
Septic NA Dt Bottom
Dosi ng NA Header / Man.
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
Forcemain Length Dia. ti Dist.Towell
SOIL ABSORPTION SYSTEM
BED/TRENCH width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMEN I N
LEACHING Manufacturer:
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM
INFORMATION Type O Q-L CHAMBER Model Number:
System:. OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: EMERALD 32.30.16.466A-10,SW,NE, 130TH AVE,
f~o
Plan revision required? ❑ Yes ❑ No /
Use other side for additional information. QJ~f ' f o}- !p
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
SANITARY PERMIT S~ G'r'o I X -COUNTY
DILHR TRANSFER/RENEWAL UNIFORM PERMIT #
aoP mP aE-.o,s (PLB 67-T) Zz/ 90Z 0 -T
PERMIT RENEWAL DATE: PERMIT TRANSFER DATE: ORIGINAL PERMIT ISSUANCE DATE: STATE PLAN I.D. NUMBER:
I /Z -/~-9Z -30-9/
PROPERTY LOCATION: CITY:
L GE_
S l.J '/a /Uc '%a,S 3 T 30 N,R 160 (or) VOWN OF•~f' Y-
LOT NUMBER: BLOCK NUMBER: SUBDIVISION NAME: NEAREST ROAD LAKE OR LANDMARK:
Ave .
PREVIOUS SANITARY PERMIT HOLDER (IF CHANGED): SANITARY PERMIT TRANSFERRED TO:
NAME: SIGNATURE: NAME: PHONE NUMBER:
lv o r- r Jon so P_ C of ~Z
ADDRESS: zel 3 6 La ~s N ~v~ PHONE NUMBER: ADDRESS:
Z ' r x-77 aey, /y1 5539 _ i~ ...dSG-5 3 / 5Z E Co e /~'i/e. env /NN. 55109
F I, the undersigned, hereby assume responsibility for installation of the private sewage system that has previously been approved for this
property.
PLUMBER'S SIGNATURE: PREVIOUS PLUMBER'S NAME (IF CHANGED):
PLUMBER'S ADDRESS: PREVIOUS PLUMBER'S ADDRESS:
MP/MPRSW NUMBER: PHONE NUMBER: MP/MPRSW NUMBER: TPHONE NUMBER:
(7/5),69Y-• 337P )
SIG URE OF ISS GENT: DATE APPROVED: DISTRIBUTION: Original -County
Copy - Bureau of Plumbing
Copy - Owner
nii WP-cRn-F3QQ IR F/ 1 Copy - Plumber
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING
LABOR & AN RELATIONS ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION
MADISON, WI 53707 State Plan I.D. Number
SW, NE , 3 2 , 3 0 ,16W CONVENTIONAL ❑ ALTERATIVE (If assigned)
Town of Emerald ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
F D ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
La ry Johnson 1 26636 Lake Aye.,Zimmerman,MN 553),9
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.:
Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number:
Dale HudsQn 16629 ~,qt. Cro.ix 149079
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
PROVIDED: PROVDED:
❑ YES ❑ NO ❑ YES ❑ NO
BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH
ALARM: FEET FROM LINE: AIR INLET:
❑ YES ❑ NO ❑ YES ❑ NO NEAREST-41"
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING OVER
❑ YES ❑ IN ❑ YES ❑ NO ❑ YES ❑ NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPTMATER 7MAR : VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET:
PUMP ON AND OFF ❑ YES ❑ NO NEAREST ~
DIAMETG:
SOIL ABSOR PTION SYSTEM. Check the soil moisture at the depth of plowin=FORCE or exca
vation. (If soil can be rolled into a wire, construction shall cease untithe soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID
BED/TRENCH TRENCHES: MATERIAL: PIT DEPTH:
DIMENSIONS
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
BELOW PIPES: ABOVE COVER: ELEV. INLET: ELEV. END: PIPES: FEET FROM LINE: AIR INLET:
NEAREST
MOUND SYSTEM:
Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW
❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED.
SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS;
❑ YES ❑ NO ❑ YES ❑ NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED:
CENTER: EDGES:
❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH: LENGTH: NO. OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER:
BED/TRENCH TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING:
ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.:
ELEVATION AND
DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO
INFORMATION APPROVED PLANS
❑ YES ❑ NO ❑ YES ❑ NO
PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
COMMENTS: FEET FROM LINE:
❑ YES ❑ NO ❑ YES ❑ NO NEAREST
Retain in county file for audit.
Sketch System on
Reverse Side. SIGNATURE: TI E:
oning Administrator
SBD-6710 (R. 08/88)
Thomas Nelson
SANITARY PERMIT APPLICATION
LHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than IY6 64 K
8'f x 11 inches in size. ❑ Check if revision to previous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY OWNER PROPERTY LOCATION
- 30Y.Ale~ a, S T_36 , N, R ~(or W
PROPERTY OWNER' MAILIINNG ~ADDRRESS LOT # BLOCK #
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
II. TYPE OF BUILDING: Check one CITY NEAREST ROAD
( ) State Owned VILLAGE b_j
"Public ❑ 1 or 2 Fam. Dwelling-# of bedrooms PAR ELT MBER( )
III. BUILDING USE: (If building type is public, check lahat apply)
1 ❑ Apt/Condo C~ lvf
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 0 ICI Outdoor Recreational Facility
30 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 in line A. Check line B if applicable)
A) 1. JAJ New 2. ❑ Replacement 3. ❑ Replacement of 4-0 Reconnection of 5. ❑ Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit - 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 ❑ In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43 Vault Privy
14 ❑ System-In-Fill
VI. 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
E,D.(sq. ft.) (Gals/day/ . ft.) (Min./ipc ELEVATION
REOI.117 r. ft.) PROPO//~/(
Feet Feet
CAPACITY
VII. TANK Site
in gallons Total # of Prefab. Fiber- Exper.
INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks strutted
Septic Tank or Holdin Tank /r' z7 _E1 Ej El I L-1 L1 1 11
Lift Pump Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number:
-J7 7Y
Plumber's Address (Street, City, State, Zip Code):
IX. COUNTY/DEPARTMENT USE ONLY
Disapproved Sanitary Permit Fee (Includes Groundwater a e Issued Issuing gent Signature No Sta
Approved F] Owner Given Initial Surcharge Fee)
Adverse etermin
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
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.
2. Your sanitary permit may be renewed before the expiration date, and at the time 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 Transfer/Renewal Form (SBD 6399) 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.
6. 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.
II. Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family Dwelling.
III. 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.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g.
MP, 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'/2 x 11 inches must be submitted to the county. The
plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of
holding tank(s), septic tank(s) or other treatment tanks; building sewers; +veils; water mans/water service;
streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system
areas; and the location of the building served; B) horizontal and vertical elevation reference points;
C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump
performance curve; pump model and pump manufacturer-, D) cross section of the soil absorption system if
required by the county; E) soil test data on a 115 form; and F) all sizing information.
- - - - - - -
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of
regulated practices which can effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater, ground-
water contamination investigations and establishment of standards.
SBD-6398 (8.11/88)
" APPLICATION FOR SANITARY PERMIT
STC - 100
This application form is to be completed in full and signed by the owner(s) of
the property being developed. Any inadequacies will only result in delays of
the permit issuance. Should this development be intended for resale by
owner/contractor,(spec house), then a second form should be retained and
completed when the property is sold and submitted to this office. with the
appropriate deed recording.
Owner of property a" o X r"
p~
Location of property 1/4 ,n cr 1/4, Section T N-R-W
Township
Mailing address
Address of site
Subdivision name/y/X
Lot number
Previous owner of property
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? es No
Is this property being developed for resale (spec house)? Yes No
Volume $ 7CD and Page Number 7 as recorded with the Register of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEE which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER, and
the SEAL„ OF THE REGISTER OF DEEDS. In addition, a certified survey, if
available, would be helpful so as to avoid delays or the reviewing process. If
the deed description references to a Certified Survey Map, the Certified Survey
Map shall also be required.
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(s) 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) have
obtained an easement, to run with the above described property, for the
construct n of said sys m, and the same has been duly recorded in the Office ,Lp of the m y Re 1 ter o Deeds, as Document No.
Signatur of a Signature of Co-Owner (If Applicable)
...,160 51110
`Date of Signature Date of Signature
V
IDUS T SAFETY & BUILDINGS
ENT OF REPORT ON SOIL BORINGS AND
INDUSTRY, , C DIVISION BOX HUMAN REDLATIONS PERCOLATION TESTS (115) MADISON WI 7969
(H63.090) & Chapter 145.045)
LOCATI N: SECTION: TOWNSHI /MUNICIPALITY: LOT NO.:BL . SUBDIVISI NAME:
W4 22_/TJoN/R16H (or
COUNTY: OWNER'S BUYER'S NAME:
MAILING ADDRESS:
Ih E4
USE ATES OBSERVATI S MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: (PROFILE DESCRIPTIONS: PERCOLATION TESTS:
Residence~
❑ New ❑Replace
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: S STEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
❑S ❑U ❑s ❑U ❑S ❑U ❑S ❑U ❑S ❑U
If Percolation Tests are NOT required DESIGN RATE: I If an
y portion of the tested area is in the
under s.H63.09(5)(b), indicate: I Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B-
B-
B-
B-
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PERIOD3 PER INCH
P-
P- 1
P-
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.
SYSTEM ELEVATION
1
4 3
z i
I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME (print): TESTS WERE COMPLED ON:
ale Z , « so /ET
JTD-DI RESS : CERTIFICATION NUMBER: PHONE NUMBER(optional):
71- CST SIGNATURE: RIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
R-SBD-6395 (R. 02/82) - OVER -
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