HomeMy WebLinkAbout020-1183-40-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St.
Safety and Building Division
J
INSPECTION REPORT ry Permit N rig 0
(ATTACH TO PERMIT)
GENERAL INFORMATION State Pi ID o:
Personal information you provide may be used for secondary purposes rprivacy Law, s.15.04 (1
Permit Holder's Name: . City village X ownship Parcel Tax No:
I~.C%r~~ ya cko5Y.e_ I-Id 6tN,- 02-0-1193-
CST CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
Zv.Zq. ra. 11s~
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic ILI Benchmark
Dosing C Alt. BM
Aeration Pr1\1 I D Bldg. Sewer
Holding 1 11 St/Ht Inlet
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic Dt Bottom
Dosing 1 Header/Man.
Aeration Dist. Pipe
Holding Bot. System
PUMP/SIPHON INFORMATION Final Grade
Manufacturer Demand St Cover
GPM
Model Number
TDH Lift Friction Los System Head TDH Ft
Forcemain Length 71Dia. Dist. to Well
I
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. _ iquid Depth
DIMENSIONS
SETBACK S EM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR
Type Of System: UNIT Mo el Number'
DISTRIBUTI YSTEM
Headerimanifold Distribution x Hole Size x Hole Spacing Vent Ai nta
Pipe(s) l Ci
Length Dia Length Dia Spacing
SOIL COVER x Pressure Sys my xx Mound Or At-Grade Systems Only
Depth Over Depth xx Depth of xx Seeded/Sodded xx Mulched
Bed/Trench Center t rench Edges Topsoil
0 Yes No Yes No
COMMENTS: (include code discreppe(ncciiespersons present, etc.) inspection #1: / / inspection #2:
Location $ q ~ DD Parcel N
1.) Alt BM Description
2. Bldg sewer length =
- amount of cover qc Ole r
J ` V Jlll J / ~lll
Plan revision Required? 2 Yes No / 3
Use other side for additional informati t
SBD-6710(R.3/97) ~ye~ U Insepctor'sSignature Z~~C
4~J~~~ l/~ (a•/ I tea, i ~ f~1o
County Sanitary Permit Application1b ST. CROIX COUNTY WISCONSIN
v ~ord with Chapert 12 St. Croix County Sanitary Ordina PLANNING & ZONING DEPARTMENT
r nformation you provide may be used for secondary urpose T. IX COUNTY GOVERNMENT CENTER
[Privacy Law. S. 15.04(1)(m))~ 1101 Carmichael Road
1 Hudson, WI 54016-7710
t 715)386-4680 Fax(715)386-4686
h complete plans for the system on paper not less than 8-1/2 x 11 inches in size.
10 MM6NI + tAAR it # ❑ Check if revision to previous application
(j 2.21
I. Application Information - Please Print all Information q Location:
114,
City, State Zip Code Phone Numer Subdivi 'on Name or CSM Number
14 c~~ Sv tic' 7l~-811-
II Type of Building: (check one) OV C , s~ amity ❑ Village Town of
® 1 or 2 Family Dwelling - No. of Bedrooms: V A
11 Public/Commercial (describe use): loo _l 8 ~►-a^F°
❑ State-owned Nearest Road
II. Type of • (Check only one box on line A. Check box on line B if applicable) Q a-ti-- )3 "
Parcel Tax Number(s)
1.btRepair 2. ❑ Reconnection 3.❑Non-plumbing . ❑Rejuvenation p ?j _ yp-- 6,ol
Sanitation
Permit Number Date Issued ~ h~~
State Sanitary Permit was previously issued 01 V1
IV. Type of POWT System: (Check all that apply)
Non-pressurized In-ground ❑ Mound a 24 in. suitable soil ❑ Mounds 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
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./inch) Elevation
I. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic
New Existing Gallons Tanks Concrete structed glass
Tanks Tanks
Ofl / ❑ ❑ ❑ ❑
11. Responsibility Statement
I, the undersigned, assume responsibility for repair/reconnenction/rejuvenation/installation of non-plumbing for the POWTS shown on the attached plans. A
license is not required for terralift repair or the installation of non-plumbing sanitation system.
Plumber's Name (print) Plumber's Signature (no stamps : MP/MPRS No. Business Phone Number
OkLrEO, a C14vi!.46 -716 -7 (S-71Y 7-3
Plumber's Address (Street, City, State, Zip Code)
I !a -2 t4 L-~ to S A a 6 ~ ,o,1-5 W; 5110 X.3
III. County Use Only
JMial Sanitary Permit Fee Date Issued Issuin a Sign re (No stamps)
Approved Adverse ~
IX. Conditions of Approval/Reasons for Disapproval:
Rev: 8/05
i
ST. CROIX COUNTY
SEPTIC TANK MAE,;' `ENANCE AGREEMENTT
AND
OWNERSHIP CERTIFICATION FORM
Owner,Buyer
Mailing Address
Property Address b0ro i V1 nnOQ
(Verification required from Planning & Zoning Department for new construction)
City/State w/ I Parcel Identification Number 0 DO - )I &A
LEGAL DESCRIPTION
Property Location _'/4 , 1/4 , Sec.' Q0 , T o C1 N R~ W, Town of H UJS On
.
Subdivision Plat: P1 neCA ruve, J-~ C, S+ AaA . &7to h , Lot #
Certified Survey Map Volume , Page #
Warranty Deed # (before 2007)Volume , Page ',r
Spec house 0 yes & no Lot lines identifiable 4Lyes ~ no
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper
maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into
the System can affect the fimnction of the septic tank as a treatment stage in the waste disposal system. Owner maintenance
responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance.
The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the
owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site
wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is
less than 1/3 full of sludge.
Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the
standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin.
Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning &
Zoning Department within 30 days of the three year expiration date.
I/we certify that all statements on thi form are true to the best of my/our knowledge. I/we am/are the owner(s) of the
property described above, by virtue of a w an ty deed recorded in Register of Deeds Office.
Number of bedrooms
SIG ATURE OF APPLICANTT(S) DATE
*''*Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department.
Include with this application 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.
(REV. 09/07)
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF EXISTING SEPTIC TANK(S)
This is to certify that I have inspected the existing septic and/or dose tank
presently serving the following residence:
(Street address) - located
at: 14, 14, Section ;-o , Town a-9 N, Range l q W,
Town of 14 , St. Croix County Wisconsin.
Upon inspection, I certify that I have found the tank(s), to the best of my
knowledge, will conform to the requirements of Comm. 84.25, and it (they)
appear(s) to be functioning properly.
Most recent date of inspection or service C, ^ l
Did flow back occur from absorption system? Yes No
(if no, skip next line.)
Approximate volume or length of time: gallons minutes
Tank Capacity: ~ J. 1000
Construction: Prefab Concrete Steel Other
Manufacturer (if known):
Age of Tank (if known):
Permit number (if known) _
(Licensed Plumber Signature) (Print Name)
(Title) (License Number) MP/MPRS
(Date)
Form to be completed by licensed plumber (Dept of Commerce Chapter 5
and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin
Administrative Code)
Rev. 9/2008
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Parcel 020-1183-40-000
01/10/2005 08:51 AM
Alt. Parcel 20.29.19.1154 PAGE 1 OF 1
Current OX 020 - TOWN OF HUDSON
Creation Date Historical Date Map # Sales Area Application # Permit #
ST. C POerm tOTyp TM WISCONSIN
00 0
Tax Address:
Owner(s): " =Current Owner
KERRI L EASTWOOD ` EASTWOOD, KERRI L
847 DORWIN RD
HUDSON WI 54016
Districts: SC =School SP =Special
Type Dist # Description Property Address(es): • Primary
847 DORWIN RD ry
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 1.810 Plat: 2328-PINEGROVE HEIGHTS 1ST ADDITION
SEC 20 T29N R19W NE SE LOT 14 PINEGROVE
HEIGHTS 1ST ADDITION TOWN HUDSON Block/Condo Bldg: LOT 14
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
20-29N-19W
Notes:
Parcel History:
Date Doc # Vol/Pa e
09/17/2002 690667 1979/550 Type
12/22/1999 615876 1479/417 WD
04/23/1999 601894 1421/251 WD
12/11/1998 593640 1386/328 QC
2004 SUMMARY Bill more !
Fair Market Value: Assessed with:
49194 230,500
Valuations:
Description Last Changed: 07/21/2004
RESIDENTIAL Class Acres Land
G1 Improve Total State Reason
1.810 28,100 150,200 178,300 NO
Totals for 2004:
General Property 1.810 28,100
Woodland 0.000 150,200 178,300
0 0
Totals for 2003:
General Property 1.810 28,100
Woodland 0.000 147,900 176,000
0 0
Lottery Credit: Claim Count: 0
Certification Date: Batch
Specials:
User Special Code
018-RECYCLING Category Amount
SPECIAL ASSESSMENT 27.00
Special Assessments
Total 27 00 Special Charges Delinquent Charges
0.00 0.00