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HomeMy WebLinkAbout040-1304-20-000 (2) Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 578952 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Precision Builders JP2 LLC Troy, Town of 040-1304-20-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: 1903. 143 'STP L DMET 08.28.19.1826 TANK INFORMATION t t ELEVATION DATA TYPE MANUFACTURER PACITY STATION BS HI FS ELEV. 1 I. O 1) 6 Septic Benchmark A. Li LE 6w) LVL (r1 -1 U Alt. tuw HE ek, 1,1: 907. 3 Aeration Bldg. Sewer p-NA &'Ned 3 15 1() Holding St44Mnlet MO l J TANK SETBACK INFORMATION Stffitbutlet gb7.73 r TANK TO P/L r WELL BLDG. Vent to Air Intake ROAD nom} inIP} 22 S7 T1tttfM1i Septic G ' 2 rh1 ~G. 1 ` I 1.31 Dosing ea /Man. 5.3 Aeration IV' JW~ Dist. Pipe J?j3 4 • 3-4- Holding Bot. System , o PUMP/SIPHON INFORMATION Final Grade Z• 9+DS.43 by~g Manufacturer GPM nd St Cove h 9b 4 4 Model Number V TDH Lift Fric ' oss System Head TDH Ft Force Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM ZZ TT BED/TRENCH Width Length n No. Of Trenches PIT DIMEN DNS No. Of Pits i Inside Di Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: /t'F~L/ INFORMATION CHAMBER OR IV Type Of System: UNIT Model Numbe C4 DISTRIBUTION SYSTEM P 0&+ IVnJU N t r Header/Manifold it Distribution x Hole Size x Hole Spacing IVent to Air Intake Pipe(s) N Length . Dia Length is Spacing V SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth xx Seeded/Sodded xx Mulched Bed/Trench Cente qy6mll Bed/Trench Edges Topsoil of XYes FE] No Ayes No COMMENTS: ( clude code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 449 Sunrise Cir Unknown (Unknown 8 T28N RI 9W) Sunset Valley Lot 20 Parcel No: 08.28.19.1826 1.) Alt BM Description = ~-i kkv- mi'v-, S ~C S US "~~CC~~xI ~l 'I/~ 1,~ 1 2.) Bldg sewer length = 7-5-451 - amount of cover = 1 Orl WUvY0 `~Jv LAV Plan revision Required? ❑ Yes No Z'L I Lys„ - Use other side for additional inform /on. Date Insepctor's Signature Cert. No. SBD-6710 (R.3/97) ~ i t `r GO ~ rCO / Safety and Buildings Division County l 1 G Cj 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.) S P (I 0~5 Madison, WI 53707-7162 t: t PAI S78gs gl~ ( ermlt Application State Transaction Number In accordance with SPS~ Was. Adm. Code, submission of this form to the appropriate governmental unit is required prior to obtal~ng a san itary permit Note: Application forms for state-owned POWTS are submitted to Project Address (if different than mailing address) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law, s. 15.04 1 m , Stats. qql `U _ l ,~f,(~/ /~IR C L I. Application Information - Please Print All Information f ~J V 9li C. Property Owner's Name Parcel # Property Owner's Mailing Address Property Location 0 2 Z Govt Lot City, State p Zip Code Ph/one Number L Q ~ y. y,, Section A~_ 1 /D_i/ LJ/ o cam. r/ b I z -8051- (circle one G 7T T-0N; R_Eo&) H. Type of Building (check all that apply) Lot# n XI or 2 Family Dwelling - Number of Bedrooms ~ Subdivision Name Block# Sbi 1V ❑ Public/Commercial - Describe Use ❑ City of ❑ S ate Owned -Describe Use CSM Number El Village of / 2,?- Z L M~JWr,~ 02S CAr# Town of T_~r III. Type of Permit: (Check only one box n line A. Co plete line B if applicable) A. )(New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) ❑ Permit Transfer to New List Previous Permit Number and"Date Issued B. ❑ Permit Renewal C1 Permit Revision ❑ Change of Plumber Before Expiration Owner IV. G e of POWTS System/Component/Device: Check all that apply) ANon-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound> 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dispersal/Treatment Area Information: q Chix, Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Req 'red (sf) Dispersal Area Proposed (so System Eleva~ ER 11-7 ©1 avre w qd'l VI. Tank Info Capacity in Total # of Manufacturer , Gallons Gallons Units d c ° New Tanks Existing Tanks o [ u y j; a U h h w u. C7 i?. Septic or Holding Tank Z ✓vo 60 Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for' stallation of the POWTS shown on the attached plans. Plumber's Name (Print) / Plumber's Signature MP/1vQ4+6 Number Business Phone Number L L orV 2Z6 ~/S Z73 ff~f~~ Plumber's dress (Street City, State, Zip Code) w W VIII. Court /De artment Use Only . . Approved ❑ Disapproved Permit Fee Date Issued Issuing Agent Signature ❑ Owner Given Reason for Denial IX. ConditidAypQpeasons for Disapproval 1'. "SapiicSank, effltfti*1110«' ' elild dispbrsal cell must 49 by s / maintained as per management plan provided by plumber. 2. AN setback requitenwft must be maintained as per applicable code I ordinances Attach to complete plans for the system and submit to the County only on paper not less than 8 02 x 11 inches in size SBD-6398 (R. 11/11) ~Sis;. ire :aka ^c a~ % , t~~a ~ ~-i 4r, , 'i;, ; PL04- fl 411 r l o- 2A) LU yk Lti~ L`\ R~+DQo f ~ ~ ~ gutGK N ~lLfitt R k~~ INC R«6 I. L c(~~4-6 9 copy