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HomeMy WebLinkAbout020-1022-20-000 co-sir .eaa imenr u' c rm=r_ PRIVATE SEWAGE SYSTEM afea ar.c 6u idinc ~IVlsl~c J: ;rOIX INSPECTION REPORT ~anrary "elrw No GENERAL INFORMATION T~' PERM71, S~~,Z 0 State Ptar ID Nc ~ 'emona'. intarmatlon Vou Drovloe ma•' Ce used fc" se:A'~:3rY JU-7~3c5 rPnV6R- .-a.V. 5.'5.04 ;'!;rri) . °emti, Hoiaers Name Dm r 3a< X Townshi: Parce Ta:: Nc. S- 3h" cie~: Insc BM Eie RN ❑_,ar.at an Se^han-:ywnJRange/Nlao Nc i da ~ vlrl I TANK INFORMATION ELEVATION DATA TYRE rv1ANIJFACT'J~:_n ~.4P4C ST.4T1'~N BS i FS {Seoiic ?t Benchmark H Zsb Q i /66 G~1 G ~~~~~t/~1 Alt 3M 1 V 1 i f~•VYGRJ~. r f~y~J1. IAe(atlOn Sl= Sewer oiaing 5U-I: Inie: Outlet TANK SETBACK INFORMATION LANK TC I'r_ WELL G B_DG ;en,, t- r:nta~- ROAC J; Inle: ~i16 9 ~O 7 1416~ Dosinc Header,'Man. 6,6 AM 7 .i°_ratlOrl Dist. Pipe S- a O 7 I 4 .9 d2~ 4 I-talainc IBot System , PUMP/SIPHON INFORMATION Final GraoE 3, 7 /d Ih4anufa turer Demand S: Cove i GPM xi ht Ih.4taoe' tier vaAJ 4 , (~p /b 1 TDH J -ri--tmr. L oss System Hea TDPF =t I Fo-cemair Lengtl DiL. ❑ t: ~'.e1 SOIL ABSORPTION SYSTEM BED,7RENCH Vhdtr Lergtr Nc Jr Tree :hes PIT DIMENSIONS Ne O` °its Insrac Dcs _iouic Death DIMENSIONS 'lo Z re-.k SETBACK SYSTEM TO =11 IBLDG -WELL LAKE"STREAM LEACHING Manuacture INFORMATION CHAMBER OR /Zo O\ UNIT Made Number. c I /4j pt, Tvpe Of System ~4 Q, 1:3 7- Ak-V DISTRIBUTION SYSTEM AJ y9 F+eao_rT.tanifolc jl ~Gistric flior a r Hndc Size x Nole St a nc Ven.. I'-, Al- I ake I Proe',s~ \ L J S enptr_ Dia--- Lenp-h ` D:;:_ Scaang SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only 2.~ a`S r_otr 7ve IDerltr Over xx ~e,.'r n' Seene 'Se,adec zx Mw nr•r l6edrTrenan enter Bea Trcru =ages Toosoi - ' - l, 1 Nc ~y N: t I COMMENTS: Include code discrepencles rersons presen, etc. inspection #1 Inspection #2 Location: /.~,_+J-~ (J 1 Ze'. Nc: Alt SM Descnptlor = t 1 Bloc sewer lenptr = 6'o >;ar, rReci-vr- - _ V es X Na / -f - - g3 T 4(75 se other side for additional inforrnatioc 4 Lo RD-6710 {F,$IgT Date Irseo ors S,pn re „_r NE s, R E E i V County Safety and Buildings Divisio ~S f , ~ 1t • 201 VU. Washington Ave., P.O. Bo 6 Sanitary Permit Number (to be filled in by Co.) A,;, APR L Z016 Madison, WI 53707-71 ST CROIp COUNTY 5U T 72 S M. mm, ~h anitary Permit Application to Transaction Number ~J In accordance with SPS 383.21(2), Wis. Adm Code, submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POINTS are submitted to Project Address (if different than mailaddre~~~sss) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary I ur ses.in accordance with the Privacy Law, s. 15.04 l mi, Stam oz 1. Application Information - Please Print All Informs ' n If " Property Owner's Name Parcel a I - j Property Owner's 71n Address Property Location Govt. Lot ~ City, State Zip Code Phone Number V~- Section jL TTG' 1 i S % '~r -a y~ circle one T v~N; REo W 11. Type of Building (check all that apply) Lot P 1 or 2 Family Dwelling - Number of Bedr s Subdivision Name acl~•W"e -Bloc ❑ Public/Commercial - Describe Use - ❑ City of ❑ State Owned -Describe Use CSM Number CD Village of 7 v C1 t Q E /a Town of f7UC~ SCI ? 111. Type of Permit: (Check o ly one box! on line A. Complete line B if applicable) A U New System Replacement System I ❑ TreatmentA folding Tark Replacement Only ❑ Other Modification to Existing System (explain) C•) 6'r 4 2 t ie/1 t /1 ? n B. ! _ n : Permit Renewal ❑ Permit Revision C Change of Plumber ❑ Permit Transfer ID New List Previo Permit Number and Date Issued Before Expiration. Owner 3 IV. Type of POW7'5 SvstemlCom onent/Device: Check all that a I IV Non-Pressurized In-Ground U Pressurized In-Ground L. At-Grade ❑ Mound 24 in of suitable soil ❑ Mound <24 in. of suitable oil ❑ Holding Tank C Other Dispersal Component (explain) ❑ Pretreatment Device (explain) ' V. Dis ersaUTreat ent Area Information: Design Flow (gpd) Design Soil Application Rate( gpd Dispersal) Area Required (sf) Dispe.sal Area Proposed (s/ft iq, - -6 System Elevation n el Idle o V1. Tank Info Capacity in Total 4 of Manufacturer 7v s Gallons Gallons Units U y V New Tanks Existing Tnnk; c u ° ' d Q 14 LIJ~ Septic cr Holding Tank ~ / ~ lC,•~, \ tr 49 ~c 14C -4, Dosing Chamber t• ~y VII, Responsibility Statement- I the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. 1Ib7 Plumber's Name (Print) Plumber's , igrature MP/MPRS Number Business Phone Number Plum er's Address (Street, City, State, Zip Code) V1I1, County!De artment Use Only Permit Fee Gate ssued lssuin cut Signs re pproved (1w n Reason for Denial $ 05. Z~ IX. Conditim w8wWW,easons for Disapproval r 1. Septir tank, etfluertl fiRrttnd 7,- ciispernsi cell must all be §MNIces ! n•Iangaf02•; 44 V as per management plan prmrided by plumber. b 2. A1'tt4thtO regUK-M nts rrwtit, t* t:~ai* Ill" 1 1 ! PK tttpPlicabla code / xdinanCea, V Attach to complete plans for the system and h it to the ounty only on paper not less than iR z I l inches in size `R'-!-hi9R (R. 11/111 Pg of Private On-Site NVastewater Treatment System (POWTS) PLOT PLAN FILE INFORMATION PROPERTY LOCATION owner 1/4 , Section g i T N, R,~E o )A, 'I' # OCity, OVillage, 5tTown of sea k -top oC- ~wji . depressV►) caacrelP .g 3 ~U3.p ~ sla t CO 171/ 041, I I ? q0 ~ 37~/OWS 1 J t ~ - i/?STQf~ b dl/ rvt rQ ! EXt`+rrG N T'y xo r~ i i lose Pg of Private On-Site Wastewater Treatment System (POWTS) Index and Title Sheet Owner: ~ ' - Pro ect Narne and System Type: J Location:/ ,E- St~-ec7 Adrh•ess Lf>gol Descrlpllon, 1 Tots nship.-Couni-v Contents: Page l: S C! ea y ~l T/; Page 2: p l c>-f plt--7 1 Page 3: S.YS ! ~m J Jz ihcl 1f- Cr St✓C'f Page 4- F , E n Page S Page 6: ~GarJCPC/~:'f~~Z ~C~!7! ) Page 7: Page 8:/Q~~~',/ Page 9: h of7 t~IQ, - - - Attachments: 12 /c t~ d- ~J Plumber/Designer: Signed: .(/,►'~'1 / Credential Number:~~~~? Date: - 7~4' v . ~ Private On-Site Wastewater Treatment System (POWTS) Pg of PLOT PLAN FILE INFORMATION PROPERTY LOCATION Owner .rAr~.Jr* 'y~~~~~ 1/4 , Section N, R, Z?E o VX PIN # OCity, OVillage, 5RTo,.vn of scQ~e r fin es z 46 Carme S Do 1,0- :S Ae 8rr1 /d0.0 r -tor d ISf~l~2 deQrc'ssid~ CanC p I (vso ~ ~ J~ 10 /Q 0412 - cep S f /v 3 r~~o extIEk::~ 3,xQp I 1 g & /nSJO// b d~~ rvn lra `VQ 7`0 Cor?4rol i^tows o 0 2X~~-~ ink L j 1 'l 4 C C 61~R~ 1 ~ • SOIL ABSORPTION SYSTEM DETAIL / GRAVELLESS LEACHING UNIT Page,Jof_ r J, Project Name: J-ei-pl"Il No. of Cells Per Cell ft Cell Width Total No of ft Cell Length ! aq ft EISA Per Cell ft Cell Spacing ft Total EISA Manufacturer Model Laying Length EISA Rating Infiltrator EZ12031-1-5t 5.0' 25.01 "20311 oft 101.0' 50.0 Gravelless Leaching Unit Manufacturer: Z r2 Mfr ? Gravelless Leaching Unit Model: A/ .5' ylJ sy.5f,~,n i~~t1✓~~ q= i~~~ 7~1C~ J ~ Typical Cross Section Finished Grade r Observation Pipe with approved cap or vent - Soil Backfill _Geotextile Fabric f Infiltrative Surface 12 in Limiting Factor in Slotted and Anchored Vent/ j ' Observation Pipe with Cap Plumber/Designer Signature: 'te'n i v License 9: G~ Date: 4)ul t ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) This i, to certity that I have inspected the existing septic and;~or dose tank presently serving the following res' dence: (,Street address) 7,7 A/e/ 7 yLO~J~~ located at: a, Section Tw n&2N, Range-- Town of - , St. Croix County 1Visconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, A ill conform to the requirements of Comm. 84.25, and it (they) appear(s) to be functioning properly. N-lost recent date of inspection or service 0 Did floe- back occur from absorption system? Yes NoX (if no, skip next line.) Approximate volume or length of time: gallons minutes Tank Capacity: Construction: Prefab Concrete X Steel Other Itlanuf~cturer (if Icno~vn}: _ (,(~iP•~Pr- Cr~nC ~P~P Acre of Tank (if known): ✓Pr.~~, Permit number Of krimvii } , - / (Licensed Plumber Signature) (Print Narne Z/ C (Title) (License Number) MP,A11316 -An (DA) Form to be completed by licensed plumber (Dept of Cornmerce Chapter 5 and s. 145.06. ~~'isconsin Statutes) or licensed disposer (NR 1 I3 Wisconsin Administrative Code) Rev. 9. `2(j(j?_ 463361 ttt/// 28 i.I X _i Ifl 1 Zoom Tool Plain lext A ~y yi. ACRM pf COUNT'd S!'~T1C tAhK MAB~II~~"'~ Ai~RZEbll'1'lr AND ovvrrEl qHM C-M771CAJ" Pam ~ r.. ModitAdds- a 4 hopwtyA4&m 7710 fhcz' tv.i&MM nq'sist taro tna.ol usP~'M: 'vs sollw~+.••) Gq►Sae FtroW fdemtbwsln N satyr - • - e _ propony tacatlm Sc. T.AL_N A _ W. I..s Of _'!P406 Cetl6d Sv rrey Nab _ _ _ Vdrmt - . ►~M _ - - w'"f"wDnd• ~4liYi _ _•vc\uoertfE _ raw 0j€± lv lips Ampkfi" 1591 sr 97 3 `IAC mmm w rN er+rr.ee^ "r past te~tK nv.m wJt nasJ . a Meese Y!~ r trMY ~efsrs i srv ~••e~w ~r pwyis[ wK d MIO~ rde er~'tw+ pets x ••ces:. A rted.d b7 ~ Gorasd Yr4Q r rl~e a.~lel r A/O1r~ d r./Ilc tai « • prsu~a •y u r.r w.t WM~% ~/rte Ors ~ ^.«iiYir w eilnw~.e V I n'~ n e7C~ I esl r c Tso R R t roa i«+r t:~.r► oMrr~ I tti lTr ..v . rf.r N k /Ms [i~ee) ]'Yefe{ 1]grc:.r. e..C6ai~ Meti .lp-e h' ~ .ee I b e «r. /rM.,1..r7"r PYr....~aW 71..ir . e i~d ~r ~ n) ~ wr ~ M~~ I asks ~ ~ ~e.a~siq ~dsirw esenlr Ui J1e toTr.sW M vMS'~t 'd u.asw41 r Ye srt r rr ~ ~ n K' rf ~ dsM hMa ~Ir rs1..t~.d r..e rr~ r eYr.s i sV.n..r r/ y.r r tiiwr rc Ps+r ~eF N~7eM1 .).e'^ aLL M a.+«a w 2-01 r. W ti V 1 M c ~aa.. u.~ M f~q.n'..r d T/.Yr.l Rw..r.~ 4 std ?'-k r n.foe.• r.&% d" "W "ft •Twr W e.. nrNr snn «wi .c ..n~e:d .1 ewr.! w I•. fit s nr Caw" fM► 7.. W . pyr`.r wum b dayk o c ds Or.. ek ~.Q. 4- ~ 71JRE CW A/f1J MT 3 -OS'r i - Y.r..W).~ati..r-.~eerr ~..•w snwrer r.r .f sw~sw t«eee~~ _ PTwq dbaOd sbr-. R -..rt d • wrm- U" "-we" in sw.c n.e. owr c i 0 ~f ~ g (?F AP['l.tt:AN 1 _c J" °'1''`, ~ H llal(72/.t~Q'U i ~ZT„~CJ~ ' Mp iatksre~ w • I~NS~ ert swat . r mMrY 1~ W r+w ~..eyycrre • M.4.+.....s deed 11en /1s d Uew Tee tre . e.ry rf Me rrAM M~7.e► • i I'J 9665SCDSILI ^.~1Q~'la A;ni~~: + r ~.0 R io to a :te 5 ca vim, :;,:L s-;r tn, it,:'*v t j'-d: -Gtj 28 GO L:. ;Visconsuv Depadme:erl PRIVATE SEWAGE SYSTEM cour•ty St. Croix safeCp ary Building Dr, Sion INSPECTION REPORT Sanitary Permit No 463361 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No Personal infornation you provide may be used for secondary purposes IPmacy Law, x 15 04 r1 )(m)' Permit Holder's Namr, !,Jv V Rage X Towrship Pa-cel Tax No Rasmussen, Je,em Hudson. Town of 020-1022-20-100 CST 1361 E ev: Insp 9M Elev SV DC=alptinu seutcnTown/RangeRdao No (~ty~ CSt 14.29.19.103A10 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS FLEV Septic Benchmark ~ /Z5b Alt. BM Iz.~Z ►12.~ /d 1680i NM F' Zak- 1CT~ I of lk o a b it i Z - -7 Z. Aeration Bldg Sewer - Z- //Or 3Z Holding S01 Inlet - Z•~Z 1a-t . TANK SETBACK INFORMATION StiHt Outlet 3 '3 i TANK TO i'!L WELL BLDG. Vent to Air -make ROAD DI Inlet Septic 7 lodr -Z k / Z I i Dt Bottom . Dosing Header/Man. SZ /01 . - z-Aeration Dist. Pipe -Sz- Holding _ Bat System /D 9. 3 PUMPlS1PHON INFORMATION Firal Grade 3``'T Manu`acturer Dcrnard St Cover / ~~tv1 -1 Model Nur er ' T 1 L /6-7-1(, TDH Lii Friction Loss 170, Head 1 7 6 , 7sL Foroemain L Dia. t. to`Pbe11 SOIL ABSORPTION SYSTEM BED/TRENCH 'Aidt i ! Lungth INo Of Trenches PIT DIMENSIONS NC Cf Pits Irsee Dia ir,uld Cec:h DIMENSIONS q1z g~ -z TCe,X, ` SETBACK SYSTEM TO P!L BLDG EL_ AKE,ST?EAM LEACHING Malutacturer INFORMATION _ CHAMBER OR yae Or System: ►~O 106/ 3`91 J, I w/~ UNIT Anc el Number L 44 DISTRIBUTION SYSTEM Z = •Hcadr_olvtu:iki'.d DisIdbution \ \ x Hole Sizu x Hole sparing lVu-nl In A - In,a,3 et Pipe,si U[ Lenglh__ LCa Spe.:ina - SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems only Depth Over / Depth Over xx a~ :h of x.. Seededlscdded xx A'ulched Bed/Trench Center o~t Z 3Z Bed!T:enrlh tdoes Topsoil \ \'es Nu Ycs No COMMENTS: (Inc'ude code discrepencies, persons present, e-c) Inspe~lion #1: inspect~cn $2 Location: 77G He:den Lane Hudson, C:I 54016 (NE 1M SE 1(4 14 T29N R191,7) metes & bamdsstLot 1' Parcel No: 14 29.19.103A10 1.) Alt BM Descriptor - Cdr CIe i.~ t,J~, lk eA- C-lCs-' 2.) Rldrg sewer length = Z7 r • amount of a ver = i! Plan revis on Required? Yes jX No 1 I DCJ 6 D J q 75 1 Use other side for additional inforrcadon. - Dahu nsepcto( gnat re Cerl No S9GE710 (R 3h71 iWisconsin Department of Commerce SOIL EVALUATION REPORT Page of 3 Division of Safety and Buildings in accordan ith CRe 1. ~ County Attach complete site plan ixn r ppt les' than 8 12 11 inches in size. Wan t inrArde, but not "led lo: vd borixontal refs M~ diradian and Parcel I.D percent slope, scale or dimensions, notlh arMw, tiar s rq~e "rest d. _ ys . ;p -AOO v R by Date Please print all info atiogr, pei=W inlannetion you tafl•+aa -y be used rice J" Pd {t) U. 7.0J5 Property owner t;on Govt Lot 114 S T N R E (o;f Pt6perty Owned ailing Address Lot 0 Block # Subd. Name or r-SM# city State zip code Phone Number ❑ Guy ❑ Vitage ER'fawn Nearest Road ifJ ) 77 - 8~ P u a New Construcbm Use: a Residential 1 blumber of bedrooms y Code denved design flow rate GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material D~trcvw►tt~ Flood Ptain elevation d appicable ef YZY R. General coff ~ Ls and recommar dations: C' / /m P. ~S c-2- ~ ❑ Barg 0 Pit Ground surface elev. _ R. Depth to drriWV factor in. S(A Applicadw Rate Horizon Depth Dominant Color Redox Description Texture SMXture Consistence Boundary Roots GPD/W in. Munsell Qu. Sz. Cant. Color Gr. Sz. Sh. 'EfRt1 'EtW2 - s Z s- 7 c s FJ~ 7 r 3 7-2s mt~r mt. Atf o~.ZY a~ Boring © Pit Ground surface elev. R Depth to limitin0 +actor FV in. Soil AvPrcaron Rate. 2 F Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPnW in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'EM 'EtT7C1 4 -/X . S-2. C I- s C - /of, z5- Effluent ill = Boos > 30 < 224 mg1L and TSS >30 < 150 mO/L XVjent #2 = BQD4 < 30 mg/L and TSS f 30 MOIL' - PST (Meaw Prka) - - CST Number Date Evaluation C"Kkxted Telephone Nurn0er Address Fogerty Plumbing 8. Park T sting ~ OZ- OS~. 7/S- S-9fpf 28288 McKenzie ~+l - Property t,/ ~,.,~1~Ig^r /l/Xe~sS~1r/ Parcel ID 0 Page of .3 Boring # C1 Depth to factor eo""g Z n. I sod Pit Ground surface elev. -/ort. 6' IN 1 ' ~a Corugsterim Boundary Roots GPDM Florizorr Depth DorTWkvd odor Redox Description Texture Stnivurs X, r,,C -ERt'l -ERR2 in. Murrser Qu. Sz. Cont. Color Gr. Sz- Sh. s L S < <s • 7 s Z _ jj~ BS ~ ~ in. ❑ Boring N ea'rg - . Depth to WTVW J tacw _ lireliorl . _ SoN Rate Pit Ground surface elev tt GPDM Texture Stnxre Canso Boundary Rom Redox Description Horizon Depth Donrnant 'ERN1 *0102 Gr. St- Sh. in. hlunseo Qu. Sz. Cont. Cola l J Boring to Mtrtn9 factor in. Pit Boring af7~ Ground surface etc v Depth - SHorizon Depth Dornwwl Redox Description Textue Structure CAttis 'ER1t1 ISM Ou. Sz. Cont Color Gr. Sz. SA. in. Mansell • Effluent q2 = Boos _ 30 mgR and TSS :E 30 ngiL Eltluunl >9t = BOD,> 30 < 220 mg'L and T5S X30 < 550 mg/L The Department of Commerce is an equal opportunity service provider and employer. f f you need a~ssistancceZtoo access services or need material in an altematc format, please contact the departinent at 608j;4& SOD-13 tR AM1 Fo-~--ty P"%, +bing :'.30 Rd. F4802 (71'::; 335-9609 9~j,~r~NfytBN SxTE} i P~`F ~ I - Ld ' s~ ~fiiu' • _ /e$B r 71 7/ S ~ fiooK DoT L.aNF _7 ACM rJ FS7-lp 1 ~Oh~ i 1tt ~.T I Imo, i 4 II 1 d#i .9cT, cw, g>r~o~- of 4 J~ = 6 of-rvG I~ I i , i,) 207 eG^Aovfl; f i x- 3 ra3.D ~ j I c c