HomeMy WebLinkAbout038-1018-80-211
'~has;ccris; Deoart~rent of Corcmerce PRIVATE SEWAGE SYSTEM County: - St. Croix
Safety and ?urlduig Division
INSPECTION REPORT Sanitary Permit No
i,ATTACH TO PERMIT} ~ 0228
GENERAL INFORMATION state Plan ID No
Personal info,mabc,) yru pr?,, de may be utied lot <_ecordary purposes [Privacy Law, s.r5.C4 {0r01 r~l
Perm t H❑Idet's Naive City Village Township Parcel Tax Nn
Emmett Meister TOWN OF STAR PRAIRIE 038-1018-80-211
CST BM E,ev: Insp. BM Elev FM nescnpt,on Sec1ion:7cwn,'Rangetf.9ap No
03.31,18.69B-11
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Qenchmark
Losing 1 Alt. BM
Aeration Bldg Sewer
Holding Ht Inlet
S
TANK SETBACK INFORMATION
ANK TO P!L A'FLL BLDG. vent tc Air Intake ROAD Dt Inlet
Septic Dt Bottom f 1
f i
Dosing HeadeilMan.
Aeration ( Dist. Pipe
Holding Bot. System
Final Grade
i
PUMPISIPHON INFORMATION - 5
Manufactt.rer Demand St Cover
GPM n tV L
Model Number
' DH Ft 5
TDI i Lift Friction Lass y. PM Head
I ("I ~JL J
Foreemain Length Gii -gist to Vvev
SOIL ABSORPTION SYSTEM
BEDITRENCH 'Aldth Tr gtn Nn Of I(enoheso& PIT DIMENSIONS Nc Of Fits Inside Dia _icuid Cepth
DIMENSIONS
SETBACK SYSTEM TO P1L L G INFI L LAKL!STREAM LEACHING Manufacwrer
INFORMATION CHAMBER OR
Type Of System: - UNIT Model Number
I l
DISTRIBUTION SYSTEM
Heade'iMar`cld Distribution x Ho e Size Jx Spacing JLrn o Ar Into e
Pipe(s) _
a Si -
l Gia I myth
, ~ i
SOIL COVER x re s re Systems O ly xx MouAdQr tt-Grade systems only
Depth Over Deoth Oven- - [(-x -lepth of jxxSevdedlSOcdled xx Mulched
Bed,'-rench "enter I; t ~edlir~nct Edges Yes No Yes No
COMMENTS: ,Include code discrepenuies, persons present. etc) inspection #1 Inspection #2
Location: 1175 CTY RD H % Li . ° L'C C'~- -ii;b be in.S b
1) Alt BM Description = 1 )1; t ~L Lb { l ppp
2 j Bldg sever length = 2 )1 D U ~Q lc G
- amount of cover = t \b
~-3
Plan revision Required? Yes ~-,4No 7
Lj P~
Use other side for additional nformation._ ~
a ,sepcte's Signatcre Cert No-
SBD-5i 1~ (R 3197)
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RECEIVE JR is
County Sanitary Permit Applicatlo ST. CROIX COUNTY WISCONSIN
FJ~041TY I i In accord with Chapert 12 St. Cruix County Sanit aG, PLANNING & ZONING DEPARTMENT
Personal information you provide may be used for secondary purposes T. CROIX COUNTY GOVERNMENT CENTER
1Y [Privacy Law. S. 15.04(1)(m)j 1101 Carmichael Road
PMENT Hudson, WI 54011:-7710
{715)3864680 Fax(715)386-4686
Attach complete plans for the system on paper not less than 8-1!2 x 11 inches in size.
County Sanitary Permii ❑ Check it revision to previous application
Application Information - Please Print all Information Location:
Prcuerty Crooner Name ~A 1;4 1 r4, Sec
01 e~~ //I I S, `7-e v` T 1 N, I P) R E (or'
Property Owner's Mailing Address Lot Number Block Number
fi
City. Sta I te G Zip Code Phone Numer Y~ rM!CSMNumber
2
11 i 157t(o 0~ 17tr 79/ 0
I Type of Building: (check one) ❑ Village Wown of
❑ 1 or 2 Family Dwelling - No. of Bedrooms. (R~
❑ Public'Cornmercial (describe use):
❑ State-owned Nearest Road
1. Type of Permit: ;Check only cne box on line A. Check box on line R if applicable) Gres 4
Parcel Tax Number(s)
A) 1.❑ Repair 2. Reconnection ❑Non-plumbing . ❑ Rejuvenation o J 10 )S
1.1 .loq --II
Sanitation
B) Permit Number W7 `J` Date lssued 7
State Sanitary Permit was previously issued 1),- I 16,
IV. Type of POWT System: (Check all that apply)
❑ Non-pressurized In-ground J9__MUund a 24 in. suitable suit ❑ Mound 5 24 in. suitable sod p Mound A+0
❑ Sand Filter ❑ Constructed Welland ❑ Peat Fifter ❑ Drip Line
❑ Pressurized In-ground ❑ Holding Tank ❑ Single Pass ❑ Other
❑ At-grade ❑ Aerobia Treatment Unit ❑ Recirculating
. Dispersal/Treatment Area Information:
I1. 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.,'dayisq.ft.) (Mirminch) Elevation
VI. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic
New Existing Gallons Tanks Concrete structed glass
Tanks Tanks
❑ ❑ ❑
❑ ❑ ❑ ❑
VII. Responsibility Statement
the undersigned, assume responsibility for repairrreconnenction!rejuvenation installation of non-plumbing for the POWTS shown on the attached plans. A
icense is not required for terralift repair or the installation of ror-plumbing sanitation system.
Plumber's Name (print) Plumber's 5ignat m s): MPIMPRS 7No fulsiness Phone Number
WD tp 7 ~ - - N
Plumber's Address (Street City, State. Zip Code) D~' f
VIII. County Use Only
Disa Sanitary Permit Fee ate Issued Issuing Agent Si, to (No stamps)
C-AppCnved Owner n n verse Z
Determination
X. Conditions of Approval 'Reasons for Disapproval: 'p, f/U /m -fhjs PeOnlif
i All) 064-h6os i~ 5*4f 1 vat are I 1 I ~ IL-
S ~ -todas~s ~
2 11 ~~5 ~ ~1 be ~v~ 09~ fblic), , r
Septic tank, effluent liter and
l uffh'M I
e
.05 as aer management plan pfovidmd t)y plumber.
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2 All setbac~ _qulro;rAn?s r,us! hro rnalntglnbd Ve
as rer 3pF40JiJO GOd810fdlilcrlt;@b
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tom, p ~T ~lrPr sP~ Col~r~ecro/J h pp_
05i'2Fi'2E16 66:5-:4I 715E4=-~S15 WOFF..ELL 02. 0L
ttrnRrat DIVISION OF INDUS-RY SERVICES
10541 N RANCH RD
r l ~y HAYWARD WI 54543-5462
D ` 1 Certtact Through Relay
p ICI http:/Idsps.wi.gov/programs industry-serviccs
www.wisconsin.gov
sSroN~*- ScottWalker, Govemor
Dave Ross, Secretary 0
April 19, 2016 DEPT
PROFS
DMSION G
CUST ID No. 22:057 ATPY- P.rurrbtng Irspe,^:or
DANIEL C WORRELL MLNTCTPAL CLERK
DANS PLLNMa G TOWN OF STAR PRAM=
1756 150TH A'~t 2118 COOK DRIVE SEA
ST CROa FLS WI 54024-7--533 SOMERSET VrI 54025-7551
COIF-DMONAL APPROVAL
PLAN APPROVAL EXPIRES: 04/19/2018 Identiricafion Numbers.
Transaction ED No. 2695022
SIZE: Site ID No. 822893
Emmett Meisel Campsites Please refer to both identification wimbe: s,
1175 Cth H above, in all corre_s ondeuce with the a m .
Town of Stan Prairie, 54017
St Croix Counry
FOR:
Mobil Homc Park Sites: 1 -25 Sites; Plan Type: New
The submittal described above has been reviewed for conformance with applicable V►'isconsm Administrative Codes
and Wisconsin Statures. The submittal has been CONDITIONAI-LY APPROVED. The owner, as defined m
chapter 10:.01(]0), Wisconsin Statutes, is responsible for cornpliance with all code requirements.
No person may engage in or work at plumbing in the state unless licensed to do so by the Department per
s.145.06, stats.
The foTlowrno conditions shall be rnct during constrsction or installation and poor to occupancy or use:
Key Item(s)
• SPS 382.30(11)(d). Maintain inl nirnu n separator between building sewer and water well as contained in ells.
NR 811 and 812 or as otherwise approved by the departLnmt of natural resouices..
4 SPS 3$2.37(3)(b) Evamiatiou of water systems per SPS 382.40(8)(d)2. Provide a means to winterize the water
supply system (drain down valves, blow out hose bibbs etc.).
4 SPS -;82-17(3)(b) Water systems serving campgrounds shall comply with the provisions in s. SPS 382.40. The
load factor for each'/. inch hose connection is 4 wsfu. Subd. (7)(3)a.; at least 15 psig. is required at each
campsite rose connection. Using 15 psi for the campsite hose connection, the 'A' value will be 9.0. No change
iu pipe sizze is required Any future additional loads on the water supply serving the campsites would require an
increase in the pipe sse.
5PS 384311(2)(c). Materials for satutary building sewer pipe shn11 conform to one of the standards listed is
'T'able 354.30-3.
• 5PS 384.30(4)(d). Materials for water service and private water mains shall conform to one of the standards
listed to Table 384.30-7, Pex tubingASTM F876, F877 shall be installed per mlalaufacturer's specifications.
Pex tubing camtotbe installed with stmlig' i exposure. Water hose sratxon risers shall be of materia: that is
combatable to above grade conditions.
i ~~r ~91~J ~s=f 1:Ea5Z31~~a FFE
_ ~A,V:E:.~:'NnRRF1J• puR : 41912016
• cps ?8 i..0. `lo `ltttSt, appliance, auptct°a t ce. tna eraL LLe.dce or atutiacr -j be Soid for use inapt eim
;,51cm or may br, lrmra led m a ❑lrmoiLg System utilPSS it is of a :ype cocfr`rmin¢ to pipe sta njar,is )r
7-eci icauuns Cf chs. SPS ?82 ",U am. -h4 and ch- :-S, Stutz.
• tiYS 381 SSacitar, dump statwas sL•al: be dengued and ins*aaed -uijfmiium4 'o this :ucc section
aCachmeas.
`tLl 312e Copy of the approves uiai:,, rpe~ittcat7ons and this .ettc= shal] he no-,cr ,i u% _:+nst-;c^ec a.:r' ]ccn u
uzrectiou by authorized r=z,C3cnmt1v^5 .~-f ~hc Jepaitrrc aL Wh:cil alav mclude '.oc_i nst ec[or.:P ii i;::':rz i arL
welr. ; rbuuued is lieu of additcnal .`til: plan seLi, a z,;pv of the approval :etter aVd iLdex dice.' :rsll he attached V.
pans -.hat ccaespond arith the or t im ile w:a the Depatt.;,ert.:f hest 7)Aus were subruixted in an electronic :arnt
J, deetgucr is respm=hle to dow-aboad prtut, and ;red the ull ;i;:n se'. of plans a eng wi'h our apczoval letter.
, epartzacat e-ectromc su=p and sigasture ;hai:'Ze yin the play which arc used ar Lis jo:, <,tr li,r c :,os _tt ui ,
permits regt..red by the arc of Ie 1u,:a1 mumcrpahnr shah be nFraina: year t, mrvenec eat f
tthstrtctrnn: iostadatlonroperaion.
In granting this apnraval the Division 3x Iadus:r+ Services re3ertiCa the rigat rc re_t: re :banges or ad-Iitor.s
oe:itrirru arise mai=g hem necessary `or cote cuwoiiance. A, per sate Jta3
5hAll rtlitvc the designer •he rPSnnr;tbi:ity for dergntiag a safe buildiag, structure, at compnuC=.
L,~u rie; % mcerrmg This rot;esp md=ce may be male to mC et 'he. 'e;ephcze nu=b~'r listed below, or a: tc adrrF:;
OG Lh:S ieuc:rbca±
Smcr;tly, Fee Reuuard S 3.ri.pti
Fee Received 3 300.',)0 77
Bala=Due S 1X,
Dunnld `t Huuklr ~
Pli=,bmg LoLsWtarrr Z Divizicn of tadus5-v Strv:cc= WtSNIART code: 765,
icrald.ho',tgh cybviSCOrssm.~Jv
.c: DonaldD Elotreh. Numpin_
lirr,ne:, Vats'rr
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06/08/2016 03: HALM 7156462315 WORREELL PaGE 02-'02
Q'lf ST 4"j _
5T. CROIX COUNTY ZONING OFFICE Od'eO. 40
0 COG ~6CERTIFICATION 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) T" r4. Ak w *-Av tj located
at: '/4, '/4, Section s Town_ _N, Range--j-3-
Town of S T?r-o ~i jo , 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 SPS. 384.25, and it (they)
appear(s) to be functioning properly.
Most recent date of inspection or service a 16
Did flow back occur from absorption system? Yes No~
(if no, skip next line.)
Approximate volume or length of time: gallons minutes
Tank Capacity:
Construction: Prefab Concrete steel Other
Manufacturer (if known):
Age of Tank (if known):
Permit number (if known)
gt~l~I c la X11
Etcensed Plurnber Signa e) (Print Name)
~&a- kN6r creel 4- c a 10 5 7
(Title) (License Number) MP/MPRS
- d
(Date)
Form to be completed by licensed plumber (Dept of Safety and Professional
Services Chapter 305 and s. 145.06, Wisconsin Statutes) or licensed disposer
(NR 113 Wisconsin Administrative Code)
Rev. 2/2012
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, '••~,:,1:•. ~.h•",m;,ir wc; REGISTER OF DEE S
! ST. CROIX CO., I
- - . --774 11 11/18/2013 2,48 M
~;~lP:U.mldebcfwcrn W.Lynne _O1kJ_er,asing It%person EXEMPTtt: N/A
_ REC FEE. 30.00
TRANS FEE: 450-00
'.~r,:'thCtc•rn_ or nl~fL'). and James F Mewter~ asingle person - ~I PAGES. 1
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