HomeMy WebLinkAbout020-1485-11-000
. Croix
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St
Safety and Building Division Sanitary Permit No:
INSPECTION REPORT 589782
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 Township Parcel Tax No:
JAMIE & CARRIE TRIEMERT TOWN OF HUDSON 020-1485-11-000
CST BM Elev: Insp. BUv 61av: BM Description: Section/Town/Range/Map No:
f0 6q,4, 21.29.19.3086
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic ^ Benchmark
Alt. BM J<J` 7Z /47.7
Aeration Bldg. Sewer
Holding St/Ht Inlet
St/Ht Outlet
TANK SETBACK INFORMATION
TANK TO P1/ WELL BLDG. Vent to Ai Intake ROAD Dt Inlet
Septic 77 /DLI 9 DtBottom
s^
Dosing Header/Man. 7, 15 /6/.3,3
Aeration 00- Dist. Pipe -7 q cQ
Bot. System
Holding
Final Grade /
PUMP/SIPHON INFORMATION 7 7
Manufacturer Demand St Cover
GPM 9 L /6 7.7 Model Number
TDH Lift Friction Loss Syste TDH Ft
Forcemain Length Dia. Dist. to well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS
W, 3
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufactur r
INFORMATION CHAMBER OR '=✓~i /L.+
UNIT Model Number
Type Of System
~ a
IVA
v
Gan~ae a y~~
DISTRIBUTION SYSTEM S}'~ + S v1~
Header/Manifold/ Distribution Ix Hole Size x Hole Spacing Vent to Air take
Pipe(s)
Length_/f - 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 discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location: 567 WILDBERRY C Jam/ t Lie- 45,\
1.) Alt BM Description = (G /
l li az~
2.) Bldg sewer length = 6
a
- amount of cover = ~-6 7 ( t .S O ~'e 40
Plan revision Required? Yes F_ -IN I L7 ,O' 17 ` J
Use other side for additional information.
Date Q Insepc s Signat Cert. No
SBD-6710 (R.3/97)
county AW
i
Safe and Buildings Division 5T'
K T 201 W. Washington Ave_, P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.)
n^y ~u~ ~ ~ I Madison, Wl 53707-7162 7TZ.
0
a caUNy ti
,,,pM1J1UNf1~~ e~II27~" A'.._ State Transactio Number
In accordance with SPS 38321(22), Wis. Adm. Code, subm
is required prior to obtaining a sanitary permit tote: Apple _ ,-v w IS arc sutimiued to Proj Address (if different than mailing address)
the Department of Safety and Professional Servies. Persons...wormation you provide may be used for secondary
purposes in accordance with the Nva Law, s. 15.04(I (m), Stars.
L Application Information -Please Print All Information
Property Owner's N e Parcel
Property Owner's Ma
SCI iling Address Property Location cl I ~ og
Gout Lot
City, S to Zip Code i Phone Number .5 y - yt, Section
e)
T Aq N; R (circleFonorW
YL Type of Building (check all that apply) Lot Y
or 2 Family Dwelling- Number of Bedrooms , Subdivision Aamc
Blue U A
❑ Public/Commercial - Describe Use
❑ City of
❑ State Owned -Describe Use CSM Number El Village of
-
Q Town of lq },S L N
M. Type of permit. (Check only one box on line A. Complete line R if applicable)
A. ❑ New System 10
Replacement System ❑ TsrztmcnUIioldino Tank Replacement Only ❑ other Modification to Existing System (explain)
g 11 Permit Transfer to New List Previous Permit Number and Date Issued
❑ Permit Renewal :,nit. Revision L-1 Change of Plumber
Before Expiration Owner
YV. I~Te of POWTS S stem/Com onenVDevice Check all that apply)
& Non-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) 11 Pretreatment Device (explain) /''1'
'V. Dis rsaUTrea eat Area Informatio 1:
Design Flow (gpd) Design Soil Application Rate(gp Dispersal Arco Required (st) Dispersal Area Proposed (sl) System Elevation
V); Tank Info Capacity in Total 4 Of Manufacturer
I
Gallons Gallons Units ~ ~ o y o
j New Tanks Faison Tanks rte. U .
f' G►~ ~D d a G s w a
j Septic or Holding Tank C )
Dosing Chambcr
VIL Responsibility Statement- L the undersigned, assume responsibility for installation of the POWTS shown on the attached plans.
Plumbe ' me (Print) Pt 77 r igrra MP/MPRS Number Business Phone Number
6y 1 15-"1 Lo- 6111
Plumber's Address (Stree City, State, Zip Code)
A J
V1III. Coun 1De artm mt Li a Only
{ ;proved pprove Permit1F_ee Date issued Issuin aeni Si re
Given Reason for Denial $ ZeS °r' L53 I
IX. Condifig WMeasons for Disapproval
1
:Sep io ark vflL n ulti - rn1 G~tJr- t /%k,-
d seer ati cell rust all be c ._ic ; s ' nt~'r ec
Wiper ir(aragernent plan p~ c, linen by dlunbe:. r4
2. Ap f `X.regt;.iftt wnis mut;toe rEvn.t; ire i
ii Per rgli=Ws miltz / a rdinanrm.
Attach to complofe plans for the system and submit to the County only an paper not tCSS H.an s ut z 11 inches in sbr
SBD-6398 (R_ I i/1.1)
MAP
/V4L
4*4
t
G Lfj
r
k b 1
~ vu1 t Say ~ r-~vp lut~,6N
v, ts
r
~x
1
CONVIENT!ONAL COMPONENT DESIGN
INDEX AND 7'1'i'L.c PAGE
Narno:
tlyjot
-
L,l
owner's Namp.
Alm (",j
Leyal t7es c, jptian:
Township
r.=`aunty: G K ~ 1
,Subdivision f\49Ty)(~ ~C br( ~p~~~
Lot Number
R„i1'G:fB1 ICJ NUYYl'kJ(~,r:
i
is 1
tn'c'X~nci file
r 2
t1-1 al ~r~r c C~c~s's ~cfr n
ta-EFITailt Plan
tic fink IVi i Ltn.~.M e Fcan'Y)
F c c± 9 _ C , ar Plat -
Dr~iF~!: r 1
T~ I r'11cr;t hJr.;17e'r
I -C-j S '70,
Designed ~xrrsuant to the „ - ound Sn1, , r -
r 4bsn,ra,ron Com~enrnt tUlan;,ra( `nr !~QVtrrS V;~rsinn 2f? Sc~n..907U:5~^ ~N-Ot/D1).
r'arye ,
I
i
s
4"
$%i7i't{tr1P 40 ----T--
PVC tfem Pie Dina! Grade,
W10) V-1-m cep
- rt
u ~r
f_ea~f~inq / r1
Ol3Wher , f
r
_Jf
~yste~ ~I~,rati~rt
t!
Trench E
j Chambers
t
4~ Qis.
Ve-rlt Or Observation Pipe Tranch 2 N ia~t8r
Full Trepch 3
~ ~u"bickWer And Model
RSA Ratin x ~q 4 Pe; atYZlZer
tJ Soit Appi1caticyn Rate •
gpci/sq ft
- U_ qpd Design Fjw, Soil
- - - 3 tows o i~ chrYtrs ~cf~.
Page of
Technical Specifications
I
, MME AI L
PL-525 EFFLUENT FILTER
617 8A L CiECK -
~i - EXCEPTS 6'~YfDW Ii ( 1435
` II I FOR INLET EXiENTION
JULETBU"IS EXCEPTS `
SLI, 9&o'SCH 40 -
I _
I
UUU / ~ - I ; If
P
~ I
- I(I ,
i
I
1934
PL-525 FILTER HOUSING ~F---
j' j a
PART NO. 30142-525 T
MATERIAL
HOUSING - POLYPROPYLENE
OUTLET BUSHING - PVC
6.5 BALL -HDPE q l
SOFT EXCEPTS FLOAT SW TCH~,,,~
EXCEPTS I`SCN43 Lq I1 : i .98 Iil ~ I ' 106/
FCR 0NOLE ERTEN➢ON _
1~ 6441
x.642 -
SOCKET EXCEPTS 604
BALI PUSH ROD OPENING -
4[ - r Ian n ~6
r~
,a9 II
I I I{ 1 , i
- OFE~IlIG I
20 ?1
I I I' '
t y i I
O) j 10l
1;190212444 i` I I t I ! .
I j 1 I
I I 'I ! I ~I j.
101 1 IOI.
POLYLOK PL-525FILTER CARTRIDGE
PARTNO. - 30141-525
MATERIAL-POLYPROPYLENE { ! II
ST. CROW C'OUi TIV
ST P(t:TCTA.JN~ !f.A.T 'TEWAT-"TCE ACTR.EE.MENT
AN D
C TER-SITUP CE.RT U'.[CATTO-PNT FORM
Owner/Buyer r-
p r`AS Tic. l
Mailing Address
Pr, op7 .rrty Address 1
(~eri:Prc Lr;iazi required from f iata ling . Loning Department 'for new
~~Sc.z►~l P~r•ceT Tdelat~~~:atpora hii.t.a>alar ! ~ -Q G 4''
Pr operfy L.oca ion J Vim ~4 c,~,
T ~ N €2 7, Town oA
Subdzvisicai P,lat:_ Lit
- - Lot ra
certiflad smwey Map 4"
VoIlame Page #
Warranty, Deed bef 2007)Volume
Page
Spec house E yes no Loi: lines OnntiCable f l yes D no
ttnproper use and rownwaaace oQm7.1r SCp%lC S}rSt.Cti] C,OLimaarat~e, a fd resu
n .Ice c It in its
onslsts of ort t:l - 1}rematixrc faiattre i:e h
P131111-ling .ac septic tack eva7l ,t Cline- years or sooner, if needed. by dle 4 a91:es. Proper
the system can affect thn function o l a lz'c~,rtsed
of the Sept c tank as treat:n7ent st:a F it t: c ptanaprr• 'Wraan you pt.rt into
responsibilities arc specified in Worms. 83.52(l) and in Claapter~ 12 -St. Croix CountysSa.zaat`ar,v Ordina cc -r aaa.;lateaaace
TIC propm? of tier agrees to submit to St. Croix
owner and
by a s Courit-a• Planning nr n Rr.
naste_ ~ plug & ttaber, joustaeyuaaza piuraaher, rest7icted phanber or a lie Zonirg ,used lj~ ~a. er verifyi
d by t:h
e
rva tig that i:i~ ntihe~ on sige
stetuatet cispasai syst:ena is to proper opcra.ting condition and/or' (2) a:er az7sp~^ction and raa ilan
s;_ i
less than 1./3 Moll of udge Pu.p (if:aecessaiyj the ae:ptlc taza.k is
I!a>:~e, the ~.andersin ed 17a..~~e. ]ca.c t:I~iW shove.
9t:a.n ~a ds , ephaments and agree 2O mini.^in tt7e ar'ia%stc se n
hcrern, as sc` ;,5; rho, tlepannient o('C'or-n;neTw and the ~ 1 aua;e dzs ~t9.a.l s ten'a with cextifcat.iol sta in t d tae l~cpa, ~tx en.~ of Natural Resources
State of t with the
that j+0111' SE',71;iC Systcxp has b°C.il inAtrll',ai fed rtal]S1 i,F' CQJnhiPd aaf, ;'etLljt7P.Cl i:0 riser;, Croix COllT7t
Zoning l7cparttaaent tn-ithtza 30 days n ' ]sconsin.
1 she i:hrec ,
ea xpnation date,. 1'iala.nirig &
Ulvc co,-,t, that all, st?fe, lent-_s 079 i. S
prOPMA desCilbed above, t {OiiA arF iailE; $0 (,bCban Of MY/our knowledge,
J Vil,1110 of a iV 'ani, ZI11/ a ?a.1C Orh%CCr(S) n'~i:i]l
deed rccordc,d jr IZog"seer of heeds
O f ce.
Number of h
.A T AP,1 T(S)
rnT
A.ng, infolaatatian i:laai is tnisrepr•eseritc;d laaay resrxli lrl slae salaira.i-~- pel-r77it_ heiraa Tei,okod bytlac Planning
Znr_.ltide tarit:h this applir_.ation a recyrded w_r:-a.nly deed Lrorn 1,11C. Register ofDceds
reference. 0;:fic;e. and a co ~t; o f Zonita .i?epart7nent ~ ~
U cZla.de in the watl<,j deed. r Me cc Cified sun-ey ;nap if
(RP-V09/67)
i
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF AN EXISTING-SEPTIC TANK
This is~~to--'-certify that I have inspected the septic tank presently se vin
yAk g
the t,
resid nce located at: S W W, S
Sec. TN, R g. W, Town of 40y~ ,
County, Wisconsin. Upon inspection, I certify that I have found the
St. tan rand
baffles to be in good conditi n, a d it appears to be functioning prope Iy.
Last time serviced
I
Did flow back occur from absorption system? Yes No."I
line. (if no, skip ext
Approximate volume or length of time: allons
.Capacity: 1A 0 g minutes
Construction: Prefab Concrete
Manufacturer (if known): Steel Other
Age o f Tank (i known) : i vl~
(Signature } J 1 IL ~t YY1`~t, f {
(Name)- Please Print
4
(Title)
(License Number} .
I~
(Date)
Form to be completed by licensed plumber (s. 145.06,
Wisconsin
licensed disposer (NR 113 Wisconsin Administrative Code) Statutes) or
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
- -
Plumber (applying for sanitary permit) Certification:
In accepting the above statement regarding existing septic tank condition,,I
certify that the tank, to the best of my knowledge, will conform to he
requirements of ILHR 83, Wis. Adm. Code (except for inspection opening over
outlet baffle).
Name :::Y\1'1\ WNV,( L~ Signature
MFjMPRS
i
+ -~J
LL J
- d Lu Ln -
r, ( a
n X67 n `t m
q o
~ C) ~r m
ro
A '-J N r, _i
. 33' 33' co
I zo I
N r-~
L m
1 Lf) dl
V- LLJ
Lr)
00 ~ 00'SZT b0'ZZT
v' C:~ z 00 n
o ,09'65
m J O"LtbZ M„60,1£oOON ,
-Ui Ln
~ cY. Q' b, ~ Cl
C7 00 0
r. O m I o 1 Ln
+ I
c? w Z I
C71 r-4 rv 0
C~ r4
r, C\j
1
~seel 3 I vJ \667 .~-r a U
C7' ~ n J Q
1-1 co
U V)
S os~ I F- Q O 11 M m - y
ti Y-+ 00 O r
/ / 3NIl b/T IS3M-1Sd3 C/}I
3H1 3O 37VID HAON
x / s) u59' ( t a aNf1O3 3dId NO'dl „9T/S T
Ln
CY)
LLJ
081 1
ti L1J
1 C=) I I o
, I
tF7 / sue, I I Q; er W I-- cc
r I I co Lr) J u
( I W o
m
00, L
/ / I I
O s ` j - 3NIl b/T iS3M-1Sb3
L I i 3H13O ,OS'O H1NON
/ o r', rn GNno=i 3dId NOW „9T/S T
r-4 pW c7:"
u (n QNrn 4
0
Q ON ~m I I N~
1 I of
j I 1 ~ f, J
1 I I C~
r I I Ln
CS(~~~~,1- doe
Wisconsin Depae IVIVF.00 fessional Services
Division of Inr~t v Page 1 of 3
31 SOIL EVA~UA
jUN 08 20In accordance with SP Code County
Attach complete si I 000 1/2 x 11 inches in st include, St. Croix
but not limited to: t 004 hffll a point (BM), dig- -,cent slope, Parcel I.D.
scale or dimeD arrow, and location and distance' u. 020-1485 11-000 Ref #2477
Please print all information. Review by Date
Personal information you provide may be used for secondary purposes Privac Law, s. 15.04 1 m G
Property Owner Property Location
Jamie Triemert El Govt. Lot SW % SE S 21 T 29 N 19 E (or) W
Property Owner's Mailing Address Lot # Block # Subd. Name or CSM#
W12313 852nd 567 Wildber Dr.. 11 Na
Plat of Cedar Valle
City State Zip Code Phone Number
❑ City ❑ Village ®Town Nearest Road
Hudson WI 54016 ( )
Hudson
® New Construction Use: ® Residential/Number of bedrooms 4 Code derived design flow rate 600 GPD
® ReplaCement ❑ Public or commercial - Describe:
Parent material Glacial Outwash Flood Plan elevation if applicable HWE = 911.90 ft.
General comments and recommendations: Site suitable for conventional POWTS. Recommended infiltrative surface elev. to be 99.50'.
❑ Boring # ❑ Boring
® Pit Ground surface elev. 102.19 ft. Depth to limiting factor >102" in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/Ft2
In. Munsell Qu. Az. Cont. Color Gr. Sz. Sh. -
1 0-10 10yr3/2 none *Eff#2
sil fill na na as - 0.0 .0 0.0 ~
2 10-24 10yr3/6 none sil 1 msbk mvfr cw
- 0.4 0.6
3 24-30 7.5y4/6 none
Is Osg ml cw - 0.7 1.6
4 30-88 10yr4/6 none
s Osg ml gw - 0.7 1.6
5 88-102 1Ory5/6 none
s Osg ml 9w - 0.7 1.6
. J
1~ t p
2 Boring # ❑ Boring ~ V
® Pit Ground surfa ev. 10 16 ft. Depth to limiting factor >106" in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/Ft2
In. Munsell Qu. Az. Cont. Color Gr. Sz. Sh.
1 0-12 10yr5/4 none *Eft#1 *Eff#2
sil fill 2mpl mfi aw 0.0 0.0
2 12-78 10yr5/6 none
s Os9 ml 9w - 0.7 1.6
3 78-106 10yr5/4 none s Osg dl
0.7 1.6
* Effluent #1 = BOD, > 30:5 220 m /L nd TSS > 30 s 150 m /L * Efflu t #2 = BOD, > 30 220 m /L and TSS > 30 < 150 m /L
CST Name (Please Print) ignature CST Number
James K. Thompson 30021
Address Date Evaluation Conducted
Telephone Number
340 Paulson Lake Lane, Osceola, WI 54020-5413 June 6, 2017 (715) 248-7767
SB5-8330 (R04/15)
Boring # ❑ Boring
® Pit Ground surface elev. 101.23 ft. Depth to limiting factor 98" in.
KSo,IAa Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots In. Munsell Qu. Az. Cont.
Color Gr. Sz. Sh.
1 0
-12 10yr3/3 none sill fill na ai - 2 12-73 10y4/6 none s Osg ml cw 3 73-98 10yr5/4 none s osg ml ❑
Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil A lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/Ft2
In. Munsell Qu. Az. Cont. Color Gr. Sz. Sh.
*Eff#1 *Eff#2
❑ Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/Ft2
In. Munsell Qu. Az. Cont. Color Gr. Sz. Sh.
*Eff#1 *Eff#2
' Effluent #1 = BOD, > 30<_ 220 mg/L and TSS > 30 5 150 mg/L * Effluent #2 = BOD, > 30<_ 220 mg/L and TSS > 30 150 mg/L
• lvca~~~~. s~
5 Ga /z„• / gyp'
-J a,,lce 7ri e rtar Prop,
0 5(,7 w'' N 6`r, y
_ ~ l~µds ~ L Syo~6
Sp~vY~J~Y9; ~eC. Z/, 7. z9il.
(&;/dbx-!'y -7;~. CV-hi,
~Y of/off s •c~e = gall JV 96, 0j. o min -cr off'
I~roposeJ
LA' Po tesko-d
s ccr/Cm 6~
EX,-sb'
~ IT r:
E.Y/.SGi~~jj 14J, '(f4/C. . J/e,0! S~.Jd~.n 4/tQ-I
62
".~l,a.s~i-ritRScpEtc i
4 s Pci Syo-C.~ sfa//e~~ \
~D ra,
~Q f e„, en ~
so
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
(ATTACH TO PERMIT) 589782
GENERAL INFORMATION 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 Township Parcel Tax No:
~
Kernon Bast TOWN OF HUDSON OIL' M,9-11-00c,
CST BM Elev: Insp. BM Elev: BM Description: Section/Townr/Rangge~/_ap N, J
/ao a
~r r ''3&3
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic ,t' Benchmark /O
p S Alt. 0:1-14-11 Ge. - z 9~ /47-54,
Aeration Bldg. Sewer t
7 0
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/Ht Outlet Z /02-3
TANK TO / WELL BLDG Vent t Air Intake ROAD Dt Inlet 11-1
Septic / AA Dt Bottom
Dosing Header/Man. ,Art 1+71-
Io
Aeration ~7 t` /O, O r
Dist. Pipe
Holding Bot. System
/do . of4 0
16.4
PUMP/SIPHON INFORMATION Final Grade
Manufacturer GP Viand St Cover 167, •s/
w
Model Number
TDH Li Friction Loss System H 7911- Ft
Force mai ia. Dist. to Well
SOIL ABSORPTION SYSTEM
BEDITRENCH Width Lengt)► No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS % Z t e~e-~A `
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer
INFORMATION CHAMBER OR .
w.~t1L_
Typ Of System: ~ ~k UNIT Model Numbe : r
A✓1r~1~ro -7 L.t
DISTRIBUTION SYSTEM ;?-I+ ZZ. = Y
Header/Manifold ( Distribution x Hole Size x Hole Spacing IVJto Aivyntake
Pipe(s) L C
Length Dia Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over In Depth Over xx Depth of xx Seeded/Sodded xx Mulched
Bed/Trench Center Bed/Trench Edges ` Topsoil
es No Yes No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location:
;
1.) Alt BM Description
2.) Bldg sewer length = Z
- amount of cover =
Q~
Plan revision Required? Yes 1 No
Use other side for additional information. 12, UP ~ 7~,
Date Insepctor'/nature/ Cert. No.
SBD-6710 (R.3/97)
~EI X11 County
V
/ka'rr Safety and Buildings Division C ~a,x
Erj `I 201 W- Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co)
U~' La1b I Madison; Wl JC7-7162
COUNTY
COMMUNITY, ezmlt A_PpIictxc~g NVD434p6 State'Iransac io^ Number -
In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate move,,...!` I V, V 4p
vs required prior to obtaining a sanitary permit. `Tote: Application forms for state-owned POWTS are submitted u, reject Address (if different than mailing address)
i the Department of Safely and Professional Servies. Personal information you provide may be used for secondary
~ purposes in accordance with the Privacy Law, s. 15.04(1)(m) Stars
1.. Application Information - please Print A,ll info -on ~ v (G b
Property Owner's Name I ~j .n 1~1 ~N l~ - ~d~ Parcel #
KeR►~ LN J CFJt
AS _I a`i . iq.
j Property Owners lvlailmg Address Property Location
Govt
. Lot
City, State
i ~ Zip Code ~ Phone Number
section a
u~S a I (circle one)
)<I. ype of )Building (check all that a 1 - T F or w
Pp y) Lo +
❑ 1 or 2 Family Dwelling - Number of Bedrooms - I SSuubdivision Name
Bloc
61C
CR DIvL ~e P toll 0
❑ Public/Commercial - Describe Use NA'
D City Of
❑ S1 ate Owned -Describe Use CSM Number
I L4 ❑ Village of
Town of
+111--T~peNof Permrt• C eck dol.- e baz, op line A. Complete line B if applicable) -
f New System L. Replacement System ❑ Treatme it/l iolding Tank Replacement Only ❑ Other Modification to Existing System (explain)
tR'- ❑Permit Renewal ❑Permit Revision -r D Change of Plumber - I List Previous Permit Number and Date Issued
❑ Permit Transfer to New
Before Expiration Owner
J
' IV. Type of POWTS System/Component/Device: (Check all that apnl,y~_ _ 3--' -
w1
\trn-Pressurized In-Ground El Pressurized In-C;round C At-Grade El Mound 24 in- of suitable soil ❑ Mound < 24 in- of suitable soil
Tlolding Tank _ ispersal Component (explain)__^ ❑ Pretreatment. Device (explain): ~.•vu~
V. Aispersat/Treat nt Area Information:
- -
Design Plow (gpd) Design Soil Application Rate(g sf) Dispersal Area Required (s ;Dispersal Area Proposed ( S stem elevation 16
z Go
`I- Tank info Capacity in 1ot.al I, of Manutacxurer ~ f
Gallons i New Tank% Gallons Units
Existing Tanks
y o °3
- I 'd SZ a n i a~
Septic or Folding
j Dosing Chamber j -
V11. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POW'I'S shown an the attached plans.
Pittmbers Name (Print) A ers Signature MP/MPRS Number Bi siness Phone Number
Plumber's Address (Street, City. State, Zip Code;)
I 6 1 0A S N ~ns~N _ 1J
V"'- County/))e artment se 921-Y
Approved 1 ❑ D' oved pew mtitTee Date Tssu Issuing nt Signahtr
❑ ' fo D vial 40
. Contt►i~ X19.~1{F#ieasonsfor)Disapproval -
1. _$leptio tank, effluent filter and' 3, a J; /setet J~
dispersal cell must all be so lc,,s / mete,
as per fidnagement plan provided by plumber.~~ufl:+K~.{'fit b A60
~Otr~l.dWdYi:!' ,
2 All etetbedk negorerients must be ;tainkirSeti
_n per apFJict►bla code / :rtiinattm. 11 - Ct ~>tw
Attach to complete plans for the system and s rnit to th County only an paper not less than 8 rrz x a t inches in sire
SBD-6398 ()t_ I I!11)
oap
13
ice' .
1 ~
1
bo
I
C
I
j t
c
CONVENTIONAL-
1 N),D X AND, i l'7; LE,' 1'10~sI=:
L'ro~nct Nat -n _ )Z 11~ t' V~1 "f~ S
~rvi-rs!l i p
kkb 3 1) J-3
vs A,
L.C) lIla1i ber: 7
D Number:
i'mge. 2 Flint F'fran
F'dCJ't y; i ] s%i?;;7I il'7 L_l;nSFi-•Y.i'(?''Ca;fJ'Y1
Rap 5 -----IVI~i=rri~.rs;.7r7rn ,.r~r~n•~1t,r.~n I
.•1 ll~Pl•,u„r,~:f~~fl'i'ii.l,t f^~iGli7
7 (.r N C, v nk r4fliTl'Ci$;!' tna'1"C;'l', l-'C ral,
t tip "'t~
scar C BM r,•s; 'lr i
i')P!rrlfar ~yhnd~~~ h
LiC-~'fl`.+C;`. J•s)[JI"p'1'x)'~;e'
?ic3r,,ait.,r;=
'tf'P.!• j•1U"~uan r 'ihe Ir'1t r~,un i 0~'
Absc+t:~lini~. Cti ,~n; nN na.:,r,t,,t! ia !'t:11N? Vr
rstc~n ' 0 l~p_9D-Y(1~~~(W.Oi/D'f )
r,IiJR 1
i
L
-13 pi s
4- 44
/OA CA 11 CRpnrQ;iw **4" ult'l
Good,
I
[l 4~. i
Qr~, ~ aG F J
' I
i
I
f
f row 'Sects I
4 So NSA
( we i(F~ t~i~r k )-in~l c~ra~lr
mrtf, wint can P
t}
an -i
19
b r_ .._1LL ~R. I_i_ 1rLSJ S_S_F } 8 3
4., Dfo.
1 Arai r OhsAlMion Pipes ~F ear i -Ir cPr1
lip 1, 1. 1! 1
- 1.
-_1 ~ 1 O f d ~ _
MalltAiaactuF~,T And Afiorl,f
EIISA N %,I i
ff - r =i Per char-P ,e,r St1i~ A~?pl'sc~tic~f~
1 Design AP Piic.) i t g,
41D Ch8l"ntler$
Page _ of