HomeMy WebLinkAbout020-1485-04-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
GENERAL INFORMATION (ATTACH TO PERMIT) 592198
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 020-1485-04-000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
21.29.19.3079
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER = CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
,
Dosing Alt. BM
3
Aeration Bldg. Sewer
Holding 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 Header/Man.
Aeration
Dist. Pipe /a L1 ,gyp , y
Holding
Bot. System ! r . y '7 .5
PUMP/SIPHON INFORMATION Final Grade
Manufacturer Demand
St Cover--p /
GPM t ! • °:a j ! ` .
Model Numb r
TDH Lift Friction Loss System Head TDH Ft
Forcemain Length Dia. Dist. to Well
l
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Lengthr No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS -r Y yys-,. ;
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer.
INFORMATION
Type Of System: f CHAMBER OR
f UNIT Model Number:
DISTRIBUTION SYSTEM
Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake
i Pipe(s)
Lengthy Dia Length Dia Spacing`
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over 1xx Depth of xx Seeded/Sodded xx Mulched
Bed/Trench Center I Bed/Trench Edges Topsoil
n Yes No Yes No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location: 846 CEDARBERRY CT
1.) Alt BM Description
2.) Bldg sewer length = i
- amount of cover
of
Plan revision Required? [_]Yes No fl,, 7~ ! (f, Ir,
Use other side for additional information. t~ ji
SBD-6710 (R.3/97) Date /i Insepctor's Signatu71 Cert. No.
i
RECEIVED s'6 ;j 1-? 17 7
County
Safety and Buildings F Division
DEC 0 1 2016 201 W. Washington Ave., P.O. Box 7162
J 'yA i Madison, Wl 53707-7162 Sanitary Permit Number (to be filled in by Co.)
ST CIR01 (,(-)I
°'~'sroisn~s~
`?'M r17Z /749
Sanitary Pel-mlt Appli 'pt; State Transaetio umber
In accordance with SPS 383 Wis. Adm. Code, submission of d A
is required prior to obtaining a sanitary ^*~i unit
permit. Note: Application Ion v..,,ou POWTS are submitted tt Project Address (if different than mailing adds
the Department of Safety and Professional Servies. Personal informauon you provide may be used for second
purposes in accordance with the Pri vacy Law, s. 15.04(1 (m),
i. A }icationInformation -PleasePrintA for do l(
A.Qtl~l(~~ j ~
Property Owner's Name '
Parcel d
Property Owners Mailing Address
I f Properly Location) 15 ~ -~7`J
~ ~ Lh hA R
City, Srnre Govt. Lot
Zip Code ' Phone Number L44o NIL J1 Y) t_.~_ V, section
Q \ I (circle one)
IL Type of Building (check all that apply) Lot u T N, R F or UV
or 2 Family Dwelling - Number of Bedrooms q Subdivisio Name -
- Dk 4b Block # C M
Public/C.ommercial Describe Use 114'al4 ~Nk
❑ City of
11 State Owned -/I}~e~scrri'be Use CSM Number ❑ Village of
2 Z L.C.~A [.t✓ Nfi ~'?i' ~q, ~ Town of ~ tkpsC /J
III. Type of Permit: (Check onl one box on line A. Complete line B if applicable)
i A. slew System - j Q Replacement System ❑ Trea',rrtentfHolding Tank Replacement Only ❑ Other Modification to Existing System (explain)
i i
j B Permit Renewal ❑ Permit Revision Q Change of Plumber List Previous Permit Number and Daze Issued
❑ Permit Transfer to New
Before Expiration Owner rA
IV. I~Kpe of PO'WTS System/Component/Device: Check all that apply)
j won-Pressurized In-Ground ❑ Pressurized In-Ground G At-Grade
❑ Mound > 24 in. of suitable soil [i Moimd <2d in. of suitable soi
H ~ Tank er Dispersal Component (explain)Pretreatment Device (explain)
V. Dis ersaVrrea eat Area Information:
{ Design Flow (gpd) Design Soil plicalion Rate velbui
I "I \ r~ ( fl Dispersal Area Required (st) Dispersal ea Proposed System Elevation
V4! 4 G l~
r VL Tank Info Capacity in Total # of 14 ^7 f 9 Vo,l '
~ Manufacturer
Gallons Gallons Units T
Nm Tanks
Existing Tanks U y N
kpticorlioldingTank IPe ~Ok• ✓ZS n N w e.
Dosing Chambcr Q
VIZ. Responsibility Statement- 11 the undersigne(, assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's me (Print} Plum r iCrta
MP/MPRS Number Business Phone Number
Plumber
's Address (Street, City. State, Zip Code) V Coun /Dana -l Only
lb . fv I t~ ~
Approved t cl Pemtit Fee Date I ued Issuin aent Signatu
r Given R i~or Denial
L8. Cond' P+1ipeasons for Disapproval
ti" tank, "/fit um i fter t~n,i
per .i cell must all a,~, 1 r r a✓ir
s~es rn~i ~
per marayemen! plan an p! pioa idari by Nlutltb@t, / tCM/ Lj (i✓l
2. IgAefbmekreq jrenwnm mtritW r.jaintrir,'ed
1 as Per Wlicnbla codil /cKnance,>t, A /'Lce, ti%rA4-cL~~-A /
Attach ib complete plans for the s3metn and submit to the County onF y on
paper not Pecs than A tn_ a
SBD-6398 (R_ 11/11)
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fY~ll;aF 'l P'1.;? 7'ITLE PAGE
I'rojc~r.f ~~lar~ra: ~ ~p S~r
Own"r's Na n
i.,_
L,l TJcrsrr'it~~iar;:
c, n,nsh
c" , y sl
1 -
Lc'~~ Number
n-,tr'rcal A'I~ d~lurttkj'~r: <
G O C
Paq(1, 3
~sF Cftr~ i
a ~ r
Pap C~
llre3i-nC.t~~l'Y Ili Ram
.,e
Pape is
CJE-----
- - r F)Iat
A"
tmfrrn~ `e;r l .j.:t 6 I lo'teyr I~'( r7: _
Dr~,ir;nFri raur.Sua,r irs the h4FD'u, nli gbsn;p)iran C;ompc,nent manw, for F'CIINT:S Vr-..rsinn 2.b Sr,3p_1f)7f),a-
f'~a„ryc 7
I
pOWTS OWNERS MANUAL & ltlkANAO1wMINT PLAN Rapt
FiLlw imI"b) tVIA, ID.N ayt spolpi'itlk5'X .
own-ar D ropt3c f artk Garwsrsity dal Q NA
parrrnrt $aptlo Wank Manut'sotwrer NA
la ;r itii p t l E i}Wmt RItsrdWlrsYlUMaturm 0 WA
Number of RWrrvc T, ,i4 0 NA Gff)went Fl(tsr Model M NA
I - -
Nurnber of Publla facility unite l "ANA Piarnp 'rank Capsolty _ HA
Estimated flow (ikvarage) UPump Tsmk MIM100turer NA 9
Design lmly (pask), lEQtimatnd x 1 ) ()1,) eildn Punt manufacturer NA
' ~ ~ u Frump Mrstial NAB
aii Applr~iorr PsCaalIAyr
;vrarx,txr sVera~a~ I?ra~as7mea; l~nit l 1 NA
nt Quality
i tsndar~ l~r~lwant/ Quality
Pats, oil & Garage (FOO) 00 OIL 0 sand/Graval Filter i l pad; FIitcr
SfachemiYaRl o,<V;;mn Demend (30'0s) :9220 111 9/~ 0 NA. 0 NSnhvilcal Aeration W~410rd
Tavel Suspendad Scolds MSS) :~'l50 tr;g! C i > fsin~spY)tm C~ Stf~tsr 0 NA'
Pretrcaxad ~aflLietl Ctuta}ity motitilly average i'sisp^er sl Waif(s)
6lcsh~emiaaa t x.ygart ~a trnand (LSI S n ff/~ Cat 1n~c=,nund forawtty) f~1 Its-r~riy►~nd ~praaswri~ed3
A
1;0 0
Total uepRndsd 8065 f i S } 1~ ttgl! Q NA ) Ax^Cr ade Mtrwrtcl
,~,1'~d afu/~°~~1tnl ~ prlp•~i~~e ~i r~.thar;
l Panel WI;t'rM (013r IPWI¢ man)
01 to
~/18ximurn Efsluerrt' Partir}a Slae Q NA
I `t~thar; F~ NA
Other, Q NA C NA.
i - - tithes=
°`1Patve4 gypirsi 3rr r3tsrrma9tic wttstsuratar anti stipt)n ^enk effMi at.
411111~irilttrat a years) "i NA
Insp~+ct ~1ndC«lrn ctf tartk(ei ii At Ina:rx sr,48 901"1` ~ erg 9_.
PUMP Out c sntents of eerrfcle) I oNttaami` Ined shidP ark6 ecwrxt s'uala G;sa th'frr tYsj of tank ypi~am® D NA
l rrtrtrtk~t,) llyl itrltat a sawsl Q NA
frtapsct diap Taal cell(e) ( At lsask 0nc8 suety
l3 NA
Ciaan r3fflt18nt filtt}r At least: onwUi 1S;lar!f • r t~a4..~&r s}, -
Q NA
6 Inspect pwinp, pump otantrds alarm At laatt enQe avary: yz5et s)
MA
Flush l;:rs;erals and preseure TsaG At At, faast nnr® e~rary~t ,air{s)
f~
a L~Gliat! At fang taros avert', }
WA
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i'tl(•AEI'` T ~1F~3•C`i &NSY`AWTIONS
inspsaftne a'r t nRg and dist,+ers+af =ifs 31,10 bP, rtetle fay an irtdfv)dual raarr It q ace of rice roifisvVlrt ii nae ar a rtlfft~atfans,
Mzat;er Phi mber, Mamer Plumber f an-tricted `*aivmpr; rOWTS Inapsator! POIN'F'IS kIi%CS' ftn, laM- 4 SIA' Wt t; A:PMtor. Tenk
inspaalftns crust include s vIguai inapection of the tankis) -to ir+entlfy ami missing or broken Kordtivara, idtsntify any rr3aks or Waltz,
rnessurs tho uc!htr.tn of cmr tbinipd siwds!a and sT- rim end t.ta rftck for sny Of* up ar p1mling of a~fluenw on the grnund eurfsne.
The dispersrii pelt(s) a'hsli ~e visually inspaoted tp chs:rk the el flu cr, is'X619 in thg aI?sanration pipm arm to oht mk swr any pandtnp
as eflTuant on trte groun+i aurfacs, 'rile nsnding of effluent an thn grow id su fee a may IndlIzAte is sslrtn'~ oand'.Iti%n snd raqutres the
trnmedlats nrtif t"at:inn 0 -the local rsvgtriit6p,t awthnrftu.
Whqn the y
C,MntaMS of t ae ~ sh tiri ~ romcivmd y~ i S n pma~p Servicing Oper on and dl~ 'd 0 In =c~ dsrics milth t~E18~p~CErr NR I11,
1A1isrcnain A.cltrt)rtia~Pxtiwe Cndi%
All ntlisr orvIces, lacIvOin; hvi' riot liltlita~ tr the servioing of ar;luent flltars, machanical or prmaawrttad rsir ~pCrtartCs; pratreatrrtsnt
i.mita, and any swInin; Wa Cereals rtf rfl ~ rmmnths, shall he p'i!rfprmad by a.aerkl~xatl f!~tVtl~'~ r~am~sit:aY-
A scarvicm rnTmrl shaft txe primlMed w tide Ian ai np-1131:orv 4~,}~rrl,V +ntitYlirz 'it) 6.1kyt~ t5`: e~rsrnTi) I+ i n* ar'aV' vv~VTCB aver
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