HomeMy WebLinkAbout020-1485-15-000 (2)
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: 592145
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 020-1485-15-000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
21.29.19.3090
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing ¢ v Alt. BM
' r
Aeration Bldg. Sewer
x ~
Holding St/Ht Inlet
- ?5! C_.
TANK SETBACK INFORMATION St/Ht outlet + 13, Y
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic Dt Bottom
Dosing Header/Man.
Aeration Dist. Pipe 719 1z ~Ie.
Holding Bot. System
PUMP/SIPHON INFORMATION Final Grade 4 y c
Manufacturer Demand St Cover
GPM -
Moda1'Number
TDH Lift Friction Loss System Head TDH Ft
Forcemain Length Dia. Dist. to Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width rnth No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS , y, rt
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:._. -
INFORMATION
Type Of System: CHAMBER OR t"'= ~ 9": 4~..
UNIT Model Number:
DISTRIBUTION SYSTEM.
Header/Manifold Distribution x Hole Size IX Hole Spacing Vent to Air Intake
Pipe(s)
Length 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
rl 7
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location: 551 WILDBERRY DR
1.) Alt BM Description =
2.) Bldg sewer length
- amount of cover = i/ C
Ld
Plan revision Required? L] Yes No / ~qe )
? r
Use other side for additional information.
L
Date Insepctor's Signature! Cert. No.
SBD-6710 (R.3/97)
County
Safety and Buildings Division 51. L f U
201 W, Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be fi ed in by Co.)
Madison, WI 5370 , 162
° *Srocs~` ST. CROIX 0OUN1Y
'()M%,jIJ ant ei mzt Application rate Trdnsaetion Number
In accordance with SPS 383.21(2). Wis. Adm. Code, submission of this form to the appropriate go, A-
is required prior to obtaining a sanitary permit, Note: Application forms for state-owned POWYS are sun.._ roject Address (if different than mailing address)
the Department of Safety and Professional Servies. Personal information you provide may be used for seconam, ,
purposes in accordance with the Privacy Law, s. 15.04(1 (m), Stats. j
L Application Information - Please Print A[ or on W ALCU, V 1
Property Owner's Name Parcel
3
L dos
Property Owner's Mailing Address Property Location r
9 L q Govt_ Lot
City, State Zip Code Phone Number t/<, Section -
1 ` v1)s 1.1 Uv 7 v' / V T ~(I N; R (circle
or e)
II Type of Building (check all that apply) Lot Y _
❑ I or 2 Family Dwelling - Number of Bedroom, Subdivision Name
ok- ot+~ Bloc F PtZ I
O Public/Commercial - Describe Use
❑ City of
El State Owned -Describe Use CSM Number ❑ Village of _
2 N64- t~J ZZk Z I erTown of S tt
i III. Type of Permit (Check only on box on line A. Complete line B if applicable)
rlew System E! Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Outer Modification to Existing System (explain)
i
List Previous Permit N her d D Issued
❑ Permit Renewal i ermit Revision ❑ Change of Plumber 111 Permit Transfer to New
j Before Expiration Owner 5 + , Tio' 1 l u
IV. Type of P01 S stem/Com onent/Device: Check all that apply)
j -a Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil El Mound < 24 in. of suitable soil ~ r / . 1
11 Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain)
I V. Dis rsaUTrea at Area Information:
LIK-
j Desi n Flow (gpd) Denies Soil Application Rate (g Dispersal Area Required (s Dispersal Are )posed (s~ Syst Elevation
1~
VI- Tank Info Capacity in Total 4 of Manufacturer
Gallons
Gallons Units o -o ~
New Tanks Existing Tanks U
I ~ ~ L w A ~
1 Septic or holding Tani a S'G r 1
i Dosing Chamber 1
VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print) Pl C s - ature MP/MPRS Number Business Phone Number
Plumber's Address (Street, City. State. Zip Code)
V oun epartmint Use Only
pproved ec Permit Fee i Date
I r 9a oa I ued issuing Q t Signature
riven Reason Denial S V11 IX. Condit s AfN lite2;s~; for Disapproval
1 Pb'' tank, effltstsnt fllt and 46 Ji /1t
dlsper•xd cell must01te ° -ic_s I m.--lntzti J t- c /
as per mar.agemo;rft.on pro tided by plumber, h/f P WU "w
2. `RN ft4t:lerk recuims0onts must be rtamta ined
as per applicablts tea / . rd;nancas.
Attach to complete plans for the system and submit to the County only on paper not less than 8 if- z I I inches in sin
SBD-6398 (R_ 11111)
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PVC Vent pipe ~ ~irtef ~3re~fr
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Win "mitin
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iP"-ns OF Obsey-vation Pipe Trand, 2 l-i~~c#~r
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"fal-Atwer And Model
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I Pe;- charriber Seii. AppiEC<ation Rate
,910d Design Flow - - ' -7
Snit Application #-:7fe
Page ~f
a: ZECEIVED tS 12olv-13T
Wisconsin Department of Safety and Professional Services A®23201 E Page 1 of 3
Division of Industry Services j _z„ 10 ~~a w • " (J 1
SOIL REPORT ST CROIX COUNTY
In accordance with SPS 385, Wis. Adm. Co4p Why' DEVELOPMENT
St. Croix
Attach complete site plan on paper not less than 8 1 /2 x 11 inches in size. Plan must include,
but not limited to: vertical and horizontal reference point (BM), direction and percent slope, Parcel I.D.
scale or dimensions, north arrow, and location and distance to nearest road. 020-149j5-1 5-000 Ref#2458
Please print all information. Revi d by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04(1)(m)).
Property Owner Property Location ❑ r El
Kernon & Donna Speer Bast Govt. Lot SW NE % S 21 T 29 R 19 ) W
Property Owner's Mailing Address Lot # Block # Subd. N me or CSM#
948 LaBarge Rd. 15 Na Plat of Cedar Valley
City State Zip Code Phone Number ❑ City ❑ Village ® Town Nearest Road
5.51
Hudson WI 54016 (715) 222-4405 Hudson Site Addx
xx Wildberry Dr.
® 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 na ft
General comments and recommendations: Site suitable for In-ground POWTS with 0.7 gpd/sq/ft. design loading rate. Recommended infiltrative surface =
92.75'
I
1❑ Boring # F-1 Boring
® Pit Ground surface elev. 97.52 ft. Depth to limiting factor >11 1" in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/Ftz
In. Munsell Qu. Az. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0-15 10yr2/1 none sil 2fgr mvfr cw 2vf,f 0.6 0.8
2 15-38 10yr4/4 none sicl 1 msbk mfr cw 1 vf,f 0.4 0.7
3 38-44 1 Oyr4/6 none Is Osg ml gw 1 vf,f 0.7 1.6
4 44-89 10yr4/6 none s Osg ml gw - 0.7 1.6
5 89-111 10yr5/4 none s Osg dl 0.7 1.6
(
2 Boring # F1 or"
®Pit Ground surface elev. 97.68 ft. Depth to limiting factor >115" in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/Ftz
In. Munsell Qu. Az. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0-19 10yr2/1 none sil 2fgr mvfr cw 1 fmc 0.6 0.8
2 19-38 10yr4/4 none sil 2msbk mvfr cw 2fmc 0.6 0.8
3 38-45 10yr4/6 none Is Osg ml cw 2vf,fm 0.7 1.6
4 45-85 10yr4/6 none s Osg ml cw 1 fm 0.7 1.6
5 85-115 10yr5/4 none s Osg dl - 0.7 1.6
* Effluent #1 = BOD, > 30 220 m A and TSS > 30:5 150 m /L * Effluent #2 = BOD, > 30!5 220 m /L and TSS > 30:5 150 m /L
CST Name (Please Print) Signature CST Number
James K. Thompson f-r 30021
Address Date Evaluation Conducted Telephone Number
340 Paulson Lake Lane, Osceola, WI 54020-5413 September 30, 2016 (715) 248-7767
SBD-8330 (R041 5)
3] E Boring # ❑ Boring
® Pit Ground surface elev. 97.08 ft. Depth to limiting factor >109" in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/Ftz
In. Munsell Qu. Az. Cont. Color Gr. Sz. Sh.
*Eff#1 *Eff#2
1 0-14 10yr2/1 none sil 2fgr mvfr aw 2vf,f 0.6 0.8
2 14-30 10yr4/4 none sil 2fsbk mfr cw 1 vf,f 0.6 0.8
3 30-37 7.5yr4/6 none sl 1 msbk mvfr cw 1 vf,f 0.4 0.6
4 37-43 7.5yr4/6 none Is Osg ml cs 1 of 0.7 1.6
5 43-83 1Ory4/6 none s Osg dl gs - 0.7 1.6
6 83-109 10yr5/4 none s Osg dl 0.7 1.6
F] Boring # El Boring Qn
❑ Pit Ground urfacerIEV. Tc Depth to limiting factor in.
1
2 Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/Ftz
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 5 220 mg/L and TSS > 30 s 150 mg/L Effluent #2 = BOD, > 30 < 220 mg/L and TSS > 30 5 150 mg/L
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j I Safely and Buildings Division R C. ~4 ""YII ~1 201 W. Washington Ave., P.O. Box 7162 Sanitary Perniit Number (to be filled in by Co )
;w uT(1 i Madison, )637 -71
OIX COUNTY
1J F51 VTD W 7 R YA State 'Fransaction N t r
0MMUNIT~ eTI2~1$ Applicanoi., In accordance with SPS 38321(2), Wis. Adm. Code, submission of this firm to the appropriate governmental unit
is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to Project Address (if different that, mailing address)
the Department of Safely and Professional Servies. Personal information you provide may be used for second
purposes in accordance with the Privacy Law, s. 15.04(i)(m), StW
I. Appl
ication Information -Please Print Ali Informs j~TProperty Owner's Name
- Parcel # - J
I
k Kf
Property Owner's Mailing Address Property Location yy 34+~~
t p
Govt. Lot
ClTy, State
Zip Code Phone Number yq N t3 Section_
(circle one)
LIS'
T N; R F or W
II. Type of Building (check all that apply) I [.,or
/
N or 2 Family Dwelling - Number of Bedrooms BloSubdivision Name -
OK o~ el.
C ~ - '14 VA I
Public/Commercial -Describe Use
❑ City of _
CSM Number ❑ Village of
❑ State Owned -Describe Use _
Z t ZZ Town of
111. Type o Permit: (Check only one ox on line A. Complete fin 'f applicable)
A. ! --t-- New System a Replacement System ❑ Treatment/Hoidt Ta Replacement Only ❑ Other Modification to Existing System (explain)
H R- !
~ ❑ Permit Renewal ❑ Permit.Revision L-1 an ;e Qf PPermit Transfer to New List Previous Permit Number and Date Issued
Before Expiration Owner
IV. TIype of POWTS System/Component/Device: a iy) ,
M7W i--
WL-&W CV
on-Pressurized In-Ground ❑ Pressurized In-Ground -Grade ❑ Mound = 24 in. of suitable soil ❑ Mound 24 in. of suitable soil
J Holding lank Li Other Dispersal Component (explain}- _ ❑ Pretreatment Device (explain)_
V. Dispersal/Treat ent Area Information:
Design Flow (gpd) Design Sr'I plication Rate( dsi) Dispersal ea Required (st) i Dispersal Area Proposed (sf) System Elevatio
VI_ Tank Info Capacity in ! Tot.ai # of Manufacturer
Gallons
Gallons Units a „ ~ o a5
NesvTanks Existin~'I'anlcs U
v o ns
f D ~~j 'n. n m LZ C7 w
Septic, or Molding Tank _
Dosing Chamber i - I I e
VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans.
Piumber's Name (Print) Ph] is Signa MP/MPRS Number Business Phone Number
In -q U, A 1
4AII
1
Plumber's Address (Street, City. State: Zip Codc:) -
R A
M. unt JDe artmen lse Only - ~ -
P-- ermit Fee- Date I sued Issuing n nt Signature
pproved Disapp
)roved i
on o
1 riven R
_PWYEAMeasons LX. ConddSM t 1'#tW for Disapproval ~~>t ` ( J ~ O w
1 ptirs tartk, effluent t5lter and
tileper si celf must all ¢g smAM / p,N nt~ne /
#s per management plan provided by plumber. t`~J►'~.~ /11•c 11CQ► ~n~
2. '°i h-$eftCkrequirerrwft must be i;:lainte iced
as Per applicable codit / crdinanras.
Attach to complete plans for the system and submit to the L'onnty only nn paper not less than fi ll3 x t l inches in silt
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=r un~;i 7~I: AI'+r;ciipiiioil C,'.tu11r~i~r~e~t i1/aNnrFti r,r 'i~1N?', V,^r,iar ?.r)
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With 1fr1~Q rap
On s
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tti I M I J( rat twit
1lf,21R OF ONSflyvation Pip., TrOllch 2 i IP.at~h~a'
Mil ITIN
MUMM
1 Hil f ~ mu
:m'~-
~ tech a~cgt~r s And Model r ~
sr Pef chaGribe; Snil. -
i AppiRCrltion Rste
gpd/sG PA
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FIEF 1NptMRMATIO.N v1C8 P tv]pl ~i. ttti
}htJntlr
{Z c SD j ropt3r Tank Cspa:alty dal ~ NA
Permit ~ $eptit+ Tank Manufticurar ie Q NA
MIOl p 9 AE4V!>=7° Pf'itygnt later M,anOwurar u ..L;, DNA,
N=har of Ndrsvm,~ - lI NA R flu-&nt tinter Model S r~ r-i NA
Nul rnber of P~it~lie ('milky Units t Q. NA Pwrnn 'rank Captaofty NAA
ani~fa>.twrar NA
1 ~sttmated flow wlaragsl t malidav 1 Pump Tank V
Deaign'1OW lpaal6}, 1M,*T!rrtstrid x 9.1=} ai/dA A ut p l anufaaturar NA
Sc+ti Ap} 1t tlctrl 1' CS a ~4/vl g a pump iVfoda~ ~ ...rte..
S n~ d~rd inilt~ari l `I~,nn •~salit~r Mc~rxntXr auarspn IAA..
Pats, Oil ra a tP t } X30 Mg!l r~itldl ravel Plties n Pew Plltsr
Siatahemirral DyVgan Dsmend iIRODal X220 M.'q/t Q NA 0 lbfer hvil"4 Aeration G~ W1,4 rd
Tout Suspendad Snilds {TES} 9'160 . /i C > 4ainfaration that Q NA
oratrcat,ad ~~i~nent ~la;tal}t1' ttlivl~'1111Y atrera~ye t-,t;slert~sl ~alits} -
-00 crtdll, n 11)~oround igrav[tyl Ci In•r ro~tr*d ~preast~risadf
t;ifvrhternlRal Ouygan ~ r. atttnand G8QG3b1 G3 t~vwn~t
0 NA l~ Ax^tarsda Qdh>ar:
Total 8uspandsd 80116, (TSSI M211,
7" afw/9G}ml prfp~~int3
Feat Gvis oYk t rrrietrio rrvapir} l~tYfis t1 NAr
- y sn eil , 1-1 NA
Maximum efttwatnt Partlate SIZO ¢ t"~Cs~ha 0 ri1A
(tiYOr; tQ NA~ ( NA
i rtissr:
°`1Palua typira! Bar rac,moatls +Nfiseavurztar 4(nd s8ptln ank of iwrtY~,
nliPtttl4't'BiARO 5ST<'tEG3ULE t~~1P? 4....
r+ri>Me ~t.►~
M NA
. ~1tl~tiP 17RYV~` r Sl1~i1 1~' (MA* tYil~Yak Yaw)
irrspest oonditton of 4anTklst At Icaae cn zB sgrgwla i$ ysac
°unnp attt rvntentQ of tfirTlc(ik}.. ~Niiert eambined sh;tdga and arum apush Orfg .~4C}fr4i iYg1 is tank ms p tdA
Y sw4 CI NA
(litirlts
inap$ct disperwal retli&} At, least csnae every"
Y"fa"1YiiflTNA
Claim) afflLSarit filter At lsast ralnrle aniary~ ~ 'aril
p ~Ia~rf~1 g, pump connntrdis aiarm At 4east rnc>a revery: Flush ist-erpla and praeoura ta9Ai; fbds4 ranc,a Nary, At. isem, On>'a sorys i
411tN)SP 4 "l~ltit
inspwWens a r T~ianO t+cs and d>siaersal ins shaii be s'izscde: Say an 1ra+diwfdiaal userey4rtg c+ne of the iitfvU,1nt lR?4~~~~ A;p,g~t~t'~W
Mastsr Piiarn1m : Mastw Plumber Roatrlrtee Sahnlnr; POW T IS 1~psmr, E'lW -S ~'1f~~1'f`E~iI17, am ~ rrerat or it;«a Tank
inspantlona must inrludp s visual inspection at the t$rrk{a3 to jftntlly arty rnissIng or broken hgrci hwg, lasn~~r any
Frainwra the valtm n Elf c,otnnolnlO slwdge one nc:LSm srd try choak for any hsolc up ar panting of a hta sw on the grouri l sur foe,
Ttna dispersal 17aiils} ahmif pa visl,islly inepestad Q check tine efflua;'r< [sots in the, ahservatlon p1gat arO to Ouk ` or'Any pnndtn+g
of afffuent; an the growiv surfars, The aendlng z5f afterit nn tho gi'pwind s•,ffeca may fndiaate a sallln~ atndItf+an ;snd mqulras the
immodlata ricitifivattnn al the lvcai rargirlAm ml ;iuthrarity. anO
1he cf1eaOf a}'tank sh 11 be:j:fomo ,adli yg a Sera age 8ruiritng t;9pe~r or1 and Olspt ff} lr4 na aw.larm with #t1 pter I~C3eI 13,
rvon'cants Ofigcanain AArnlnlatr;g6wA Cride. etra tntlelnS
All otihsr 4aritlaas, !Deluding but not iimitail fie the sarvioing vi sh1wem filters, mechanical ar pruawrIzed gr r~axtrlpt4ne*ts;
units, end arty w0ning m 1 tervels of !fl:2 manths, sh&il be pprforrnad by s aertilflnd,POWTS.Mtrit4in r-
ttla"t4t n ct tw a r s Sve'1%.
R srev}ra ar crt slr~,7e r r +;rrded i,,s i2 l aE resilwf ~i;4sry +~tilnri V 1 ritihis1 'i) k1YyA Mf resrli , mokk) 14101)