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HomeMy WebLinkAbout020-1485-12-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 597314 GENERAL INFORMATION State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Village Township Parcel Tax No: Permit Holder's Name: City The Kernon Bast and Donalda J Speed TOWN OF HUDSON 020-1485-12-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: Z Z - 2 CST' 21.29.19.3087 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Z_ SO Benchmark b /b7 / 7 PL4 Alt. B o L Nrn Z. 99.7 Aeration Bldg. Sewer 9G 1 Holding St/Ht Inlet 7.6 d7gy. S 0118 9~` TANK SETBACK INFORMATION St/Ht Outlet 11018 7 TANK TO ^ P/~ WELL BLDG. V Intake ROAD Dt Inlet \ Septic *7S6 Dt Bottom Dosing Header/Man. 9Z p 7 I 1713 Aeration Dist. Pipe Z. Holding Bot. System /ar 9/ r19~ PUMP/SIPHON INFORMATION Final Grade Manufacturer Demand St Cover 'T { `,r GPM 1.,nLt-- I Model Numbe TDH Lift Friction Loss System Head TDH Ft Forcemain Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of~Trenches , PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 76 L. 1 (e, I ~/~r~ 1 SETBACK SYSTEM TO P/L BLDG WELL LAKF,STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR hh wT+/L Type Of System: AZ .C l a5 ,6 S7 UNIT Model ber4.A- .51 66 DISTRIBUTION SYSTEM ,Z't'ZZ = `7r Header/ManifoiP Distribution x Hole Size re Spacing Vent to it Intak - Pipe(s) \ g Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over 1xx Depth of 7ed/Sodded xx Mulched Bed/Trench Center 4 - I'Z Bed/Trench Edges Topsoil Yes No s ] No Y COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: 1 pection #2: Location: 563 WILDBERRY DR ' W ri ~ ~-to ~ b l 5 e 1.) Alt BM Description 2.) Bldg sewer length - amount of cover X/Z Plan revision Required? Yes )l(No -L1% y I/' Use other side for additional information. L -i _-71 L Date Insepctor'?Sature Cert. No. SBD-6710 (R.3/97) E E i v Safety and Buildings Division County 201 W. Washington Ave-, P.O. Box 7162 ' Sanitary Permit Number (to be filled in by Co.) 2017 Madison, W1 53707-7162 -QMMUN _ State Transaction Number In accordance with SPS 383.21(2). Wis. Adm. Code, submission of this form to the apY,..,._ al unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS arc.1--_ fitted to Project Address (if different than mailing address) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary u oses in accordance wish lire Privacy Law, s. 15.04(1 (m), Stats. L Application Information - Please Print All Information Property Owners Name Parcel# Y 0 0 Property O~ers Mailinig Ad r~s f PropertyTocatianaf ~9, 4Q. ~$7 li L;tty, State CrovL Lot Zip Code Phone Number 1 Sect i on ~ (circle one) IL Type of Building (check all that apply) Lot 7 T N; R_ F or w ❑ 1 or 2 Family Dwelling -Number of Bedrooms _ C 4 sit Subdivision ;v me A Block # C ❑ Public/Commercial - Describe Use 5 ✓baii H a( l?ovs~ ❑ cis ❑ State Owned - Describe Use CSM Number El Village of 0-gown tgunow of III. Type of it (Check only one box on line A Drop e e ]me if a [icabie A. PP ) ew Syste ❑ Replacement System ❑ Treatment/Holding, Tank Replacement Only ❑ Other Modification to Existing System (explain) R- ❑ Permit Renewal i ❑ Permit Revision Q Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner / / n A~r IV. Cam onent/Device: Check all that apply) 'on-Pressurizer] In-Ground Pressurized In-Ground ❑ At-Grade ❑ Mound 24 in. of suitable soil ❑ Mound < 241 n. £ ita I soil o mg an ` Other Dispersal Component (explain) El /r!!~ ^15 Pretreatment Device (e.~tpiain) [L( i V Drs rsaUTreatment Area Information. Design Flow (gpd Design Soil lication Flat, (gpdsf) Dispersal Requ ir (sf) Dispersal Area ropased (s Syste Elevati n VL Ta Info Capacity in Total # of `,-_Manuthcturer Gallons Gallons units 11 New• Tanks Existing Tanks 2 / E U , 1 Septic or olding Tank ` A y U C7 A. i Dosing Chamber ~V II. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POVffS shown on the attached plans. Plumber's N (Pei PI be ' Sign MP/MPRS Number Business Phone Number Plumber's Address {Street; City, State, Zip Cod C J . Coun /Department Use Onl ~proved Disa ed Perm, tj r rVl + Date Lcsued ~ Issuing Agent Si ire Owner Given Conditions of Approva easons for Disapproval U /Vl SYSTEIA OWNER' Nortk~n P~ -,b-e a e 1. Septic tank, effluent filter and sp~e-h :41 dispersal cell must be serviced l maintained as per management plan provided by plumber. .All t5tback requirements must be maintained asNc~ Y~ SdbtpiY r0 tBe County only un paper not ins than A ~n_ z 7 t i~Les in sin - i I Lot 1 t 777 Vile, I H~ r ~ PJ J I Yv~ r,14- M, 1,~c(?fz dlr. Lot s r rL 4.. x.. e y p m. *7 y ~ a 7 u u cy,. 1 i S l ti r' rs CONVIS ~ ZONAL ~~.r~POr~a:4i~ rE~~~~ INDEX AND 7T- Prujc ct iVame: K, E C yv ~j L-- Owner's Mamp: Own Owner's Adrjres,: q4 Lea l Descriptic il: r 1 f 6 i Tnwnship lh S t) County `,tibc'ivision Lot Number: P$rc819 ID \iumlyer: P 1 in' x' amd t je Page 2 _ T'lni: Plan l Page 3 _ 1`S't~lll alcfil'z PP-Q,6? f FtI+-,-,r 7'~'~CS II Page J _ Mair tona'n-aa., in orrnatiLxi Page es h4a n~~ r r 7 t i"' P1ri;t S?_ Gralx C,fi ;~ntiG -Bank ~air~t rta.rl'n'w Fond Page F Pagn 9 --a-M rs a Hol:ltye Plans, nesir~t~Pr/Y~'Iurt-ru er: Data Sign ~ti.rrr--. Uc'-sigr',ed Wursuant to the 5 ountl SrG .4bsci;ratial C:on ponnnt wian,a! ;nr F'QWTS %lorsion I o s,,n1)..907Ct5-P (N.Ot/tli). rage 7 i 1 Soil PVC ~Jept pipe Final Gmoe wool van, Gap Z-- ("h l_tt - °N i S fste..es~ tic?vrat{~n f-t f4 : . ' t vty;,k3er~ Trench _1 L tr - 4" Dia. r ©rase,, Pipe f •Tr.Inrh 2 H~ar#~r Trench 3 ManLeMrIuFerAno, Model F17A Rating ~ C) q =-t Pe; chamber Soi1-Application Rate ~7 Mari Design Flog ; ° ,"7 - 9AdisG ff - Soil ,1tapiicaition r2.,,Ite ^l~ Page csf i POWT• OWNER'S MANLi,AL MANAMENT PLAN FILiz INIMIRMATCta: i ~ s a l t i±l ~sl 1 NA C3tiN.iar ~Z )v% rv fi~S Soptio Tan1 sparaity :7t S L> Permit $eptltt Tank 11Ranafocit trar F Q NA t ( r~I NA p5st" 6f'ive,rt Rtsr tuterrteara^wrer P~ Number of ~0rvntr9 C3 NA Effluent Flttar glade[ NA - Ni!mhar of Put Ile Fola"Ilty i inltia T M NA Primp T°pnlc Capeolty fA Re'tlrx'tetetf'~itaW (a~rarat~ef rump Txmk Rllans>Ifat~wrar A (peak?, i i5ftatnd x 1.All A ur xp ~lenufaGtwr~r A 1 _4 isltrlttll a Frump {Vf>Mai lUlt, call Ap P,sCS _r " ~ Pr~t~estmart; unit f„t NA J StandArd Is;t'ltaantl~ffluent Duanty 11ri thly sauerF0n pata, 0ii & Qara"a ipiz'2I :80 mff/L fiend/ naval Fltkar 0 Pepd Rfiter ~/I (^7 NA ~1(v~sr~tY$nt~l AaraGidn ~t Vt1't~titend :9220 m F BiQahernool D. V9ap Demand (IRODs) 'I r~1 t teiel.si~I;1 t b Other. T ntai Suspended anilds (i figt , G NA month1v average ~tsF^er~at ~eiita} retrca~ad 6;`fiuan GWaliil y tIn~Aound (~rt#u[ay} In-arawrtd (peeaatcried) 61oz htern3nFi Ogygan DOMr11d (sold ~~Ct rrg& Gi gr~Crada iMl taawri+l m/!, 0 NA Total 6utependad 6np6s i1S} G3rip~i3tsa Gd17Gr: Fe al GviifoYx { p~srnetrics Mean'} A't'l9' afw/j' l7mi fA~ _pg- - r--- 4T4tir9r; Maximum Ellluettt Pat"41F1e 6ixe~ n1 llta, 1 ;A >M1 NA t~thsr; fS"~18r; Q NA othar. "~al~taa nlPiral yu~mnawia was Awgtar anti ipeptin ^,n lk at 1wArs , fiirrri i.ws... 1TiA9iit'l t #jr,,K VS;1«i? 3 )Ifte ~van# t r t t~ ftt3 ` (MAXIMUM, a va"a) t"3 NA Afi Ina at .^-noB a~aeY tr c 99 Q NA irnspsat oonat"zn al wankfel - - oJUhan romtrtnad shadpe arfu sawrrs s~uaia G"sa~~htt~l (}rat of tank VOi~ama out mantan'm of •tarrlctsb >tmp (M~~itkitat~ ~ v~sers4 E S NA l At ?Sag anca saatlf ill (sl tng ppaot tr p>Yt? i ceit(el _ y t i Yfi(} C3 NA ~At IF. s5l: W10e VWV'~ ve Clown 13ff3uent: filter Q sYYSothX NA• a3ar_tr ,lit IBast ensts WAVY: Inspac,, pLIM, az pjMP controls ,~5„ k ht l NA Flush lr.$rria avid 7,0"VfO 5a9 jet; tge$4 Dn ~rdry; Cw3 ~ 't + zltas, ' - - I AT iaext 2"s every; 4_. NA s C1Cd~ar: enam ar o rtt icy aR~. MA6~1't"~,Rft9.~6 inspeatsions Of TIR110 and disper l moils shall as r anti by an ladles uat (rli Ali itX ° Ap' Gt r. Tank i -Pttsr Piwt>;rY~ : 4~~i,zmw Plumber Flawlatad SaWAY. broken hardwarn inspaorh moat 3n of a nWri l irssfa6cp- end Lawn And v1 heck, fmr Any htaakgu; or ~ d ng of o~Yf svt en tilt gIrrawrid ewrfaae, The daro n the vel1na of arJ a VT ed . 3w vondtng the ti l++a faaa. The pWIng t ~tf eVIt t nn thm ground as rare may ndiaia e a nng o~ dR pn andaraquIras the The luen a ~f eft't~sant an ?rte gr+SanWritl ats~ tfr'C~ft? at:sthnrip. 'immodlau notit'tctatinn Of the local rahci avad sludgy S ®ga t 3Servicing pnrar 3 and 43 '~)spoled 4rt a eatdsrtoe 9th rah tr~r t~a113, 1N119ri the oomYainetl acrXarnutt3on or3tTCents Of ~;•~a ~csnk shell be rerr by retrr'atrrlgnt Wier-onain 15dminlArrathm Grtdn, All ether ,~e~~cl~s,v rc~u~~~g ~Brvaia oitrt~se~ morn'Me th~eshtal! ~a pPf affluent erforr~attfl~lf a oe~~Iad ft~lV~T Ni~m~a~rer~~~pnmerts: p la.~t9, and any ~~t ~ A 'wwftc vapor" shall lv' "prov"ded iR "h' tL7C.ni PCmmi'story r'utj1nrP;y 5pj1 k11S1 .t rl C1'Apri thf r~"rsrp rietfaYt in" ov wv%a avenry ' C?rv1U1 darn 11 epos ant Elxalu;wpy ulsuaa~lNi'1t~J 'fL)ba"'E5 Pue i J tf}'BtRJtIJfgJt2'}SZ"E~ u`wa~ se~deKo yy3rn eausryrtcuv~n ul a , + ~ ~ .►1 ' ~ aun4d Ry~3datp s~tan. auausnaap a:9.L OWelll \ •f C, suoWd .Ullat9H Lf]t l klgyV 7rivau la'oo S -41A QF atuRN tl dlFll d} $ICt1tt'k( 40 SNIOIAIgS 37t1'1djS aUegd - S I jq euo4d I 'Y auJa~q ~ li lMltl:CN"M S.1Mod w eiu0ly I~~~.iLl~lLMCtd 91NSR1VWC3O "It~1WCII1tC![lv d 3Cl s ~f ".LjnS4I# Avw H I.vaa 'SS~IN1f15JYl(l2OIiI~dAl~tV 03UNCII)JNVl .LNjkVJ.tt ~17d Mlo UO JiNfla of- as v kigmg iaN 0 " IdS ,.Xtai N i ldd l ,Ct I I INb MSSVS WNI,31 NIV.LNOD At/W SNNV.L JMtN.Lv3jdL u31410 ❑NV dWnd '011das g {lua~M~ ~ awry. 414 ze a ae~t~s u1 sa1nJ Q41 q~yn A1dUJQ0 ;sn;u &WaWs 4ons ~a suolaon»a0u02SH 'r,0.9;Jn8 GA R244 my;. 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