HomeMy WebLinkAbout022-1048-40-100 (2)
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No: _
State Plan ID No: ~1731 a
GENERAL INFORMATION (ATTACH TO PERMIT)
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.D4 (1)(m)].
Permit Holder's Name: City Village Tnwnchin Parcel Tax No:
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic ` Benchmark
f U 0..
Dosing Alt BM
Aeration Bldg. Sewer
Holding St/Ht Inlet
St/Ht Outlet
TANK SETBACK INFORMATION v 17, `C5
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dtr Inlet,
Septic Dt Bottom )
Dosing _ [*acler/Man.
Aeration Dist Pipe ) I n , /
Holding BpL,System
Final Grade
PUMP/SIPHON INFORMATION
Manufacturer Demand St Cpver r) J >
GPM ~i.~ } F- ,,SOUL
Model Numfarer
TDH L4t Friction Loss System Head TDH Ft
Forcemain ength_ I Dia. Dist. to well
SOIL ABSORPTION SYSTEM
BEDlTRENCH Width, Length- No. Of Trenches PIT"MIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer.
INFORMATION CHAMBER OR
Type Of System _l UNIT Model Number:
DISTRIBUTION SYSTEM
Header/Manifold isttjor~ ( Ix Hole Size x Hole Spacing Vent to Air Intake
Length Dia " ength Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over jxx Depth of jxx Seeded/Sodded r Mulched
Bed/Trench Center Bed/Trench Edges\ Topsoil Yes D No 0 Yes No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location
1.) Alt BM Description
2.) Bldg sewer length
it
- amount of cover = j ( $
Plan revision Required? Yes E] No ] ; f✓ r9
LA -
Use other side for additional information.
Date I n s e _pctor's Signa ur Cert. No.
SBD-6710 (R.3/97)
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yrv - Q01? OTT-
Safety and Buildings Division County St.CrOIX
RECEIVES
D rryy Nil 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.)
S P S APR 2.7 Madison, W l53707-7162
S~y73/z
-►-~:4~ ~ ouc couNrY
tiOMMUNf State Transaction Number
In accordance with SPS 383.21(2), Wis. Adm. Code, submission of ,nit k
is required prior to obtaining a sanitary permit. Note: Application forms for s-_ Project Address (if different than mailing address) the Department Safety and Professional
. 1s. Personal information you provide may
purposes in accordance with the Privacy Law, w, s s. 15.04(1)(m), Stats. //G/.d1(f
1. Application Information - Please Pr' II Information
Property Owner's Name Parcel #
Morgan Barnum Adam Folk 022-1048-40-100
Property Owner's Mailing Address Property Location RLOB
367 Liberty Rd. Govt. Lot
City, State Zip Code Phone Number SE NE 17
Section
River Falls Wi. T 28 N, R 18(eirelEoor V
IL Type of Building (check all that apply) Lot #
R 1 or 2 Family Dwelling - Number of Bedrooms Subdivision Name
Block # -I-
0 Public/Commercial - Describe Use
❑ City of
❑ State Owned - Describe Use CSM Number ❑ Village of
1(J J. G~i~/f J c.1V~. [I Town of__ _ nicki~`~nnic
144U16 AN III. Type of Per it: (Check only on box on line A. Com ete 1' e B if applicable)
A.
❑ New System ❑ Replacement System D(Treatment/lIolding Tank Replace me t Only Other Modification to Existing System (explain)
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber El Permit Transf er to New List Previous Permit Number and ate sued
Before Expiration Owner 233448 (r 7 9 S
IV. Type of POWTS System/Component/Device: (Check all that a I )
❑ 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) ❑ Pretreatment Device (explain)__ _
V. Dis ersaVI'reatment Area Information:
Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation
VI. Tank Info Capacity in Total # of Manufacturer
Gallons Gallons Units to .2
New Tanks Existing Tanks p
Q 5z ` 'o a~
.5 0. U
W Y'~ f e
Septic or Holding Tank 320 Weser X
Dosing Chamber
VII. Responsibility Statement- I, the undersigned, assn a respo 'bili Installation of 'e POWTS shown on the attached plans.
Plumber's Name (Print) Plu r' Sigma MP/MPRS Number Business Phone Number
Keith Knudtson `llhle~ t648443 651-470-1737
Plumber's Address (Street, City, State, Zip Code)
927 150th St. Roberts W. 54023 A /7
VIII. oun /Lle artment Use Only
Approved ❑ Permit Fee Date Issue Issuing nt Signature
15 Own even Reason or Denial $ ZS lb ' °D -d / 7
IX. Condi"ITM easons for Disapproval \
1. Sept~o tank, er'tl;~t Iilts~ rt i d( c o r 6J y1A
tii~spewsu cell -t it jll be is s I 1111Z ,t~'-ec 3)
1 5
isiper Irtar hement pl4n p o naeh try Nlumbe:. ct-ip J
2. `Aj:ilelkylticrWWv*tpen.'9 M141A w; i,~,wrt,
as por fppkriblls cork / 9.PttirlA.' mi.
Attach to complete plans for the system and submit to the County only on paper not less than 8 112 x 11 inches in size
SBD-6398 (R. HA 1)
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KNUDTSI)N PLUMEINO D'z
C,O[9 TRA' CTING, LLC
927150TH ST. 648447MPRS
ROBERTS, WI 54023-8526
CELL 651-470-1737 _
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CONTRACTIN3, L L 0
927150TH ST. 648447MPRS
ROBERTS, W! 54023-8526
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CELL 651-470-1-437
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927 150TH ST. 648447WiPRS
ROBERTS, WI 54023-8526
CELL 651-47Q}1737
71
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ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
0-wner/Buyer
Mailing Address
Property Address
(Verification required from Planning & Zoning Department for new construction.)
City/State T\V = of t ~Parcel Identification Number 5 Z Z ~j 2 - Ll G - 1 y CV
LEGAL DESCRIPTION
Property Location S~ 1/4 , mil L 1/4 , Sec. , T Z N R i Town of I°~ t y'1 C1 C VV)
Subdivision Plat: i , Lot #
Certified Survey Map , Volume , Page #
Warranty Deed .7 (before 2007)Volume , Page #
Spec house ❑ yes ❑ no Lot lines identifiable ❑ yes ❑ no
SYSTEM MAINTENANCE AND OWIfTER CERTIFICATION
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper
maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. 'That you put into
the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance
responsibilities are specified in §SPS. 383.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance.
The property owner agrees to submit to St Croix County Planning & Zoning Department a certification form, signed by the
owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site
wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is
less than 1/3 full of sludge.
Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the
standards set forth, herein, as set by the Department of Safety And Professional Services and the Department of Natural Resources,
State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix
County Planning & Zoning Department within 30 days of the three year expiration date.
I/we certify that all statements on this form are true to the best of my/our knowledge. Uwe am/are the owner(s) of the
property described above, by virtue of a warranty deed recorded in Re ' r of _ ends Office.
Number of be #ooms
Z71
SIGNATURE OF APPLICANT(S) DATE
***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department
Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if
reference is made in the warranty deed
(REV. 04/12)
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