HomeMy WebLinkAbout040-1029-50-000 (2)
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
(ATTACH TO PERMIT) 597309
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:
MARK & DEBRA LOUGHNEY TOWN OF TROY 040-1029-50-000
CST BM Elev: Insp. BM `leev BM Descriptj*p ~ SectionrTown/Range/Map No:
4enlim 06.28.19.94E
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark ~ ~p der Qr ~ Q
j;iQ@ 140- 44, Qi .It. BM -rb 6..• ' Q c'•~ I ~•O I •9a
1 C t -0-4
Aeration d Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION SUHt Outlet
TANK TO P/L WELL BLDG. Vent to it In ke ROAD Dt Inlet
~t'
j n_ Bottom
Septic y / 56 6 5 DeC1c. / Dt{ 6 3.'7( ! ~ S• I
Header/Man.
De!'R1g _j I -7 ~
n
Aeration Dist. Pipe
Holding Bot. System f 3~
Final Grade
PUMP/SIPHON INFORMATION
Manufacturer Demand St Cov r` -
Al to - I e~ g
PM . S •ZO
Model Num
TDH Friction Loss ead TD Ft
Forcemain Length Dia. Dist. to Well
SOIL ABSORPTION YSTEM ? •7Z
BEDfTRENCH Width Length No. Of Trenches PIT ENSIGNS No. Of its Inside Dia. Liquid Depth
DIMENSIONS :3 2
SETBACK SYSTEM TO P/L BLDG 1 WELLLL9 LAKE/STREAM LEACHING Manufacturer
INFORMATION C~ CHAMBER OR~~i
Typ Of Syste IZ5 15to UNIT ,
R Mod tuber:
DISTRIBUTION SYSTEM l `7 -4-1 1 -~3 cJS
Header/Manifoll it Distribution C ix Hole Size x Hole Spacing Vent to Air Int ke J*j 9 Pips)~ P 9
Len th Dia Length Dia S acin
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth of Ixx Seeded/Sodded xx Mulched
Bed Trench Center ( • / Bed Trench Edges Topsoil \ Yes No Yes ~i No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspecti #1: Inspection
Location: 392 RED BRICK RD , "e, /t',s~-c,• ~ f
1.) Alt Description
2.) Bldg g sewer length
- amount of cover = } 32-6 *w,._ , !Z
Plan revision Required? [2, Yes IN I t
Use other side for additional information.
SBD-6710 (R.3197) Date Insepctor's nature Cert. No.
-AA I
c'V1.. cc r
uof~v~o~ D o my
~~E
Safety and Buildings Division cko,fx
201 W. Washington Ave., P.O. Box 7162
Y MAY, ry Permit Number (to be filled in by Co.)
533q 7-7,162
Q Z J I! Madsrt, 53
16
5 9 13Oc~
,^,OMMUN i"CI'I3 h _ State'Ftansaction Number
In accordance with SPS 3831(2), Wis. Adm. Code, submission of this form to the app) up,...._ ~ unit
is required prior to obtaining a sanitary petnlfL Mote: Application forms for state-owned POWTS are submitted 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 with the Privacy Law, s. 15.04(1 (m), Stats. / -,1p7_ 12a &el_
L Application Information - Please Print All Information f
Property Owner's Name } parcel #
uk~ KA GvU Yl 6 b-1b~q Gvc
Property Owners Mailing Address Property Lot,ation
3
IL c. Govt Lot
City, State Zip Code i Phone Number
bcS L 5 S S F_ V., Section
(circle one)
T N; R F or W
IL Type of Building (check all that apply) / LC:~
❑ I or 2 Family Dwelling - Number of Bedrooms ! Subdivision Naamm~e
~Gl i a U
❑ Public/Commercial -Describe Use 4 [J2 . BlS~ ► " ,
❑ City of
❑ State Owned - Describe Use CSM Numberr, ❑ villagge of
t GtiJ )-7+-1-7 A-AL TXTown of
I.H. Type of Permit: (Check only one b on line A. Complete line B if applicable)
r4.
-
El New System LkReplacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain)
G
g ❑ Permit Renewal i ❑ Permit Revision ❑ Change of Plumber ❑ Pemut Transfer to New List Previous Permit Number and Date Issued
Before Expiration Otvner 5 / 9 _3
TV. T e of POWTS System/Component/Device: Check all that apply)
Iclon-Pressurized ht-Ground 11 Pressurized In-Ground ❑ At-Gradc El Mound ? 24 in- of suitable soil El Mound = 24 in. of suitable soilr t
❑ I loading Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) sy
V. Ds ersaUTre eat Area xuformation:
Design FI(to~w (gpd) Design Soi] Application Rate(gpdsf) Dispersal Area Required (si) -7
Dispersal Area Proposed (s System Elev ``oea
~a 1
VL "Tank Info Capacity in Total 4 of Manufacturer
»s Gallons Units o
i Nety Taai:s Existing Tanks n 1 ~ ~ ~ ~ U V
W 0 a a` rn in w c7 A.
f Septic or Holding Tank A
Dosing Chamber - V ) e h
VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print) P1 Signatu' MP/MPRS Number Business Phone Number
rY\ -M--,ZAA,4K D
Plumber's Address (Street, Ci . State, Zip Code)
VUI. Coun /Ae artment Ilse [
Approved I rsappro Permit Fee Dat h: Issuing bent Signatu
Ownes (:ivett' eason for ~7 ' I / ) 7
IX. CondilfMstisl'$
i A,rjllkta"easons for Disapproval
i °,>:>5sptiz't8rk, ~i'14ucn: filter t~ilii' ,
o's0eP,.s, cell mast all be s,~ cn!_lz!ri-ee(
"per,'?taragement plan p!c, 4aer1 by piumbe;.
l 2. "Akil~*fWAaG+°.t:IOM5 Mubt pe m'amtc il,'E I
So pw 7W110WS cod.- / ,:rdittil,V 1,
Attach to mmp)etc plans for the system and submit to the County onto an paper not Jess than 8 rn_ x 7 t inches in size
SBD-6394 (R_ 1 I/ 11)
3 T)
t
41- r7
All
IYil f,",
w E iv~~ r
f
Ac J c o p i6
r
C "ON' VEN T !ONAL ifCJ'I'1/('PONENT DESIGN
keESidPtitia! ,~jaialir.,~tinn
INDEX AND TITLE PAGE
Name.
LQ4Cw,eis Namt~: . ~ ~
DNnrrac:•r's narlr-ess
Legt'l1 Drsrilptior: ` /
Township I t< 0
~~JCG~iV1alOr v C
~ierYir3:
Loo Number:
i' rrrai ID Nurrii~Pr: d.._
Nip 1 1nci1 d °sru~nd "itle
P -.1g"
PagP 3 ,.3yS L'n7 i i Cro :s-~. ctid4 n
pac,P n__ F'i Wr ST P ~s
'e 5 -i:rttfA!1'~`!? lrt;(srrnli~}~a
Pan•P ci _nar~tl:s~rP7it Pig n ~
_ '~y ' L ' ~nl< Ill i^~C n. x1r Ftarf t
page 8
Pt~c± g ~_Delczd
m err P!Pt
~rUht'npY1~:;:::ni1 T~~i I-ic7t,,;~r• ~'Ir.~~i:4r
n,~,~ignPr/1=~'ItrrS-r~Fr:
Date: ` ~ Q Lii: 17:s Num~b~?r;
J I
S rg n;~ tt.r re
r]rtgigned raursuan; to ;h
Ir `around Sof! Absorption Conipenent m8ou"! fn; PL)WTS Version O S n.107f)5 P Or/D1j.
raag! i
I
I
1
I
MAP
T114. M.
k~ Bra, 0 .
Low S nwk e{ a3
a
ri 'A lie
All 0 0-
41 o rn-~
0
(~la f i
SON Absoi• ~fifS~*H~ .fib ~9
4" 8a,1jccj(fjL. 4D Of
I Y PW vant PFpe ' Final Cirsop
With Vent cep
c~
Chamber
~jt
ik_ is SY:,tales►1~~tit~n
fi
SLR ~~a~~5';r4'~;~~~R 5•'~~~~5'6 ~~f ,ti°
v►.c~
3
Tranci
lfer►i e Ohservation Pipe !-iF Ct i
Trench ;i
nuf?-vtfihO~r And Model f
~
RSA
Rating _ O sr Pe;
chasri&.)er SoilAPPlica#►on Rate
-9.0d Design Flcm 2
Soil r pplir-ation R7t 14
Chambet-s
rom IS
page cif
Technical Specifications
PL-525 EFFLUENT FILTER (COMMERC/ L)
61rak! C9ECK - _-------1
-EX PTS 6'SV r
-ON
lI i , FOR IN, ET EXIEII➢A.N •l 57 1135
JUREi aUSNINGEXLEPTS
S:J14J 8 o SCH 40 B J 1
II~ ' ' ~Iv~ ' _ _ 10.68
~J 1 r ~ 'f
~ . I.
'l I . 5,23
3302
1 ) - 1934
PL•525FILTER HOUSING
PART NO.-30142525 T' ~ i`• I ~
MATERIAL _1 y
HOUSING - POLYPROPYLENE
OUTLET BUSHING - PVC
6.5 BALL -HDPE
--SOOC-T EXCEPTS FLOAT SWTCI i -
Ioz3
WWI
40
,-~FCN IAN%E E%TEN➢GA tOdl
7+
--53POF tt!6'SLOTS
j ~ ~ t_.--847 9 56
SOCKJEXCEPTS _ 604
21 t BALL PUSH RDJ r'- OPENING
3 ~ ~ I ~ Tt IC~r
ri
® ~ I j ~ II I I ~I I
I
~ I -'~I j l II
I i
g - 6°EltNG
X7' I,
1 L i
~ I ~ ~ I r ~ jOf I of
- :I 19f02 12244 I I
ti
POLYLOK PL-525 FILTER CARTRIDGE ' I
i
PARTNO. - W41.525
MATERIAL-POLYPROPYLENE I
,11OWT Cwr`'f'd `kER"S MANUAL & MA7.71A MT..dHAENT MAN
1~t3 1PeI=91U9Pt:fci SYS 4mvptY~i?I!t
Otnr:iar M~j YLX f D~~ Lc wG, ataptb an-P, wapa*lty 0 NA
Permit -~aptt ink tJtanwttxwra✓ W I NA
C'ESION mAtiVin- S WItytnt RRItar -M-vn of Wrer O rl mNA,
f\lutnber of dreo,.,s j 13 iv, fffluant Fitter Model ~ 1 a ~ r"4 NIA
NLimfaer Of Pvhilc Ppnliaty ls.:fta G NA Primp T'pnk Capsolty PEA
szim tee Vow (atrarage) _ allds_y Pump Tank MrvAtRawrtrt NA
resign 1100 [peak), O'.stimetnd x 1.') I h alldtt Pump Manufacturer CIA
S G1 iUA
A-0 ma a Frump made!
a pl1 Appall Cf+itl f'.aC
trtreatmetat ~Inirc !"1 NA
S*sntlsr~f InfltsontlEfiluent O,Ls01W Monthly avPmS
p ~ata, OIf & Caro"a tiwU) 00 MAIL C1 ~~t7di~raval Piiter n PaA4 Flitsr
8140hemids] oxygen Demsnd (!RODS) 420 mg/l Q CIA. 0 Mechist7t"1 Aeratlon 01NVIPO
{
Soilds 1 h ~5, _
Total Suspends 9160 r,ig&,
lttionthiv avaraga i'iapar&al cell(3) 0 NA
1?r vo.M ~Afittafl CuJe)ity I tN ln~Cround {gravity} CI In«Craund lprsssUri )
~iash~emicai luy~gan tr> iEnd monz.{ ,e *0 rq&
l 42-C) rttgIL 0 NA 0 AT-rArsda U WON
l' Total uapendad 9 liar (SSA) Drip«i3nt~ Ut Gtlirr:
Fee?ai Colfae: (e~srnavia rrra>~n --1 t " nfW17 Gl 1m1 - 01 fA4
- DIMAr:
i---'-- - in Via. Q ;~A
um Sftiuent Par'~icl S17 in 4-1a, Q NA
-'IM
i "r3thar;
> raA_.~ M C NA
fstrrar;
OualtSas al Wr dcmSeft INt ntgwatar 20 atptln °Bttis 8 Xlu6i ia-
vP;"
- LlarY .
~fAr9i14'Cl~ttl~['~~~ 5r,,,.KfKL7tS,L,2
9 n:1ce ~erlk a Pn NOW years) n NA
At, Imaat w 1as svgr rt ar
l lnepatvk artndttfian csf tankis) -------T^-°-
_ iNhen cr mhlned s 4914 ar'4 arum 6919t rrt wtPtirrl 1%) d tar€ Oi~?ma NA
► is r S yews} 0 NA
pumt5 attt c ntertt>a of tarrkia} - 111} (Mal
- -m-- -
{ At. leaak csnca sustY ar{sl .
apect diafr"' at rmll(s) 9 "ip l6Yiii 1 0 CIA,
Clean affluent filter a~ feast: ul1>,a nvan~: r~ « ~ .far s} A
Inspect pwtruz pumo controls & alarm At laast eneais COveYys v NA
At Nast once every;
F1 ash latarrls and p°amtJre ,.eat r h- - NA
AT. 1899t, mn~aa every; 0 ,w*
M NA
l1F(Aiti2T t 44i•Ci $T1S"1'ig mmtddilt'` p .~41Yt Op war. ttil. Tank
ri ted Wa made la TSnins 8v1CtY1'2I POWT`S [ Sr 1fS i; i * A 4 ~p fir. ons;,
inap~Gtions of taccls gnd d)sper t colt
i~.aater Plumber: Mavv P1,2M er RnAtricta., ~et:vax, P~ItAI p eaf~sr
inspeatfona must irkcluda s vlauel inapsetian of the 4arikis! to ir.Ianpliu ant! mtdno air broken hardwetro, ideritify any rr wetalas or p teaks,
~i aks,
.~Saaura the vclumo of mr imbn4d slwdga anei ga .ti r~ anti tra aheckr. fear any bsQk up Ar }~r nj jng of ol`lft snt on tht ground surfsde„ Ohtmk
any
ior
ftg The dispersal the gahali be fjss, T'he aonVngtc~f aflw n t nnfithn groutrd surface may ndlizate a fafl(ang o~ dW n and requires the
effiuant on tkt ground awCFac iatory awtl7nrity.
,rnmttralats r~rt~ifloatnn nl -the i~cel m >;r mare ( nun the ommOned ad sca>talx:uitrrpi sludge anO &ourrj 11)
ally Unk
Sad 0 In coo darto milth oh ptw NRa913,
Oparmor) acid ~thlrd
crsntants of ~f t:~ra tank shall Da ~rrta recl by .9 SaPaga
Wiscanaln ~.4~tY1ir11AtrA~iaB Cndt`.
All other santloss, irinlu Oing Wt 131~'~ liMOO V) 8 Ser icingsaof aftluent fe filters, a M}ch-2 S'~G'~T pfc~alnMa ~arr-Omprr~t~>m, faratraa5ment
r.~ri2a arci artyEYvirirtra at l7tarvsi af !fl 2'
w r7ln~ rnport sl~a Pe rrcwi od to ^,hn, inra, re~tf~tia~:c~ry 9+sthnrl:U tin!iti~is~ '1 ra ti~t3vq e, crsrrtpl'ptisf~ t', ffw. S~19 sa?2
A ~n-gut t~t:)nv)