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HomeMy WebLinkAbout020-1485-06-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. CfOIX Safety and Building Division INSPECTION REPORT Sanitary Permit No: GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: 597338 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 020-1485-06-000 CST BM Elev: In BM Elev: BM Description: Section/Town/Range/Map No 21.29.19.3081 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER j CAPACITY STATION BS HI FS ELEV. ~1 S Septic y Bench rr ,1 l O ~a Sitk~ Alt. BM 5- 00 Aeration Bldg. Sewer Holding St/Ht Inlet ct- TANK SETBACK INFORMATION St/Ht Outlet 11 TANK TO P/L WELL BLDG- V nt to Air Intake ROAD D Inlet 1 Septic / t I Dt Bottom Dows_, „ ✓ Header/Man. Aerati., - ~ Dist. Pipe q ` Holdin 8 Bot. System 10, PUMP/SIPHON INFORMATION Final Grade .71, .??9-5- Manufacturer Demand St Cover GPM -1:V4kCA Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM wQl BED/TRENCH Width Length t No. Of Trenches r IT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS zl SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufac r: INFORMATION Type Of System: Ir CHAMBER OR 7fcr~' ~ +~j{' ( UNIT Mo / eG~U Cm~-tx~~.~l l.x-. DISTRIBUTION SYSTEM y~ Header/Manifold Distribution / x Hole Size Ix Hole Spacing Veto Air Intake Length ~ Dia Li L/ Spacing t U pipe(s) / / J SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of r77eded/S ded xx Mul ed Bed/Trench Center Bed/Trench Edges Topsoil 5• ~ Yes [I No j Yes ~ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 847 CEDARBER..R~Y C1 ,TL r 1.) Alt BM Description = I1.3 2.) Bldg sewer length = * 3-9 - amount of cover 141 Plan revision Required? Yes E] No q f Use other side for additional information. i~ Da Cert. No. SBD-6710 (R.3/97) 01 L , ~V~ ~ ® County if V ■ Safe and Buildings Division k(~ ; 201 W. Nlashin n Ave., P.O. Box 7162 p~~ I Sanitary Permit Number (to be filled in by Co.) 1 53707-7762 p~ 111~~, va /a~y(J '~rSrQNwt C~ ~uNrr ^ AMUN ermit Applictiu State Transacting N umber In ace accordance dv SPS 383.21(2), Wis. Adm. Code, submission of this form to the apt y r is required prior to obtaining a sanitary pemtfL Note: Application forms for state-owned t ernmental bmitted to unit project Address (t f different bran mailing address) the Deparirnent of Safety and Professional Servies. Personal information you provide may b. and U oses in accordance with the Privacy Law, s. 15.04(1)(m), Stats. L Application Information - Please Print All Information Y G~~i~tt (Z~~~) Properly Owner's Name Parcel 5 Property Owtrers Mailing Address `s a V O V `I Q ~ v1 ~ ~ 'Z Property Location Cry State (o Code Govt- Lot i ~ A Phone Number ~1 U ~7 is F i S \(~'~1 J N k, Section a 7 f T 1 Q (circle one) Building (check all that aPPIY) Lot # °l f N; R 1 For W IL Type of N I or 2 Family Dwelling - Number of Bedrooms Subdivision T~Tame % t3 cue f,ti. O Block # C ~101~ p 4 ❑ Public/Commercial - Describe Use ❑ City of ❑ State Owned - Describe Use CSM Number ❑ Village of Z VL G _ t? Town of r~L'C.r. G r • - III. Type of Permit: (Check o ly one box on line A. Complete line B if applicable) ;ZD A. 5-New System I C Replacement System D Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) R. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New I List Previous Permit Number and Daze Issued Before Expiration Owner fV. T of POWTS S stem/Com onent/Device: Check all that apply) Von-Pressurized In-Ground 11 Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil 0 Mound = 24 in. of suitable soil e~"1 EJ Hoidi Tani. 0 Other Dispersal Component (exptam)❑ Pretreatment Device (explain) V. Dis rsal/Treatment Area Information: Design Flow (gpd) Design Soil Application Rat Dispersal Area Required (sf) Dispersal Area Proposed; sl? System Elevation 0 9.5 j VL Tank Into Capacity in 1 14 Total # of Manufacturer Gallons Gallons Units New Tans l Existing Tanks 13 O -7 a U $ ~ . 3 L,-.f I a v rn ir. c7 a. Septic or Holding Tank 1 ~ y~ ,DosingChambcr l - ds,~ VII. Responsibility statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) PI er Sign MP/MPRS Number Business Phone Number lYh 0klN\0,~ Plumber's Address (Street, City . State, Zip Code) VIII Coun /De nrtme Llse Onl Permit Fee Approved ❑ pprav_ $ G Date Issuedt Issuing gent Sigma ire O Gwriar Given Reasun for Denial i'GV 7 M Cond- jjj~ ~Vvow eas foriiy;ietDisapproval` f,°ep,tEtlldliif~'~~ cAi - - Intl Ocwew Off'/ E ~v~ ar✓~Q-b 1speF: tarty ritrtd ec: by _,L;Iribe~. 2. `A` c m Ue MaLrl& ,r.cd r` r /r„Yd/ NVrl.T7v~'t li '(1kti.t.~ 21~ L! QGf'''. Attach to complete plans for We SVSLCnI and . ii to the/County on! Y an paper not r¢ss than s ua s ] t inch in sirs SBD-6398 (R_ I 1/II) mte- ~Ge~s►~ G AII~e~ 3 v, J, I' s F <Yc, av ~ ~ r T I r4 I Alt l co 1 14 .J ;'FF i f r t I st, ltv nOpiV N OIN lrtx ~E'•-~ICiCfltt~) ~'t71Jii(;rlf)l7t INDEX AND TITLE PACE Ownar's Owner's Ad L00c'1I T: ~ ~ Tawnshii, -ounty_ Sk . C ~_fk ;'i,!(7dIlliil:7n Loi Number ~ i i'„lr'rrl 1C~ 1iut~tk~r~r: } -sue: ~ ~..=~1_•Lsz;L.: ~~?f~ C>~~ Pad ! 1rlcr'~ncl tifile P-OS t'In't Ian _ or"Ol", Plan P'. % 5%- CrOIX 5L'tIG T3n~ It ~1{rl jb~'n.c7: w ale Form, MY D F)l De it(ilrai7'("ILtr-pt"er: j _ ~I1rJn'f Ml,jr1 ber na r.rrr:. Clresirlred J~ursuant ko thr: Ir,-(a;~u Soft x~bsarntian Component ~Jl16r8J .n; F'C1WTS Vrrsior~ 2.O ap[l_9D'7Lil5~t~~(>•1.0~1/E11}. f ;:cqe 7 f i Akme. s TI'm''abal 4, iR. e s4tr y ; • a 31Y rve 1~ t 1301 ~2t tv C ~ ► 6 3 j y 4 'Pub L _ i fi I ~ PVC vent pipe la, Q3ra F F7Vitl1 1/~li Cap ~Il2,FYtE7~; 1 i 1.111M fir < I LGachifig Trench 17- H s ds_ `VF'ni ~c ©i~sO,v~s#icn E'i~ Tranch 2 -Ieatief' f CIA 3 Man ufac"tt Rating sr~ ~ t s Per -h.ar" be; Scil lic~a#lctr! Rate gPd Deaign t=lm - , .7 o gpd/sq ft S it Apr3[icrZ#iort Rite ~ r ff I fIL5I»PORMATION SYSTIR ply PIt$~ii'I t~avar fi N Pv p:5 S~ptlo Tank Cerw;mfty So gal NA (serr-sit saptla Tank Manwfaawrar W'i c5kk Q NA Efl'icre. l {ter{~1'srt~tf RSdW7sr o' 0 NA Number of fl;acl som-,; l 0 NA I-Ufluom Fi{tsr Model n=t NA Number of PLIN- It, PacMN Unlis ~ M NA Rump T rink Capaolty NA UtImetad '{tow (avdra* i 4 ~ C? g" d Pump Txmk M$nwfar wrar NA design flow (taaek), {~stlrr)att3d x t.1) Q la sildu P. mp MantafRotwrar NA zz Pump {lRr~ttal NA allay Brill Apls!!t}~tri !'aGar~ lrs1 aa~man, 4tni - NA 5tsndarri ic~fits~sni<~~~luant O,tealitir 1Urrxhigr iaueraoa ata, oil & Gresee {F X0{3 crisp" 0 snd/caravel Pllter n Pei,: f itAr ~Ct) G~ ~'Gl~nd F~1Qdhem'iraat ~3xv9Rn l~eand {~~1~C~n) :9220 rnq1i'- 0 NA C3 MochvI t rAeratlort ~/V' p t~~ltar" _ 'lSt Yrtg1G !a l9sk)n°s;tora ¢ i ntat Susparde I'se) (°ls~~$r at eitts} 0 NA I r~*LrERwf3~I E~liient CltQiY manthiv average 410 tx / ic~lt~rnund {grawfey} L"1 In-Cra~tsryd riPrse~urt~edl fnaherniaet Cs~.v en bxrn~snrl {Epps) i i~ Ax~Carsda a Mbar k '1 o?* suspondad E~riidS IT SS} 4~4 ittgll, 0 ILIA i~ i irip-i"inta i»t Othtarr Food WI t"`YkYk Wofftni9tilc m &Bn; C7~ti~i't Maximum Iuant Partirle Slars n tzar; tVA f~thart Q NA CrtiS9T, *%Jatt a" typ3ral 4+Hr dwmastta ktiantswataY stt i s9pcln °Ank e` latorti~. i+n~ulM'I'-itjiYtl>u1:5{~i L?ib,LE ~!$it1i~'9'.ttK~Yri►.. . e> 'r3n Erraskf p It i'~'$ gl ad " yrse b M NA insiaert andC4tan of wank{e! Afi ioa WnaB atIgr/,p aaurtt sr uala a rew~Ftiir l i!)st of to k vofwn►'a i=l tdA T-i ~1Uitan cescntzlned stttdga srrd pump cart" r.ntgntn of tankltx) , _ - _ .{e} (Nti►~ttsttrs ors) t NA At, laeax csnra everyl xr sl tnepsat d;eparset aetl{s) I i rtia~~lif4} Q NA At tt9s8t: tsl~><t~! 8J&CtifR i a Claan affluent filter ithl~ RA xsla pw~P G At fiar7t entaI4 RYAN: f yt5iy, (scontrols 8~ afaTm rtiYi ►{a1 NA. - - d s ra seai At lmast OFlce avBrI/, Flush (at erata anrra Y{lei q rfitt,Tr III (IV NA UtlSas: As. t88g Onza avary> - D NA Ciedlar: { aMAIR MA-1 GE ti'r1S' RIXTIDN'S ;,spatrrzians of tertka and diparl cons s"tett be mads lay an inelvidtrai wrryt_mg Ona 01 ho 1CYR~).iri p ppe~ti rC2i Seim vaster (~iwrrtfaat: f~h83u8T °lr~ftlk7$!" 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