HomeMy WebLinkAbout020-1221-50-000 (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. SAN-2017-146
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:
LORA COBB TOWN OF HUDSON 020-1221-50-000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
17.29.19.1226
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing Alt. BM
a ~
Aeration A, N, 7", Bldg. Sewer
Holding St/Ht Inlet
St/Ht Outlet
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic Dt Bottom
Dosing Header/Man.
Aeration Dist. Pipe L e~
Holding Bot. System!
Final Grade
PUMP/SIPHON INFORMATION
Manufacturer Demand St Cover
G~
Model Number
TDH, Lift Friction Loss System Head TDH Ft
Forcemain Length Dia. Dist. to well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS
SETBACK SYSTEM TO P/ BLDG WELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR
Type 17FSystem: UNIT Model Number:
DISTRIBUTION SYSTEM r;.
0
Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake
Pipe(s)
Length Dia Length Dia Spacing //A/ ;
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only ( ,j% ' ^ d=~
Depth Ove Depth Over xx Depth of Seeded/Sodded xx Mulched
Bed/Trenchenter Bed/Trench Edges Topsoil 7 ❑ Yes No ❑ Yes 1-1 No
COMMENTS: (Include code discrepencies, persons present etc.) Inspection #1: Inspection #2:
c ~ r
Location: 932 WERT RD rte t , I~t I~~J Wi_ ` 1•-
p
V r,
1.) Alt BM Description ,ti I b
- FF
2.) Bldg sewer length
t✓ u~ n t" V_(
- amount of cover = J) ~((t.
Plan revision Required? ❑ Yes
Use other side for additional informati o 7)2
SBD-6710 (R.3/97) Date epctor's Signature Cert. No.
y
J
q County Sanitary Permit Application ST. CROIX COUNTY WISCONSIN
jr, accord with Chapert 12 St. Croix ount Sanitary Ordinance PLANNING & ZONING DEPARTMENT
10 ~ ~Q Fe,sona; iniomation you provide rn '5e us for ~ condayy wposes, ST. CRO[X COJN~ GOVERNMENT CENT=R
t• OPMEN~ 1101 Carmichael Road
3 E) VE I Hudao-;. wl 54015-T710
✓M~ i (7" 3)330 4080 P3 5;386-4586
Attach complete pians for the system on oaoei x 1 i inches in size.
County Sanitary Permit # ❑ Check;' revision to previous application
5q-Au -Zo i7- I
i. Application Information - Please Print all Information Location:
Prope,,y0wnVr Name
1/45-- 1i^ See
Q_ A 7 N, R~ (or) W
i
Property Owner's Mailing Address Lo Nun-43¢j Biock Number
A --7
y Zp Code State Phone Numer ogu3 or CSI M tuber
'K
II Type of Building: (check one) D~,fy ❑ Viliage X7 own of
r^
❑ o _ Family Dwelling - Nc o` Bedrooms:
❑ P;15id(:;onr ercai (describe use)
L-1 State-owned Nearest Road
[B) ype of Per it. 'Check -niy 1e box line A. Check box on line B if aophcab'=)
Q- , Parcel Tax .Number(s
A, Repair 2. R dnnecuon `No plum Ding` ~eju"Der `ion G . 'j O 00
r - Sanitation
Permit Number Date Issued
State Sanitar Perrnit was previously issued t 7
iV. Type of POWT System: (Check all that apply)
Nc~- aressurizec in-around ❑ Viiouric _ 24 in sr,itable soil ❑ Mound 24 in. suitable soil ❑ tJiouna F,=O
San-- Pilfer Constructed Wetland ❑ Feat =ilter ❑ Drip Line
Pressurized In-gro!nd ❑ Holding Tank ❑ Single Pass ❑ Other
Ai-grade Aerobic Treatment ~Jnit ❑ Recircuiailno
V. DispersahTreatment Area Information: 8; U" `
1_ Design Row (gpc 2 Dispersal Area 3. t ispersai E 4 Soil Application Rate 5. Percolation Rate o. Sysier Elevazion Final Grade
equ{fired Proposed (Gas./day/sc.-ID (Min./inch) Elevation
b
VI. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- ?lastic
New Existing Gallons Tanks Concrete strutted glass
Tanks Tanks
n
VII, Responsibility Statement
the undersignea, assume responsibility for repairirecon^enction;r~juvenationiinslallation of non-piumbing for the POVdTS shown on the attachad pians. P.
license is not required for terra6% repair or the installation of non-plumbing sanitation. system-
Plurnbers Name (print) Plumber's Sionature (no stamps) MP/P,APRS No. [Business Phone Number
Lz- ,RLYF NFcW41"E L~ o Y `emu 2Z?-7l v -7r S- 7Y - 3z Z
Piur=ibe-'s Address (Street. City, State, Zip Code)
Ede R ca:,`
Vill. County Use Only
j Disappra~d Sanitary Pe m~r Fes to iss ed issui, Agent Si at (Nc s mps)
1 Approved QYVn~r IVeri Initial Adverse . 0c)
j! ~ cJ VV !l
;eterminailpn
lX. Conditions of Approval !Reasons for Disapproval:
i
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER n
ADDRESS__
SUBDIVISION LOT
v
SECTION T N_R W, Town of ST. CROIX COUNTY, WISCONSIN
PLAN IEW
SHOW EVERYTHING WIT N 00 FEET OF SYSTEM
- 1 Id i) 1 Ch'I'1: iJUK'1'?i T, l: ]lc)1.'
Provide setback and elevation information on rovet-se of this form.
Provide 2 dimensions to canter of se[)t ic- triril. m<3nlic~lc> ~c't _
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER__(4n(3 ADDRESS-
-H AJ&ZO
SUBDIVISION / CSM#_ t'Ar-f`'~ V 1-~1 Q Lp,I,
SECTION T N-R W, Town of ST. CROIX COUNTY, WISCONSIN
PLAN IEW
SHOW EVERYTHING WIT N 00 FEET OF SYSTEM
' M
~ Q
I N [)I CAT}: ~JOIZ ~'}iA1:}tUh'
Provide setback and elevation information on r~v~rs~ of t1)is form.
Provide 2 dimensions to cc>ntor of ;opt ic t,inl. ,n<3ntimh, ('ovOr.
ST. CROLX COUNTY
SEPTIC TANK MAINTENA_NCE AGREEtiIENT
_N D
OWNERSHIP CERTIFICATION FORM
Owner/Buver LO'-G• S C
Mailing Address 3 aZ U_rA S 0'
Prope-rv Address W ey_~_ IR-oa-A uk-a l,.,)T ~O
(Verification required from Planning & Zoning Department for new construction.)
City/State 4LkC SO'n , Parcel Identification Number
LEGAL DESCRIPTION
Property Location 1/4 , Sec. 17 , T N R i_ ( W, Town of r-
Subdivision Plat: 0L& Lot ? i 2 7.
Certified Survey Map Volume Page
Warranty Deed 4 (before 2007)Volume 1/1) Page 4 .S Y.6'
Spec house yes 9 no Lot lines identifiable j'yes ` no
SYSTEM bLAINTENAiNCE A_ND OWNER 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. What 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 i,'3 full of sludge.
Iiwe, 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 Naturai 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.
Iiwe 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 Register of Deeds Office.
Number of bedrooms
SIGNATURE OF APPLICA_NT(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)
Z~ PA,R K_ (N89015'14"E )
® J ~ 630`` ~
N 89'11'47"E
243. 00
roo 96
129
66187 Sq.Ft.
cnl .S`q s~~a'- f (1.520 Ac.)
A 'fi► Jam. ~s6`~
\ \Q
! \ .O
u
0 co
U C7, I
uN al / 128
u
w o, 53179 Sq. Ft.
u 0OD oo~ (1.221 Ac.)
~ .o
w d, t!1 O ~
~ ; ~ NA9~11(~ 'ti ►ry 12'1
04 o / Nry0
Q / Co
N /
126 125
~ s esos ' ~(o 63022 Sq. Ft.. O
/ (1.447 Ac.) o •
L2.7_.- ~L ° 47961 Sq.Ft,
12 / 61803 Sq. Ft. Co
(1.101 Ac.)
(1.419 Ac.)
0
9'
/ ---582.01'--- ,112'
• 'f`' 3b 6- off' _ _ _ X33 . ~'o r - ! 67 1'.'
1 12.34' 205.41' 206.63' 182.80'
84 85 i 86 1 87
WILLOW- RIDGE -EAST.
VOL.5. PAGE 34
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF EXISTING SEPTIC TANK(S)
This is to certify that I have inspected the existing septic and/or dose tank
presently serving the following rest ence:
(Street address) 13 -X A located
at: Ntt 1/4, 5c-~ 1/4, Section i 'l , Town ;2-1 N, Range W,
Town of ~,a,z,,~_ , St. Croix County Wisconsin.
Upon inspection, 1 certify that 1 have found the tank(s), to the best of my
knowledge, will conform to the requirements of SPS. 384.25, and it (they)
appear(s) to be functioning properly.
Most recent date of inspection or service -7 - I ! 7
Did flow back occur from absorption system? Yes No
(if no, skip next line.)
Approximate volume or length of time: gallons minutes
Tank Capacity:
Construction: Prefab Concrete r` Steel Other
Manufacturer (if known): YA
Age of Tank (if known): -7 i b
Permit number (if known) a i ^l
e L-J h-1- rr i:~ L r
(Licensed Plumber Signature) (Print Name)
i
(Title) (License Number) /MPRS
1,0 i
(Date)
Form to be completed by licensed plumber (Dept of Safety and Professional
Services Chapter 305 and s. 145.06, Wisconsin Statutes) or licensed disposer
(NR 113 Wisconsin Administrative Code)
Rev. 2/2012