HomeMy WebLinkAbout030-1079-40-500 (2)
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
(ATTACH TO PERMIT) SAN-2017-149
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:
MATT STEIGER TOWN OF SAINT JOSEPH 030-1079-40-500
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
28.30.19.286E
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing Alt. BM
Aeration Bldg. Sewer -n -
Holding SUHt Inlet ct
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic Dt Bottom
Dosing Header/Man.
Aeration Dist. Pipe
Holding Bot. System
Final Grade
PUMP/SIPHON INFORMATION
Manufacturer Demand St Cover ,
GPM
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 SYS T P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION T e f ste CHAMBER OR
YP~ e ' UNIT Model Number:
DISTRIBUTION SYSTEM
Header/Manifold Distribution ix Hole Size ix Hole Spacing Vent to Air Intake
Pipe(s)
11-ength_ Dia Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulche
Bed/Trench Center Bed/Trench Edges Topsoil
Yes E] No Yes ~ No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location: 568 PERCH LAKE RD
1.) Alt BM Description =
2.) Bldg sewer length = r
_•r,
- amount of cover
wl r ~~1
Plan revision Required? ❑ Yesy No
Use other side for additional information. + s~
Date Insepctor's Signature Cert. No.
SBD-6710 (R.3/97)
County Sanitary Pe 4 ST. CROIX COUNTY WISCONSIN
C,OJ194 Inmm+ith Chapert 12 St. Croi , jroinance PLANNING & ZONING DEPARTMENT
~%IeValLLinf rmatjon you provide may be used for secondary purposes ST. CROIX COUNTY GOVERNMENT CENTER
OlJtATY acy Law. S. 15.04(1)(m)] 1101 Carmichael Road
S SA 0,P D .QpN►& Hudson, WI 54016-7710
(715)386-4680 Fax (715)386-4686
Attach complete plans for the system on paper not less than 8-1/2 x 11 inches in size.
County Sanitary Permit # ❑ Check if revision to previous application
1.. Application Information - Please Print all Information <
Location:
Property Owner Name
+-r] 1 /4= F_ 1/4, Sec
i ! C I e_ ,I -71[a N, R E (o
Property Owner's Mailing Addres 1 Lot Number Block Nu er
APIr
City, Stat p Zip Code Phone Numer Subdivision Name or CSM Number
t.
Irk
II Type of Building: (check one) TJ- amity ❑ Village own of
1 or 2 Family Dwelling - No. of Bedrooms: P
El Public/Commercial (describe use): eel a"~
El
State-owned = Uparest R d
Il. Type of Permit: (Check only one on line A. Check box on line B if applicable) C' 1 t.
rcel Tax Number(s) (ib•~
A) 1Repair Reconnection Non-plumbing 4. ❑ Rejuvenation f y,~-l1
Sanitation P 5 V J56TP
B) Permit Number Date issued
1
El State Sanitary Permit was previously issued
IIV. Type all that apply) HOUSC Tb ,Oj E /NS"1i`L 0!
In-grou d ❑ Mound ? 24 in. suitable soil ❑ Mound 24 in. suitable soil ❑ Mound A+0
Sand Filter 11 Constructed Wetland ❑ Peat Filter ❑ Drip Line
❑ Pressurized In-ground ❑ Holding Tank ❑ Single Pass ❑ Other
❑ At-grade ❑ Aerobic Treatment Unit ❑ Recirculating
Dispersal/Treatment Area Information: 1-311 A1711
1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. S Nei Elevation 7. Final Grade
/ y Required Proposed (Gall/day/s ft.) (Min.Anch) Elevation
r~ L Z
VI. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic
New Existing Gallons Tanks CV13p,',~ oncrete structed glass
Tanks Tanks G
❑ ❑ ❑ ❑
a- n ❑ ❑ ❑ ❑
VII. Responsibility Statement
I, the undersigned, assume responsibility for repair/r connenction/rejuvenation/installation of non-plumbing for the POWTS shown on the attached plans. A
license is not required for terralift repair or the ins 1 tion of non-plumbing sanitation system.
Plu`mber' Nam(print) / q Plumbe ' gnature no stamps): MP/MPBS No. Business Phone mb~r
7-7 Plumber',A ress (Street, City, S te, Code)
III. County Use Only
roved Sanitary Permit Fee Date Issued Issuing Agent Sign ture (No stamps)
Approved Owner i nitial Adverse S /
5/ -7
FCetermination 3~ 201
IX. Conditions of Approval/Reasons for Disapproval:
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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division Sanitary Permit No:
INSPECTION REPORT 574309 0
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No.
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)j.
Permit Holder's Name: City Village X Township Parcel Tax No:
Stei er Matthew & Carrie St. Joseph, Town of 030-1079-40-500
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
, Z 6 M Z 28.30.19.286E
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTUREf~ ` CAPACITY STATION BS HI FS ELEV.
IL
Septic J ,1 Benchmark D a Z
Alt. BM L C 73 4r2- li7
Ga „w1.o q
Bldg. Sewer / r Z I 9 tf 91
Holding St/Ht Inlet tV • T $ c 71 • g
Ht Outlet
TANK SETBACK INFORMATION SV-It Outlet
TANK TO P/L WELL !-BLDG, ent Air Intake ROAD Dt Inlet
I UD~~ 10a~ ~
Septic Dt Bottom ZO 3 y0,
Sd s4 [~V
Dosing Header/Man. 9 Z '
Aeration S Dist. Pipe
141, f, z~ 9 .9" 7
Le,
Holding 'got. System Z ' ! • $
Final Graded 5 c~5
PUMP/SIPHON INFORMATION 4" M. ~1
Manufacturer ~6 GPmm~and St Cover $ 73 9'L. y 7
Model Number Q
TELift/1 Friction LLLos3 S ystem H TDH F -3.3A- . -
Fogtl Dia Dist. to well
SOIL ABSORPTION YSTEM g 7• A
BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: +<L ~~d
CHAMBER OR f"
l Sb n 1 UNIT Model Number:
INFORMATION T Of S Z-,
6 1 V 4
DISTRIBUTION SYSTEM e 4
x Hole Size x Hole Spacing Vent Air Inta
1-leader/Manifo4 It Distributio0
Pipe(s) ` J
length D Dia 7 Length Dia pacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx De th of xx Seeded/Sodded xx Mulched
Bed/Trench Center ~Bed/Trench Edges-~ Topso Y$s ` No Yes No
COMMENTS: (Include code discrepencies, persons pres\ent, etc.) Inspection #1: ! / Inspection #2: ! /
Location: 568 Perch Lake Rd yuds n, WI 54016 (SW 1/4 SE 1/4 28 T30N R19W) NA Lot 6 Parcel No: 28.30 .1 .286E
= y 1 Ga
1.) Alt BM Description tib
2.) Bldg sewer length =
- amount of cover = r f ' n I' 4q 1 0 n
5~- Z 1,^3v a aJt"' $kt.Jl t
Plan revision Required? Yes ~No Z5~ 14 &aSq 7<
Use other side for additional information. 1
Date Insepctors Sg ture Cert. No.
SBD-6710 (R.3/97)
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County
Safety and Buildings Division S j , Clf?d / X
s _ Y r 1` 4 ( 201 W. Washm t0
162 Sanitary Permit Number (to be filled in by Co.)
Madis I 11f 71f
'0
7 Z/ 3 6
tary Permit Application State Transaction Number
In accordance with SPS 3 2), Wis. Adm. Code, submission of this form to the appropriate governmental unit
is required prior to ob a sanitary permit Note: Application forms for state-owned POWTS are submitted to Project Address (if different than mail' ng~ddress)
the Department of Safety and Professional Servies. Personal information you provide may be used for secondary
purposes in accordance with the Privacy iaw, s. 15.04(l) in , Slats. Jn ! Jy {C~'/`°
I. Application Information - Please Print All Information P 1 -5 /4 Property Owner's Name Parcel #
err - C 12ti s,-ri~c=~~ 03o-io7~/-yo -sou
Property Owner's Mailing Address Property Location
56 t)C AC H L ,4 K r Govt. Lot
City, State Zip Code Phone Number
Ji-_ Section z U
LA 1) S J 7 l7 / trcle one
T_J,0 N; R Eo
11. Type of Building (check all that apply) Lot #
El I or 2 Family Dwelling - Number of Bedrooms Subdivision Name
6k. 0A eve Bloc 3(0%
❑ Public/Commercial - Describe Use j~~ ❑ City of _
❑ State Owned- Describe Use It"f C Number ❑ Village of
Town of S 7• J 0.SC /JZ y
No l r'~ v
/3 h" l S -
Ill. Type of Permit: (Check only one boz on line A. Co plete tine B if applicab )
A.
New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain)
❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued
B. Permit Renewal ❑ Permit Revision
Before Expiration Owner Ez
IV. Type of POWTS S stem/Com onent/Device: Check all that apply) VV `
lK 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. D rsal/frea nt Area Information:
Design Flow (gpd) Design Soil Application Rate(gp 0 Dispersal Area Required (sf) Dispersal Area Proposed (s System Elevation
7UD
VI. Tank Info Capacity in Total #1 of Manufacturer
Gallons Gallons Units o v
New Tanks Fxisting Tanks v r aUi a m
t7 R,
'l a /Uvr rn i: G
Septic or Holding Tank / OC90 NA /,goo
' / SC K Jt
Dosing Chamber &,5-0 r (V j f,5 L` l~ x
VII. Responsibility Statement- 1, the undersigned, assume responsibility for Installation of the POWTS shown on the attached plans.
Plumber's Name (Print) Plum a MP/MPRS Number Business Phone Number
4A) SCHWITr c 7Z37i~ v 760 V9
Plumber's Address (Street, City, State, Zip Code) 1
/b /JOTS AL) p,klr&ISC % w ~ S-/ Z S
VII our /De artment Use Only
Permit Fee Date [ss ed Y Issuing gent Signature
A oved ❑
Pp' ❑ t
14 Z~~
rven R for Denial $
'71-91 1
/ 5
Sr~ _~Ni VA 4
IX. Condf 0Weasons for Disapproval
f - Sfeptld"tank, eftltiient filter and 3 r /~8
dit{>[ersal cell-must all be servlim I maintain r
00 pair management plan provided by plumber t~ e l t 14 1
2 SAN s k Mqu nts must be maintained J
80 per ippYtsstila Coda / ordit*vAs.
Attach to complete plans for the system and submit to the County only on paper not less than s 1t2 z 11 Inches in size
SBD-6398 (R. 11/11)