HomeMy WebLinkAbout008-1043-80-000 (2) r
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:
Personal information you provide maybe used for secondary purposes [Privacy Law, s.15.04 (1 m .
Permit Holde ' Name City viiiage Township Parcel Tax No:
CST BM Elev: Insp. BM Elev: BM Description: 4kW Section/Town/Range/Map No:
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic LA_J , ,7 r Benchmark /b`'
d 0'. ~ Zpp
Dosing Alt. BM ~I
Aeration J2 Bldg. Sewer A4
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 l J
Dosing Header/Man. I
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
pth
BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid De
DIMENSIONS
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION Type Of System: CHAMBER OR
IT Model Number:
DISTRIBUTION SYSTEM
Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake
Pipe(s)
Length Dia Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Mulched
Depth Over Depth Over xx Depth of xx Seeded/Sodded r
Bed/Trench Center Bed/Trench Edges Topsoil
L] Yes ❑ No El Yes E] No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location:
1.) Alt BM Description =
2.) Bldg sewer length = 5$~
- amount of cover =
Plan revision Required? ❑ Yes ❑ No
Use other side for additional information.
Date Insepctor's Signature Cert. No.
SBD-6710 (R.3/97)
~n'rAi l~Iti ' CC G
pet . t y1~
~rC County
1f' I ~1 ' Y 6 Safety and Buildings Division St. Croix
201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.)
Madison, WI 53707-7162
tr7 I
JUN 0 7 2011 _
u N u t ✓
01 INTY
MM E Applica lon , State Transaction Number
In accordance with S>I
383.21(2), Wis. Adm. Code, submission of this f
is apprepriate'goveTASental unit Na
required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to
the Department of Safety and Professional Services. Personal information you provide may be used for secondary Project Address (if different than mailing address)
u oses in accordance with the Privac Law, s. 15.04(1)(m), Stats.
1. Application Information - Please Print All Information Same J.
Property Owner's Name / Parcel #
Randall & Melanie Durrence 008-1043-80-000
Property Owner's Mailing Address Property Location ) ,TI
369 Co. Rd. BB Govt. Lot
City, State Zip Code Phone Number SW v, NW A, Section 16
Woodville, WI (circle one)
54028 (715) 684-9527 T 28 N; R 15 E or W
II. T c of Building (check all that apply) _ Lot #
1 or 2 Family Dwelling - Number of Bedrooms j 3 ) Subdivision Name
1
Block # CSM
❑ Public/Commercial - Describe Use
Na ❑ City of
❑ State Owned - Describe Use CSM Number ❑ Village of
CSM Vol. 12, Pg. 3262 own of Eau Galle
111. Type of Permit: (Check only one box on line A. Complete line B if applicable)
A. ❑ New System
❑ Replacement System Treatment/Holding Tank Replacement Only Other Modification to Existing System (explain)
Emergency Treatment tank replacement
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued
Before Expiration Owner
IV. Type of POWTS S stem/Com onent/Device: Check all that apply)
❑ 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 ersal/Treatment Area Information:
Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation
450 Gpd
VI. Tank Info Capacity in Total # of Manufacturer
Gallons Gallons Units 2
New Tanks Existing Tanks o Y u 2
U v~ ~ v~ tom. C7 0,
Septic or Holding Tank 1,200 Na 1,200 1 Vdieser Concrete WLP X
Dosing Chamber 800 Na 800 1 Combination ST/PC X
VII. Responsibility Statement I, the undersign d, assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print) Plumber's gnature MP/MPRS Number Business Phone Number
James K. Thompson MPRS 30021 (715) 248-7767
Plumber's Address (Street, City, State, Zip e)
340 Paulson Lake Lane, Osceola, WI 54020
VIII. (3eun /De artment Use Onl
k
Approved 11 Disapproved,f Permit Fee DatIssue~d Issuin gent Signat e /
$ P
(0 7
❑ Owner Given for Denial
Reason
IX. Condi#Y#.T&A, Reasons for Disa roval - ) r
1. " rk, e.Vtx 'lot+' :'h ! pp 3 (tea l`'_c.
ult-par: n Celt Must X11 "s ' w nt~'rec r
als per,3'taragernen! pl&n p+a ndt3d 0Y plumber. ~~•-~t~ . 64- Cod c. ut I
2.I s! IYAg1;lYAC7A11k~ 11tUllt 1+Ii tTttwfltr It € i' L ; 4 -
M per Wkwe cou / ,:rdtlll)10lbll, vE a~rX . ` Gr^^' z J~ j a W 'Y - t `J
Y% ra
Attach to complete plans for the system and submit to the County my on paper not less than 8 1/2 x 11 inches in size
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