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HomeMy WebLinkAbout030-1058-40-000 (2) Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: _ ATTACH TO PERMIT .51_ ~ ZZ °af 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 Na e City Viiia9e, Township r Parcel Tax No: m CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: L 3. ,;3G TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM Aeration 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 Holding Bot. System Final Grade PUMP/SIPHON INFORMATION Manufacturer Demand St Cover GPM Model Number TDH Lift Friction Loss System Hea TDH Ft Forcemain Length ia. 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/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM [Len eader/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) gth 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 Mulched Bed Trench Center I Bed /Trench Edges Topsoil ❑ Yes E] No T ❑ Yes ❑ No COMMENTS: (Include code discrepencies, persons present, etc.) pp Inspection #1: Inspection #2: Location: a (t 1 C4,Cj 1.) Alt BM Description = 6 2.) Bldg sewer length T1 C_ ~ot ~LrTu~4f_~- - amount of cover = L Plan revision Required? ❑ Yes ❑ No Use other side for additional information. cert. No. Date Insep is Sign re SBD-6710 (R.3/97) A County Sanitary Permit Application ST. CROIX COUNTY WISCONSIN ~p-w.Ol In accord with Chapert 12 St. Croix County Sanitary Ordinance PLANNING & ZONING DEPARTMENT ~JJ ~~'1Qersonal information you provide may be us`At)~or s nd pu s ST. CROIX COUNTY GOVERNMENT CENTER G C, V [Privacy Law. S. 15.04( 1101 Carmichael Road Hudson, WI 54016-7710 (715)386-4680 Fax(715)386-4686 Attach complete plans fc 11 inches in size. y Permit # ❑ Check if revision to previous application ORO, pop 1. Applic ation - Please Print all Information Location: Propertcaner Name 1 /4 O 1/4, Sec r) (l lb1 J : av ~c~ ~F'c`rv I ~~~U' J1 `L T C? N. R 19 E (o W Property Owner's Mailing Address Lot Number Block Number ` Y 7 City, State Zip Code Phone Numer Subdivision Name or CSM Number SC/t~1~i.,, i C~ l 5~/G`5 /-7y7 77G"Ctd-~ II Type of Building: (check one) amity ❑ Village Town of 1 or 2 Family Dwelling - No. of Bedrooms: C~l ❑ Public/Commercial (describe use): G,e,.64 . ^ 'ST • Yr-, It J ❑ State-owned Nearest Road II. Type of Permit: (Check only one box on line A. Check box on line B if applicable) Parcel Tax Number(s) A) I"% Repair 2.0 Reconnection 3.❑Non-plumbing 4. ❑ Rejuvenation ~ 3 O O; * l©^ 000 Sanitation B) Permit Number Date Issued q Q J~ State Sanitary Permit was previously issued 7 ®v p - L f 70 IV. Type of POWT System: (Check all that apply) ;;13, j o, i5, go3 '0 Non-pressurized In-ground ❑ Mound ? 24 in. suitable soil ❑ Mound 24 in. suitable soil ❑ Mound A+0 ❑ Sand Filter ❑ Constructed Wetland ❑ Peat Filter ❑ Drip Line ❑ Pressurized In-ground ❑ Holding Tank ❑ Single Pass ❑ Other ❑ At-grade ❑ Aerobic Treatment Unit ❑ Recirculating V. Dispersal/Treatment 'rea Information: 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. System Elevation 7. Final Grade Required Proposed (Gals./day/sq.ft.) (Min./inch) Elevation &4/Z_ p,7 VI. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic New Existing Gallons Tanks Concrete structed glass Tanks Tanks /Dd /ocao EG" tV s ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ VII. Responsibility Statement IT the undersigned, assume responsibility for repair/reconnenction/rejuvenation/installation of non-plumbing for the POWTS shown on the attached plans. A license is not required for terralift repair or the installation of non-plumbing sanitation system. Plumber's Name (print) Plumbe ' ig ture (no s am MP/MPRS No. Business Phone Number oHo SewmtrT IZZ3760 `7,1,0 ~fJ6 Plumber's Address (Street, City, State, Zip ode) _ _ ~o 15c l K /7, r/~ S O r►-t G ~2 5 C T I~(f.T S-(-/o Z S Vlll. County Use Only pproy-pd Sanitary Permit Fee La Id Issuingent Signa a (No tamps) Approved Giv ni I ere Determination IX. Conditions of Approval/Reasons for Disapproval: t a. c..r~G Rev: 8/05 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNTERSHIP CERTIFICATION FORM OwnerBuyer) 4 1Gr~t fi 5 ~ ~~Fe w _ 171i 1 4 Mailing Address 7 G'U,~25- he i-~ i rw, Property Address S ft7l ~i- (Verification required from Planning & Zoning Department for new construction.) Parcel Identification Number city/State LEGAL DESCRIPTION 1/4 , Sec. 3 , T ,3 L'` N R / aW, Town of Property Location G 1/4 0 Subdii-ision Plat: , Lot # Certified Survey Map Volume , Page # Warranty Deed # / d'- Z (before 2007)Volume Z Page # / Spec house ❑ yes Yno Lot lines identifiable ❑ yes ❑ no SYSTEM MAINTENANCE AND 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 o Amer 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 1/3 full of sludge. Uwe, 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 Natural 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. Uwe certify that all statements on th~ 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 w r deed recorded in Register of Deeds Office. Num er of ed oms 3 i /ry/ zC~~ 7 1 ATURE OF APPLICANT(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)