HomeMy WebLinkAbout020-1485-01-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
(ATTACH TO PERMIT) 597367
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:
KERNON J BAST TOWN OF HUDSON 020-1485-01-000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
a 21.29.19.3076
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. 941
GAL, Septic ~1 Benchmark
z„,.,3.. i 5.33 Ids !0~•6
Dosing - Alt. BM 11.0 110q.93
Aeration Bldg. Sewer •J3
Holding St/Ht Inlet ~i Or `
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO P/ WELL BLDG. V nt to Air Intake ROAD D Inle
Septic O t 7j~b 4161114 ll-
ottom
D
D Header/Man.
r .t q8.
Aer n Dist. Pipe
to•t3
Hold Bot. System 11.33
O"
PUMP/SIPHON INFORMATION Final Grade 5. 10 Manufacturer Demand St Cover
GP
Model Number
TDH Lift Friction Loss Sys ead TDH Ft
Forcemain L th Dist. to well
SOIL ABSORPTION SYSTEM u,~•} a,
BED/TRENCH Width j Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS ag, -
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer
INFORMATION CHAMBER OR io
Type Of System: t I t UNIT
11+V(',N~ ~a. Model umber:
DISTRIBUTION SYSTEM
Header/Ma ifold Distributiora\ x x Hole Spa, nq [VNt to Air intake
1 h Pipe(s) \l \1 \l 5
Length Dia Length Dia Spacing
SOIL COVER X Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over r ( Depth Over 1XX Depth of T Seeded/Sodded xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil
v Yes No Yes No IF- COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location: 550 WILDBERRY DAR Q
1.) Alt BM Description CV ,
2.) Bldg sewer length
- amount of cover =71 Ses
Plan revision Required? [ Yes [ No
Use other side for additional information.
7~
Date Inae~d or s nat. e Cent No.
SBD-6710 (R.3/97)
~v~ ~w°~ nuntya? c _ 7
RECEIVED Safety and Buildings Division S croX.
l 201 W. Washington Ave P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.)
per,, Y iadi 5377 7162
i ~p~'eYS70NP1-~~ 44N tiJ o 2011 3(f/
rry 7
QMM MY- t AppncauuA. State Transaction N n er
In accordance with P5 3$3.21(2)_ Wis. Adm. Code, submission of this form to the appropriate governmental unit
is required prior to obtaining a sanitary permit. Note: Application forms for State-O'AMed POW'TS are submitted to Project Address (if different than mailing address)
the Department of Safety and Professional Servies. Personal information you provide may be used for secondary
u uses in accordance with the Privacy Law, s. 15.04(1 (m), Stats.
L A lication Information -please Print All Information 5 6J 'p 1 ~L*Y, Oft VT
Property Owner's Name
I~/ Parcel 4 c~ 5 `
1T °
f~E 13b s
Property Owner's Mailing Address Property Location
jj Cj~
~bov
, Slate Govt Lot
ry
I Zip Code Phone Number
Section
d a 1 V (circle one)
TL Type of Building (check all that apply) Lot Y T AI-N, R J E or w
FS I or 2 Family Dwelling - Number of Bedrooms _ Subdivision Name
ok Block C
❑ PubliclCnrnmercial -Describe Use
S 1M. e J ❑ City of _
i CSM Number
❑ State Owned - Describe Use 1 .r` ❑ Village of
Z a J mss) I%Town of :ffu 05 b N T
111. Type of Permit: (Check on#y ne box on line A. Complete line B if applicable) 0 ~
j A.}
yste~ ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only El Other Modification to Existing System (explain)
i
1 B El Permit Renewal Permit Revision L1 Change of Plumber ❑ P nit Transfer to New L' Previous Permit Number and Daze Issued
Before Expiration Owner
TV. Type of POWTS S stem/Com onent/Devzce: Check all that a 1 y
c
y) !G 06 -
1 ,lon-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound 24 in. of suitable soil ❑ ound ; 24 in. of suitable soil l~ Holding Tank ❑ Other Dispersal
Component (explain) ❑ Pretreatment Device (explain)
V. Dis ersal/Treatm Area Information:
{ Des II I!, 11, 1 g11111 Design Soil Application Rate( dsf) ' Dispersal_ Area Required (r Dispersal Area Proposed /f) System Elevation
80
VL 'T'ank Info Capacity in Total 4 of Manufacturer
Gallons Gallons Units " ~
° New Tanks °
Existing Tanks
_ am a ~ ca
Gly ( y t~ Qi
Septic or Holding Tank GO in w
~ ~ -
t Dosing Chamber
LV:J:1:R:;p::o:n:s:ibilitY -Statement- I, the undersigned, assume r onsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print) Pt Sign r
MP/MP Number Business Phone Number
`
] lumber's Address (Street, City. State, Zip Code) J'
~ is ah~ 1;`w
VU Coun /De artment Ise Only
Approved s d Permit Fee 1 Date {sued Issuing t Signature
Ow ,rven Reason for enial $ N d- ~b + / Z 7
M Cond' easons.for Disapproval
;;lbir{3e,, tali ix►II t~ttisf ap PlAg1h;i +n t / ► 1 J _ /N ~ Ir iaM Platt pe
2. trridect by plumber. v Av i:9Hidzire l
a. PW 1; iwk oack I OMMAM. OIf' Se- Ae.w
Attach to complete plans for the system ands mit to the Cormh' y only on
paper not t¢ssthan $ rn_ l iMhet in sits
I •r^'~ ~t'v~ I
SBD-6398 (R_ 11/11)
M41V
s
AlAte- r
Q6
3a, I
t c t
34
30
i
rn
rev 9~
CO i l VENT ! i ,r~(_ ('~1('P NEITT DCS1GN
Residential Applicalicvr
INDEX la;.ND Tii'L.E PA--CL
Pro.jent Mama: _
Owners Name:
Ow- n is Address:
-Sys _t~; ►1i x _ _ v~_
- n
,4QI Dc-vscrilptjor: NW (~,i r
Tovmshil;
County:
Subdivision NarYtr~~
Lct Numbor: ( -
('~,irct?'i I'D lxluml,er:
Page 1 ln-dex
?r end tle
Page 3 'stT~ ~a I a7iYi~ c4 Crass-~;~
_ Gf)on I
Pao6i
n•
''a g e 5
~ i~~r~h^,I~r:~.rle'~'Pl'~f? I:r}~'(JriP.r~IG)31
tF1aq
Pace S%. Cr^ X
oiSeP~ tic Tank >Ui.irrtnn.a'.rw Fcirttl
Page -Warrant Deed
pa n
L
_w. ~M ur F t
`"ail '1"st 1 I !c~'1,rE,•F~
D m ra]`~t1~-f3~~L.~ Lir'~t,~ Ptltttrrbr~r: ~?~~.s~.~D
C~nsif)ned Fiursuant to the !n•G untl Srli ~1bso;t~tion Component ivi~nur3! ,n; p _
-)VUTS %/t,rsion 1.0
S[ D--107Lt:5 1' (fJ.01/01).
T'~4E 7
1
I ~
I
MAP
I-
fi
vi~Qa~l,o1~~ sod'
Q-Trutic~s
3x~S
U'
it P
f
h
69Pl S~
is- WIP~)~L~l~s~s
1
v yv D
-Mdrv~
~y Qm IeV. ~8.g~
4" ScIleCiute 40
PVC vent Pipe Final Greoe
6l/ith va-,l Cap
~~l?arYll'J°i 1 .
1 ~ Q
A li`
System ~ievation
it
~7 R1'(,P ~ W.+F~,.C F 6.~f ~k.C~ fi A~'rl.~'. ear. d ~L'u 6 ~*Yi R ~A'F:F•n~
~wm
/ Tretach E
1 ! LheTnb4t3
Trend 2 4° Dggl.
Vent Or oasej-v$iion Pill Header
Manl.esack;Y`:es And Made! (A l
EISA Ratine+. 4 r i=-
•
406 f4 rc a@s Ctcl
her Soif ARpflcatjon Pate
9Pd Design 6-loit qq -~d/sq f#
Soil APPlication Rafe ~ O5~ I EiaA
TTt 0' o~ _ chain
Pale of
Technical Specifications
PL-525 EFFLUENT FILTER (COMMERCIAL)
- 61:7 BALL CiEGK -
i r a I
',I EXCEPTS 61 IM 401
FORINETEMNTICN '157 1435
1 iF
;
JUTiHi' GEX(~PTS
SCN g 10t8a SCH JO ! I 8~9 I
i
_
Z T'
823 I~
} `-y 1 ~ I I I i Ji02 i.q I I i
i
PL-525 FILTER HOUSING 18~
PART NO.-30142.525 1 ! \ r/
MATERIAL
HOUSING-POLYPROPYLENE
OUTLET BUSHING • PVC
6.5 BALL - HDPE q gl
L - - -
SOCKET EXCEPTS FLOATSWTCH
I _;-~~,u23I
a °r
-EX..EPTS1'SCN40
FOR iANOd EXTENTIOf. i~ _ ' tCd1
6:2e
J
5V OF I ^F SLOTS
_ 647 rte -
-SOOKETEXCEPTS 801
I .C BALL PUSF RIM j OPENING
I I i I I I!
I
i
I, I J i i i I II i!
l 7.09
f
_ I OPE~01G
! I ~ 2G71 ii iB 0212241 I I
i f '~7 II 10 1 rJ(
POLYLOK PL-525 FILTER CARTRIDGE
PART NO. - 30141.525
MATERIAL-POLYPROPYLENE
94 L~ d IoI ft lai
PO a S NE 'S r €A~ AN•AM T~ PLAR Paps , f
FILE IMPORMAM-ON
rw. tar YC1 c q y tnp w'T'ank Cia~msity o~ S sl Q NIA
i
fsermit ' raptiu Tank ?1 anuf awrar ' Q M NA
df f ius"It Rfar Uri uferri<"m M WA
t Number of ~~c!r~Arr s Q Wfluo.m Pinar itch[ a Q NA
NuM- blir Cif PUWb , F?aii'rty ljnlt& uU G NA ~ pump -1 111% cap>zafty ~i _R MA
~yl itaw (avaral } l V y- itdau Pump Tank iarai fa>u4mrgr NA
r^uctt• m mufuturar i ~asiyn 'i~ru (;~e~fCl~ 6lrsxim>~rl x 7.~) ~ ~Q U r~fJds
cd?i A¢SIiC~:4~1.t Pets
i ~ iU;r~rxh[ avers o~' ; ' Pr>3treaxmen; t.irt(C _ I=f NA
andar ? ir,~lisan l ffiuan~ ieei,Ci' ' send/Graval Fitter t.l Pr--w Fiixar
cats, Oil & Crape IF~G}} ~3t~ mt3fl
+ Ricahamirdsl Oxv9;m Demend (BOD;) sn4- 0 NA 0 Mpeh-aalm. Aeration W 'OfiP>sd
Olairr; Pram f r
i t~wai S mss ae raifci riSS, _ 0 NA
Monch4y' ai+ars~P ~?sper~sl Ca4i{s}
irotraataia P tiasrit C!~taii R In^ iuurad {grawtcy} i it Ground IpmostrrUed)
g c. i rr irl a
sinchtemi Fl z; ypan ttnand l GJp) 0 ~~rr:~nd
R IAA Q A7^r-ids
T MI ` u9panded SdiiBs S 5) d 1Dr?p.ui ix R t thGr:
Fe~ai Gwirr~ n (pmt rio r;seaYt) tt a•~ul9p mi R MA-
C74ti
Maxim rn ~F lus c Parriata ~fza in iiia^ NA ~ rite
;t«hsY;
~trar; Q NA R MA
- ~,cher=
-v.iaai f; dranan tc Ni~sa~nra SYs~192prip :Ank e.flua, r4.
°`~atttaa a
RTiki~4'I'IJftI>wfttLei i-^-- GYl3e Wtt
3Yi':t~rsrt# 1 {~+Eihxt~j ` ..Il.fttiilttr~sV vases): C1 NA
tnepsct ~rz~n~tt r tanklsl i Ati } of tank uoiutrre CI MA
I ~Iillte~t e:nreikiined sli~t~ti7~ a~ aauwrrs sor~~i~ a:~.- u ;iris ~'!a -tt----
p aGit sntari rf t~rrkia} , t~idlrckix) { a~it irs z ° s ar) Q NA
- ; twat ar,~a suety L ' say 1 1
Irtapact dis-peraat r.,ati(a) ! f mdsas (3 1 S`sA
At issst errV-1 a KV ~ IJ e?
4ifrtusnt filter tq Y:.... hi} RA '
i At itlj!~t mnog twer+d. IM yumLi61
I>lsfaac pivrna, dU?~D >awrtrais aSarrsi1'q; SSA
_ A: lmnQst truce emary^ ~t
sri i§ ar: + a^asaura te9t MA
~Ri1Ar: A^ is= Ones c1WYC 1µi r1 Y(~'
3 C R 14A
PiTAr;>;ist'zrne Pd)1rfgit lie 11" criiict4ort~^
ft,
nspaat3ons [ n}ta end r~,} ,2 f oatls gtsall. as .,•.a~la taY all Ir~dlvir3uai aartylr~ ri ssmj Opamto.r. Tank
rLir. tar PliarsmrraY: Ma[Sm PIzm Pr RastKatai q-V,r'4t7-Y: > t~tifT~a 1;apsattsl'i nWT1 MOM
inspeetlons must inWludt e isisual i apses an at'' a terikls} to i*fan~lfu any missing csr broken hgrd nrsrs„ idm-firv artp w atafks or t~k~~
-M t
MiNg `!4rre the valurns mf 'Mi -NnO szwdep, Rnd Gm.- and try cheek far snv hi?>iiC sap Or pfaOng at ~ p ta ~h t gr rld psrer aae.
-ha
The diispersai reil(s) sha4i ire visus'ii,~i pactee, v) hs twit a~hn lic~urrt9ls~ ca nasya~rdiioata s ~iCits~ aearrdieian and rsgi,trap the
oi 9~iiLiflYli~ on t1'1~ QY~Wii~ Bi,C~4~
irnmadlate rritifaattrn Gthe 1POW regifIn i-11 mutrtatv. ch# *aiYi~ Wili~ tea, the dTt re
tiUii3n xhs acs rYsSnEd sccutx,~tS i a o Sludge P.1, sniJirl i11 e1~1 ter4c aq.!~s9s tst'r ^~~ktird. i 4 v im'a .
c-Orments of xl7a tank shali ise retrnved by a SgNlage Seru?cing OperMW and d POCA'd tl ICS amardari a iY0h ohal;W NR 713,
to?iscaeaair: ~.+~?i'ntnistrari~s C:nza'e, r~'e:3ttt»n1
All ct~taP aal1rloes,Vt c utt i t rva not aim s rnrn hs, shiailntgs p farrrred by a oW find S?~WT nom ainpunits, and any w g nf r,12 A scvka mpurt shah tre prrvFded
try tfla to. ei mamiatorv %t ,,bnri,v wi*un 10 tayr, C~'f csX~~s'8~~3Ft o° to SVF-rn,
M." t4-1011