HomeMy WebLinkAbout030-2087-10-000 (2)
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No
(ATTACH TO PERMIT) SAN-2017-175
GENERAL INFORMATION State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]
Village Township Parcel Tax No:
Permit Holder's Name: City
DANIEL RICHERT TOWN OF SAINT JOSEPH 030-2087-10-000
CST BM Elev: Insp. BM Elev: IBM Description: Section/Town/Range/Map No:
22.30.19.735
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 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 Ix Hole Size Ix 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 7d/Sodded r
Bed/Trench Center Bed/Trench Edges Topsoil
Yes No Yes No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location: 677 N BAY RD
1.) Alt BM Description =
2.) Bldg sewer length =
- 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)
v -a ,1 1Ts
County Sanitary Permit Application ST. CROIX COUNTY WISCONSIN
GpV~ In accord with Chapert 12 St. Croix County Sanitary Ordinance PLANNING & ZONING DEPARTMENT
Personal information you provide may be used for secondary purposes ST. CROIX COUNTY GOVERNMENT CENTER
G' [Pri 1101 Carmichael Road
0 1o Hudson, WI 54016-7710
t1_4 (715)386-4680 Fax(715)386-4686
Attach complete pla--' s than 8-1/2 x 11 inches in size-
nitary Permit; Vr revision to previous application
J , S - ~-7-- rT5
1. Application p Information Location:
Property C
1/4 It 114, Sec v`Zc~
C N, R I E (or)
Property Owner's Mailing Address Lot Nu Block Number
City, State Zip Code Phone Numer Subdivision Name or CSM Number
;z J
&5s ~_Akt
11 Type of Building: (check one) ity ❑ Village WTown of
ZV 1 or 2 Family Dwelling - No. of Bedrooms: 3 _
❑ PubIWCommercial (describe use): J ~tti~ 5 G'J t j,
❑ State-owned Nearest Road
•t'
II. Type of Permit: (Check on one box on line A. Check box on line B if applicable) K d
Parcel Tax Number(s)
11.0 Repair 2.~ Reconnection 3.[]Non-plumbing . []Rejuvenation ~..3:) 1~f 73 S
A)
anitation ~ ~ ~ r C~ % CIC f!
B) Permit Numb Date Issued
State Sanitary Permit was previously issued
IV. Type of POWT System: (Check all that apply) 20
Non-pressurized In-ground ❑ Mound z 24 in. suitable soil ❑ Mounds 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
DispersaUTreatment a 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
,7 U VI. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic
New Existing Gallons Tanks Concrete structed glass
Tanks Tanks
❑ ❑ ❑ ❑ ❑
II. Responsibility Statement
I, the undersigned, assume responsibility for repair/reconnenction/rejuvenationAnstallation of non-plumbing ttf~~or the POWTS own on th ached plan .
license is not required for terralift repair or the installation of non-plumbing sanitation system. G !!2 1-2 1 J!J
Plumber's Name (print) / PlumbftL&-Signature o st rnps : / 4&MPRS`-No. us ess Phone Numbel
Plumber's Address (Street, City, Stat , Zip Code)
Ill. County Use Only
appro nitary Permit Fee ;7; ed Issuing ent Signa rstamApproved Owner Given Adve 00 7
ton
IX. Conditions of ApprovalfReasons for Disapproval:
SYSTEM CVVt :
1. iiOi : tack, A^r^r tiRe* : n•i
04p2 rsu C rust -ill be -,,.!c .,s ! rn itG -ec
y,~~ per ~-7Rr*en plan p: o nae 1 by plumbe- .
2 '-1 .1( irec^ents must be r'=knt ire,i
IiN
as por #pp1ftM co& / adiiklJ n.
Rev: 8/05
r
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER Q i3 E~t i
ADDRESS -At aA 1?,,A n
,-a1 DO`7Eld SET GUT. .~~10.~ S
SUBDIVISION / CSM# RA/ T ZAA-&= AIM LAY LOT WT-
SECTION-q' "7n N-R / W; Town of 6TQf46FP/1
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
Nat SAY R01+0 !fir t°~
GvRNe2
50 tart
Ot)OL 5`4 5 30 "I
$ 140User,
~avd vLzy
Si i, X57
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER d► % a1 ~V SO~~
ADDRESS N
G1 a!"I617 SET t '~-Vou 5
SUBDIVISION / CSM# RAS5- Zdlc& Alal?L61 LOT #
SECTION__42.,g_T3,N-R_7W, Town of Sit &rgE5 JV
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
No ~Ay Ra1+0
9.11--
N Qom, a
C
4 '~o
~YT~
30
Nvu sE
100d G,LY
TREHtHE~
i
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
a
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SEPTIC TANK hADMANCE
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PIPE PRO'S PLUMBING
911 Frontage Rd.
Balsam Lk Wi 54814
715-485-3368
6-8-2017
To whom it may concern,
This letter is to provide information on the septic system at 677 North Bay Rd. Somerset Wi.
After inspection of system I find it to be in good working order. Any questions please call. Thanks.
N
James F Flaherty
M P#668164
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BENCHMARK: 7? OF S r6cl PF
ALTERNATE BM:
i
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: WE= /'C Liquid Capacity: 10)6
Setback from: Well House Other
Pump; Manufacturer RA ^ Model# Size LSC~
Float seperation /1(A Gallons/cycle:__ IYA
Alarm Location
SOIL ABSORPTION SYSTEM
Width: __S Length 52 Number of trenches
Distance & Direction to nearest prop. line: ~,¢Sj
Setback from: well:.-,-5-07', House 30` Other
ELEVATIONS
Building Sewer r ~ ST Inlet; 9 ST outlet
PC inlet NA PC bottom f A Pump Off NA
Header/Manifold 97, 4,~ Bottom of system Z 4
Existing Grade_ Zad Final grade 1&4t
DATE OF INSTALLATION: 3
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR:
{I
3/93:jt
LQ,QAT n%%; t,,9e`fntofA9 H 22.30 • AfVkf5EINKGE J'~5 l=MBAY RD. County:
Labor and Human Relations
Safety ane! Buildings Division INSPECTION REPORT
`GENER 'AL INFORMATION (ATTACH TO PERMIT) sanitary ermit o.:
Permit Holder's Name: ❑ City ❑ Village Town o : State Plan {D No.:
ev.. Insp. BM Elev.: BM Description: i Parcel Tax No.:
etj c_ _
TANK INFORMATION LEVATION DATA A9300022
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
D00 ~.o ( loS,u' /00. 0
Dosing
Aeration Bldg. Sewer
Holding St / Ht Inlet y 9 ?9 j
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P/ L WELL BLDG. Airinta to ke ROAD Dt Inlet
Ar I
Septic :!!s-„Z )/p NA Dt Bottom
Dosing NA Header/ Man. 7, q q _ 6 y
Aeration NA Dist. Pipe 7•5'6 97, VS
Holding Bot. System 9~ yy
PUMP/ SIPHON INFORMATION Final Grade Su!
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
[Forcemain Length Dia. H Dist-To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits inside Dia. Liquid Depth
DIMENSIONS '2 2-..A DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manu acturer:
SETBACK
INFORMATION Type O , CHAMBER Moe Number:
System: /lP.jr env d y Q > S O ~1 ~i! OR UNIT
DISTRIBUTION SYSTEM
Header /M7ani old Distribution Pipe(s) t( ( x Hoe Size x Hole Spacing Vent To Air Intake
Length ) J Dia LL; I Length ~r Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over I Depth Over r'" t xx Depth Of xx Seeded/Sodded xx Mulched
Bed /Trench Center Bed/ Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION:,4ST. JOSEPH 22.30.19,NE,QNE, LOT 1, N. BAY RD.
V, Je
_ . .
4 <1z
Plan revision required? ❑ Yes U/No
Use other side for additional information. a~ ~3 C 1 ~ L. TL< (o
SBD-6710 (R 05/91) Date - Inspector's Signature Cert. No.