HomeMy WebLinkAbout020-1320-00-000 (2)
1,v ' ennelr Departmurl ul Cunone'a' PRIVATE SEWAGE SYSTEM 0ju U St. Croix
Safety arc Gu IJ "I soon
,.ani;aryPC•ImaNc
INSPECTION REPORT p
A7TACi I l o -1FRM171 597390
GENERAL INFORMATION s:au =tar u:. v,.
°crsoaa iv'nnnane qou provice ma:' tc oscc lo' suu..Jnry pugro t!x'nnuac; Lax. IE i 1'goil ll
Permit Ho'Jv-" Www Gty VII;rgE Ttm.nship Pamel Taz Nc
RON DAULTON TOWN OF HUDSON 020-1320-00-000
C5' BN Feu u. BM I PV B!d Desu DI.-r. ' I Ss01 bn!Tnim! Rarau.Mip No
92'65 T &F Cfna~-b~-~ `J 28/29.29.19.1636
e
TANK INFORMATION ELEVATION DATA
I YPE MANUFAC T UHLR CAPACITY S-ATION BS !II FS FL EV
SePnc een;;nmarx
6e; a I` / Zed /0, 4(0 /41.7 9?- 0 5
Dcs'ng Alt HM
/r d ~ouu. 3
Aeratior Bldg Serve,
I $ ~
c
Iloldinq StVHt Inie7
TANK SETBACK INFORMATION SUH; Outel
TANK TO L`r VJCLL BLDG. .nt 1 Air Irca::e ROAD D' Inlet
Septic Dt Bottom U-75
Z7 Ugsln4
7 Q
~ Z 7
Aeration ! HeatlzKNtan
7CCJ Dist pine • U ~j• 7
i::ldmg Dot. System 7r C? 9 S
9.I
Final_G~ I: S.S ~7T
PUMP/SIPHON INFORMATION Z. !
~A~A1 _j r'ii~ Maudamurel Demand St Co er 1 66 4h l GPM _ G.pJ
Model Numee' / G 0 b
I Dil Fn; ^ion I offs ~ System He TDH
I r
Fome.'nam Lengtn Dia. Dist to wel /
SOIL ABSORPTION SYSTEM
BEDjRENCH %NflI•rr Le-rg:h Nu 0'7w;" ~ PIT DIMENSIONS Nc J' P j nscP LLa qu C Ixg•I'
DIMENSIONS 3
SE I BACK SYSTEM TO / P:L BLDS i `1VELL KEELLLLLNL IAKEtSTREAId LEACHING r,t::n.. =cu~,/
INFORMATION CHAMBER OR 1 l
It' SY`r"" 11 ZZ_ 177 11
UNII
A1r,pr umt~r
~e nJRi
DISTRIBUTION SYSTEM Llosil- ZZa Vid
HcoJorH0avtl 11 DISt,,LJbCr. , Hoe soe n Hae. Soaore 'dent tC Alr ti:* c
Tenet' Dta__r- Ir-nli• D` SUacn51_ ` e
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
JCpth Ow~i DrplL Cmq %N DCaUi J' JPeOCG `JOCJe;1 aR i&:.^ne)
(ier.Trenc^ Q•nlC' 71 Kedir=nc" Ecyes Te:+xail ` -
L l ~~s Vc Vey Nu
COMMENTS: (mciude code discreoenaes persons present etr i Inspecuor #t Inspection #2
Location: ; 26 CROSBY DR~ P+U r /
/ eti 3~oKK+ Gina .
' i Alt BM Description -5
=
c i Bldg sewer length - L t~~t xr /dGK.S
- amount of cover = v ~v z+' "r'~~
Plan revision Required? Yes 7r~No 5 / 9 ~3/S
LJFS othe! side for additional Intormation.-- -
:)atP Ir:-BP
57D-6 ~ 1 P (P. 319''.
_ SflMl-a~~-~ - ~Y---
:..V. RECEIVE Cmmly
Safety and Buildings Division St. Croix
e ' 0 201 W. Washin on Ave., P.O. Box 7162 Sanllan Permit N=Il , (to he filled rn by Co.)
PS i+ JUN 2 7 2011 Madisl~lU~1G~~
597396
CROtX COUNTY
~o►nM Slalc Inm~rcti.v +mltir
,NMnE-VE
c Application
In acn,,oLnu:cw.I hU'S'txi-'I('-1.Wu.Ad ...G,dc,.I.misuon.•I Otishnm b, the.gq,r..I.W. yav<nnnenlal writ
Icq ..mJ pn r 1 h mnmc a s.m "I I. l N t ph 1 n Ii., I c1 o wn.. I I't)W I'S ,tic art mnl J I,, 1 r r Add,", UI hl fcr<m Ih:m madtng:uWress)
the IJap'u1m tit t Svkt~ 'J I I nx I l r.r 1 non I ml 'rnalam ♦ u pn cute mrv be usaJ for.- mLrn
-a a. w uaa nJark.... 11r 11 I'm uw I.al I \ 11441 It In) Six'. 726 Crosby Drive
1. \ lication Infor ion Please Prinl All Information
4Tgwrty Owm.:r'. Nam Recd P
Ron Damon 020-1320-00-000
Prol,rny turner'. Mullin). Add,,, R.g.cm I.oan,,n , a
726 Crosby Dr. G"It 1„I A
tfly. YUL: /q, C,,]. Pbooe Numhcr NW SW y Scclion 28
i
Hudson I. I 29 N. R 19 (arrcle 1` l'., )
r11. l ypc of 11t ilding (check all that apply I //^,~t Lol n
CJ 1 ,r ] I aml% D„cllmg Numbcr m Bcdrklk ( ' / 24 Sulnh. icon V:mx - _
n St. Croix Estates First Addn. tioNe A~f
❑ I uhbdCommemml Ikxubc Use ~ ❑ C14' of ~
r CSN7 Nuud,cr ❑1dP y.: .,1
7, U,t li ~_rr w ZZ rzz d44 S %l I w+,,,l Hudson
C..~S
111. Type of I ennlt: (('heck only on box on line A Complete line li if applicable) -
\ ❑ Nos F stem CK Kcpla<em<at System ❑'frenmrenV1l..Wmy 1,nk Rgdac<nraH (hdy ❑ Other Mabfieauon t,, F.xrsuog System (explan)
R. I a t PI n.u L] E] t f ❑ Pcrmu Numbcr and Date Issued -
❑ I'cmul Kcncw:d Pcmul Kccnum '1 :nq~c o I'Inmba~ Permll'frarefar lu Ncw Q
6<lixc I(zp"W.", (hwncr 353277 - I Z I Z.1 / ] C, 1
W. Type of PONS SrslemlComponent/Device: ((heck all that apply)
Q9 N n-Prt..un<zl Im Grnon. ❑ Prc..uni J h,-1,!, At-O+adc ❑ 1laund -:'4,n nl odahl. aul ❑ N .ul '.4 r d suilnh ~1,~' ^~L
❑Iloldiny l':mk ❑(nhrrlbnp ,d G.a,I.r 1r pl.ri.,l ❑ I'rctmalmenl lk,o. (ezplart,l s r'1
Uis IsaVf atment Arcs Inforntabnn
IN, .pnr I low lyp I U<sryn S,al ,1ppl rcuh 1 tcl .id,Q 1H.Iwc1 Arch RcgwreJ I1) Urspec.:J Arca I'ropos< .1) S~.ICm 1'.k. at
600 .7 858 880 95.0 96.0'
N 1. 1 auk Info Clg t m l- sal U M- - 1la'adachurr _ I T
( dl ns Gall... that, i s,y /-~c' t y
N'<aT A. Ix.hIt, Tanks
c,hr, lh+lJrn~ l auk 1200 - 1 ~ - '~'Ard~St x
ur:my Ch.K:t - 800 Combo x
- -
N'D. Responrlbility Statement- 1, the undemma.d, aau rezpnnw in Ila7e- Keith
f
Plum`. r ..V11t , :,~uecL Cn„ State. Z:p( ..Jv) _ _
927 150th St Roberts Wi 54023
\ M un tl'IDepartment t se Onl1 - - - -
App. al Pcnnu Fee ..Dote sced I"%aoy.l I Srgnalurc
' ,L,ema s70-/ 301)71
IX. Condi keasons for Disapprma]
1. ~ tank, aAkxrr: )iRa* still
fYKilnnr *A mums all be n ta" : w.. injs
as par maragernw. plan pro aded W plurritw.
2. All wittark rwwratr.pn:s mutst w r.ikrdriCM
as per mffk4 bl+ cod, i : rdi:wir a 7.
AIIl h to compkm pima fur lM v).Lm and .nhmil to lLr ('mroM1 ed~ eo paprr not fen. Iban a ni a t t inNre. in .l,e
Sill)-fi39x (I(. I I?l 1)
-o~ O 7'
~D ~ n G T ~`~cd5 O~
dot S j . sfC,
KNWTSON PLUP
Y • CCNTRACTIN t
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CONVENTIONAL COMPONENT DESIGN
Residential Application
INDEX AND TITLE PAGE
Project Name Daulton Sc%>er
Owner's Name Ron Daulton
Owner's Address. 726 Crosby Drive
Iludson Wi.
Legal Description: NW 114 SW I14 S 28 T29 R 19W
Township Hudson
County St.Croix
Subdivision Name: St. Croix Estates First Add.
Lot Number 24
Parcel ID Number: 020-1320-00-000
Page 1 Index and title _
Page 2 Plot Plan
Page 3 System Sizing & Cross Section
Page 4 Filter Specs
Page 5 Maintenance Information
Page 6 Management Plan
Page 7 St. Croix Cty Septic Tank Maintenance Form
Page 8 Warranty Deed
Page 9 _CSM or Plat
Attachments: Soil Test & House Plans
Designer/Plumber: Keith Knudtson License Number, 64811;
Date: 06;2312017 Phone Number (66 1 1 470-1737
Signature
Uesigned Pursuant to the in-Ground Soil Absorption Component Manual for POV TS version 7 0 SBD-to7ob-P [N 01!01)
.
Page
~D ~CL i:L L /O:7
~Q I n G ~~ua/5 O!'7
lot a2'f on. . c P 4;x
5IG~7~cs Jc f /~a
KNUDTSON PLU" :
GONTRACTI`<0,
927150TH ST. $4u447i4.rr..
LL< C
\YO
3 / Cf'`
02 P~ y
- - -
Cf3
1
a j3
Soil Absorption System Cross Section
9s.oo
ft
4' Schedule 40 Final Grade
PVC Vent Pipe 3.00
With Vent Cap ft
Leaching 95.00
Chamber It
.0~ 3.(ft -System Elevation
Soil Absorption System Plan View
ft
ft
ft ench 17
Vent Or Observation Pipe Leaching Chambers Tr R
4' Dia.
Trench 2 Header
Leaching Chamber Specifications
Manufacturer And Model W--}
EISA Rating 20.00 sq ft per chamber Soil Application Rate 0.70 gpolsq ft
600.00
gpd Design Flow + 0'70 SOB Application Rate + 20 EISA = 43'00 Chambers
22.00
2 rows of chambers each.
Page of _
Septic-Dose Tank Cross Section And Pump Performance Specifications
'l'ank Manufacturer - / ~ Pump Manufacturer
Tank Model Number ji Pump Model Number ,
Total Tank Capacity
Alarm Manufacturer
Max. BuryDepth ~Alarm Model Number f, L_ Li
Switch Type
Filter Manufacturer cc Total Dynamic Head (TDH) - Feet -
~Filter Model Number Elevation Head ~3 -
Distal Pressure
Network Loss
Maiimum Pump Performance K aired
- Force Main Loss -f
GPM Ft TDH Total
Outlet Manhole Min. 4" Above Grade With
Locking Device. Inlet Manhole Manhole Min. 4" Above Grade
<6" Below Grade Scaled Walertipht Securely Mounted With Lucking Device \
Weather-proof J\
- Finished Gmdc
FT Juny ox
® Depth of
Cover Vent Min. 12" Disconnect
Ft Above Grade Means
- With Vent Cap
Outlet
Outlet Filter
Inlet I f. = Inlet Baffle I
Switch Settin <s and A
} K erve Capacity a
Tank Volumc = GPI
Weep
Dimension Inches Volcu~me Gal. B Hole
(reserve) 3 3`= <•;
(alarm) B 2+~~~=~~~/ Off Elevation C
(dose) C «J ✓ 4ZA Pt
(dead) D Bottom
7 D Elevation
Total Ft
• > , , = . , , > , > . a>`>• a i ~T aT~T~!-mss > • < 'yyrtl-
GENERAL INSTALLAIION: The septic/dose tank is bedded and back filled in accordance with the
manufacturer's product approval specifications. Maximum depth of bury as specified by the manufacturer may not
he exceeded without prior approval. Manhole covers exposed to grade have an effective locking device (padlock)
installed. Piping at the inlet and outlet is of approved material, connected to the tank with watertight fittings, and
laid on stable soil to prevent settling or sagging. The force main is sleeved with 4" Sch. 40 PVC to bridge the tank
excavation and the sleeve is scaled watertight. Electrical service complies with NEC 300 and Comm 16.28 WAC.
02/05 W Page_ of
2r~,2, GOULDS PUMPS Submersible
I
Effluent Pump i MODEL 3871
E P04 & E P05
Series
APPLICATIONS • lully submerged in high ■ EP05 Impeller. Thermo- ■ Bearings: Ur and Saecifiwlly designed fe the grade turbine oil for plastic enclosed design
for heavy duty ballbearin g con-
following uses: lubiicalion and efficient improved pe:fornaance. siruction.
• Ffrlueot systems heat transfer.
■ Casing and Base: Rugged
• i,omes thermoplastic design provides AGENCY LISTING
• Farms Available for automatic and
manual operation. Automatic reSiSt or strength and corrosion `
• Heavy duty • sumP p resistance.
CaneJa Sranda+Js
• Water transfer models include Mechanical A Association
• Dewatenng Float Switch assembled and ■ Motor Housing: Cast iron for File # LR38549
preset at the factory. efficient heat transfer, Strength,
SPECIFICATIONS and durability. Goulds Rmps is 1509oo1 Registered.
FEATURES ■ Motor Cover: Thermoplastic
• Solids handling capability: cover with integral handle and
maximum. ■ EP 04 Impeller: Thermo- fioal switch attachment points.
• Capacities: up to 6o (in.t. plastic semi open design with
• Total head's: up to 31 feet. pump out vanes for mechanical • Power Cable: Severe duty
seal Pmtcaiort rated oil aid water resistant.
• Discharge size 1'4," NPf.
• 100 hanical seal carbon-
rotary4rera m ic-stationar y,
RUNA-N elaslomem,
• Temperature. rot-ens FEFT
104= f (400 Q continuous lie
140° F (60' Q intermittent. T
• fasteners: 300 series
stainless steel. I ►I ~fsri+,+
•Capable of running Rr 2.S FT __j
dry without damage to L 25
components.
Motor: c~ zo
• EP04 Single phase: 0.4 HP a s
115 or 230 V. 60 Hz. 1550
RK.1, built in ovcloid with = 4
automatic reset. LrOs
• FP05 Single phase: 0.5 HP, C.
- -
115Vor230V,60Ilz,1550 I - -
RPM, built in overlcad with Zr Er'04 -
automatic reset. I s -L
• Power cord: 10 foot
-
SJAV th three l gu prong
o sa Gen
Optional 20 C °0 10 20 30 4
aroundyP 9 OP
foot length, 1G3 S1TVu with -
o ] c c ll; 17 m'r'h
throe prong grounding ploy
(standard on LP05). CAPACiv
Goulds Pumps
zcwn W t` , ITT Industries
rfPe3L:o J.:nu. D;CS
r-spa
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF EXIS'T'ING SEPTIC TANK(S)
This is to certify that I have inspected the existing septic and/or dose tank
presently serving the following residence:
(Street address) 726 Crosby Drive
located
at: NW y,, sw %4, Section 28 Town 29 N, Range 19 W,
Town of Hudson St. Croix County Wisconsin.
Upon inspection, I certify that I have found the tank(s), to the best of my
knowledge, will conform to the requirements of SPS. 384.25. and it (they)
appear(s) to be functioning properly.
Most recent date of inspection or service 12-16
Did flow back occur from absorption system? Yes No x
(if no, skip next line.)
Approximate volume or length of time: gallons minutes
"Dank Capacity: 12001800
Construction: Prefab Concrete x Steel Other
Manufacturer (if known): Midwest
Agc of Tank (if known): 312000
Permit pumber (if' nUwn) 353277
L~ /i Keith Knudtsai
rr
T ,,e2L'
(Licensed Phan er Signature) (Print Name)
&18443
(Title) (l,lccnse NUIlihcr) MP,AIPIZS
(Date)
Form to be completed by licensed plumber (Dept of Safety and Professional
Services Chapter 305 and s. 145.06, Wisarnsin St(ltutes) or licensed disposer
(NR 1 13 Wisconsin Administrative Code)
Rcy. ?/'?01?
ST. CROIX COUNTY
SEPTIC TANK MAIN'iENANCE AGREEMENT
AND
OWNERSHIP CER I IFICA I'ION I.ORM
O~v'I1cr,Buycr Ron Daulton
726 Crosby Drive
Nlailing Address
Property Address Same
I Verification required from Planning & /on" 19 Department for new• construction.)
City!State Hudson Wi. Parcel Identification Number 020-1320-00-000
LEGAL DESCRIPTION
Property Location NW, . SW Sec. 28 129 N K 1 9 W, Town of HUdSOn
Subdivision Plat: St Croix Estates First Addn. Lot # 24
Certified Survey Map # - Volume Page #
Warranty Deed # (bcfm-c 2007)Volume Page a .
Spec house❑yeslnm I.or lines identifiable Elycs❑no
SYSTEM MAINTENANCL AND OWNER CERTIFICATION
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper
ilia intenance consists of pumping out the septic tank every' 11twe years or sooner, if needed, by a licensed pumper W hat you put into
the system can affect the limction of* the septic lank 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 owner 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 veritping that (1) the on- itc
,oaylewater disposal system is in proper operating condition and or (2) alter inspection and pumping (it necessary), the septic tank is
Icy than 1/i full of sludge.
V we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the
standards set firth, herein, as set by the Department of Safety And Professional Services and the Department of Natural Resrmrces,
State of \4'isconsin. Certification stating that your septic system has been maintained must be completed and returned to the Sr Croix
County Planning & Zoning Department within M days of'the three year expiration date.
I;wc certify- that all slatentents n this font are trite to the best of my oui knowledge. I we ato arc the owner(s) ofthc
property described above, by virtue o 'a warranty decd recorded in Register of Deeds Oltic<.
Numbe Aroo s 4
SIGNAfU L• OF.APPLICAN'I(S) D.A'FE
"'Any inlinmation that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department.
Include with this applir-atwn a recorded s.arrauty deed from the Itcrister m'Deeds Ollicc and a copy of the certified survey map it
reference in made in the warranty decd
(REV. 04? 12)
...Dec 01 99 09:56a Pete wanks 17151 740-2356 0.5
eAa L bf
1 sr,w 1
57T.49 I
lid
w<.,aa
LOT 28 1 !
Ww tsllar t.ar .<aa ,
• qt,.o w, n Z S
.
vV. Wl•wWt fa.., y 1
,
r - _ LOT 27'
I Is scats
IILi a.,rY M I. _w
1
G •rr y.
y.I LOT 26
U
* LOT 25
t .r
s. '
w.tn w..
LOT 2
L.' , .W te.w 'jam /t
wt u.Y - Qgq'~ LOT 21
~ ~ aw c a•o r
M,.NW 10
~ F
a.•a~~
' LOT 23
1
t.
V .e a
<t. iw w. rrt? 0 ~1
a it K O2 Lwa }
l~
Fill,
Wisocinsin Department
ngs-Dosiorl ce
Safety an end Btil6ngs•OiHSi«I ' PRIVATE SEWAGE SYSTEM County:
INSPECTION REPORT St. Croix
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit NO
Personal i ilomia ion YOU provice may be treed for secondary purpoeea (Privacy Law. 5, 15.04 (1)(m)). 353277
Permit Holder's Name: City Il Village Tpwno: State Plan lD No.:
I Ron Town of Iludson
C T BM E ev.: Insp BM flew.. BM Description: Parce Tax No.:
/MID r O/ sr Bu* = 020-1320-00-000
TANK INFORMATION ELEVATION DATA 528. a9. /9, ~G3G
TYPE MANUFACTURER CAPA~CIIT-,Y1 STATION y-S p)BS HI FS ELEV.
Septic lltsC raj co 12Benchmar O 7.}° a
(D
Z, t
Dosing t Alt. BM
Aeration _ - " Bldg. Sewer r
Holding- St/Ht Inlet } SU y •py/
TANK SETBACK INFORMATION St/Ht Outlet
TANKTO P/L WELL BLDG. Vent to ROAD Dt Inlet
Air Intake
Septic >X)0I V T NA Dt Bottom 21. 9S yk) •'}S
Dosing NA Header/Man. 4'S cI2-9s
Aeration NA Dist. Pipe 1 2
(7.•e 9e•bo
Holding Sot. System If io
Be-aS'
PUMP SIPHON INFORMATION Final Grade B.aa 9Y•
Manufacturer 0 and St cover } 90.9 S r
Model No r 01GPM
\ W-V TDH Lift TDH j-5.,t9Ft
Forcemain Length2((z Dia. Dist TOWCII
TIONSYSTE (a (L•s/s/ .4 (Z•'~`F
I by *96-NCH Width r I e;41, r NO(01 renches T No. Of Pits Inside Dia Liquid Depth
/ DIMENSIONS Of ENV
Of EN j` SETBACK SYSTEM TO PIL71 BLDG WELL LAKE/SIREA LEACHING Man Ca}tur r.
INFORMATION IypeO 67" ~ CHAMBER Ntrm r. _
System t OR UNIT I'
nu
DISTRIBUTION SYSTEM ~l
Hea er/ nio „ Dntn orlon Pi s xNote Size xHO eSpaong Vent loarlntake l
Length L Dra e• nghDo Sparing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only t
De th Over De th Over xx Depth Of xx Seeded/Sodded xx Mulched
tied l trench Center Bed /Trench Edges I Tupsu l U Yes ❑ No ❑ Yes 0 No
COMMENTS: (include code discrepancies, persons present, etc ) Inspection 1/ 370P.1 n #2: rf P5-i cv
Location: 726Crosby Ro d,HudsoT}*WI ~40 6_ NW 1/4SWA28'P29NRI9N (A. .t9.
l.) All BM t)eseripti n - tJ-U-5e-Z+ s. - - ""~^(tBr"` C°t"yi~ ( & C~, /
2.) Bldg sewer length= 30 7 Y 7 /
-alnount of cover - 1 + 'j&
~ PAS~- v' ""Q ((.qs M"
"
m an vt ion required? ❑ Yes O3 12 0.3 - 0AAA Use other side for additional infor ation
SBD-6710 (14.3/97) ret-eg19Qs., OattU IT, ZODO. Inspecto,iSignature Cen No
z
• ~ Sros~ naaa) `;:.-a -le.e~pr~ MPp, /
~ a,,,,~_~ / Safety and Buildings Division
207 W. waahi v
`•ISCOns n SANITARY PERMIT APPLICATION P 0Bckx 7162
P O Bo
7162
Department of Commerce In accord with Comm $3.05, Wis. Adm. Code Madison, W 53707-7162
• Attach complete plans (to the county copy only) for the system, on paper not less County T
than 8la x 11 inches in size.
• See reyerse side for instructions for completing this application Stale Samtury Permit Number
~ ;i 3s3a~~
Personal information you provide may be used for secondary purposes Check a reNSion to pravxaxr application
l Privacy Laws- 1S.04(1)(m)1
Stake Plan Review Transaction Number
APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATI N
Property ner Name Prope Location
itJ io 1 r4 l.U 1r4,S p~ Tay ,N, R I9,`(or)W
ProZr~Owner's Mailing r Lot Numbg( , L/ Block Number
City, Stitt zip Code Phone Number Subdnn on Name or CSM Numrer
t.
TYPE Of- L : (check one) ❑ State Owned ❑ AY Nearest Road
L/ Village
Public 1 or 2 Family Dwelling - No. of bedrooms L-.-.. Tnwn of G
III. BUILDING USE: (If budding type is public. check all that apply) Parcel lTax Number(s)
1 ❑ Apartment/ Condo V~ 6 - /Q -00
2 p Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash
5 ❑ Hotel/ Motel 9 ❑ Office/ Factory 13 ❑ Other: specify _
IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable)
A) 1, kNew 2. ❑ Replacement 3. ❑ Replacemenlof 4. Q Reconnection of 5. ❑ Repair of an
System System - --TankOnly Existinrg5ystem Existin System
B) A Sanitary Permit was previously issued. Permit Number 3~ 3 Date Issued If Z/
V- TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 []Seepage Bed 21 L] Mound 30 ❑ Specify type 410 Holding Tank
12 El Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit p 43 C] Vault Priv
14 QSystem-In-Fill • ~d•`•h - - L~` Tom, a yX 76.02
VI. ABSORPTION SYSTEM INFORMATION: L. O 7
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System EIe - Final Grade
Required ( ft.) Pro sed (sq. f}.) (Gals/day! . ft.) (Min./inch) qLF G,,~/ fleiiatmn
O 7S 6- 3, 'y'am meet Feet
Ca c
VII. N TANK ORMATION in gallons Total # cif Manufacturer's Name Prefab Site Steel Fiber Plastic Fxper
New Existin Gallons Tanks rnrwrete structed glass App
Tanks Tanks
Septic Tank or Holding Tank / ~t~t70 ) ❑ ❑ ❑ ❑
Lift Pump Tank !Siphon Chamber 00 ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for in Ilation of the onsite s wage system shown on the attached plans.
Plum a e (Pri t) Plum Sign urea( /MPRSWNO.. Business Phone Nummbe,
Plumber'sAddre (Street. Gt ,State, (ode).
IX. COUNTY / DEPARTMENT_ USE ONLY
❑Disapproved Sandar Permit Fee e ° ° o ww ;Me. a e ssu Iswl Agent St " re (No Stamps)
Approved ❑ Owner Given Initial wru»yrtRt
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
7( 1cA~•5,`.'• rn-','; C4 ~n r' ^K4.CYC% ~~'0.
SBD-6398 (8.12199) ail ~naunua: onawr re cwrar. Drip <ooe tit. smw s wadi„ y. t~+,~o~. r,r..... no.,w.
ru•w s ~ ~ ~ ~4htY p~~ ~
Wisconsin Deparmn ntotindusby, 5 AND SITE-EN -A TIO PORT Page 1 of 3_.
Labor ar%:Numan Relations
Orvrvon or salary a Bindings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 8 112 x 71 inches in size. Plan must include, but St. Croix
A
rat limited to vertical and horizontal refere point (BM), dr aod,% of slope, scale or PARCEL I.6
dimensioned, north arrow, and location aencnd distance tt *"p0rgad. • 020-1320-00-000
APPLICANT INFORMATION-PLEASE PRINT ALt1NFOWATION R VIEWEDBY DATE
PROPFRTYOWNER- PROPERTVIOCATION
Bridgeland Dev. Co. ; GOVT LOT NW 'A SW 114,S28 T 29 ,N,R 19 W) W
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK x SUED. NAME OR CSM t
1176 117th. St.
CITY STATE ZIP CODE'PH0.VENUMB3Ai'+,~ - 24-La St. Croix Estates First Addn.
LakeVlller t41. 55044 ❑CTY []VILLAGE 2?OWN NEAREST ROAD
{612~u 5C1610w Hudson Crosby Dr.
P<I New Construction Use lTq Residential/Num*41bedioortis ! I Additiontoexisfinlgbuilding--_-_-___--
[ I Replacement ] ] Public or commercial des~nW'-
Code delved day flow _ 600 gpd Recommended design loading rate - 7_ _bed, gpdM2 8 trench. gpolftyxe Absorption area required 858 bed, n2 750 trench, 112 Maximum
design loading rate • 7 bed, gpd1R2 _ .8 trench, gpdRtRecommended infittration surface elevation(s) starting E 95.90' --n (as reterred to sile plan benchmark)
Additional design/ site considerations trenches below rade loweer trench 4.50'below grade
Parent material outwash_. _-F4xtd piam elevation. it appiicable na ft 12
~J
S = Suitable for system CONVWrIONAL MOUND IN GROUND RRESSLRE I AT GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable for s slem US ❑ U ❑ S ®U [3S ❑ U El S ®U C*S ❑ u ❑ S ® U
SOIL DESCRIPTION REPORT
BoringX Horizon Depth Dominant Color Mottles Texture Structure Consistence Botrr~y Roots GPD/ft
in. Munsell Qu. Sz. Can. Color Gr. Sz. Sh. Bed Tin arch
1 0-34 10yr2/2 none 1 lmsbk mfr , gw if .4 !.6'•
2 34-4 10yr4/4 none sil 2csbk mfr yw if 5 6
Ground 3 49-905 7.5yr4/6 none ms Osy ml na na .7 .8
elev.
94.00ft.
Depth to
limiting -
factor
+981.
Remarks:
Boring 8 1 0-9 10yr3/3 none ! 1 lcsbk mfr
gw if 4 .5
2 2 9-21 7.5yr4/4 none sl 2mgr mvfr gw if .5 .6
3 21-11 7.5yr4/6 none ms Osg ml na na .7 i .8
Gourd EqPV94.9 It
- -
Depth to
r
limiting ot..-
facy~ - --r
mW151.
Remarks:
CST Name:--Pkasc hint Gary L. Steel Plane: 715-246-6200
Address: 1554 200 Ave., New Kcftond. WI 4017
Signature: Lz~lr
- Date: 3-16=2000 CST Number. m02298
PROPERTY OWNER Bridgeland Dev.-Co; SOIL DESCRIPTION REPORT page 3
PARCEL I.D.8 020-1320-00-000 -
Depth Dominant Color Mottles Structure GPO/ft
Boring # Horizon Texture Consistence BOi Roots Bed Trend,
Munsell .
in. Qu.Sz Corn. Color Gr. Sz. Sh.
w` 3 1 0-6 10yr4/3 none S1 2mgr mvfr gw if .5 1 .6
2 6-88 7.5yr4/6 none ms Osg m1 na na .7 8
Ground I 1
leev.
98.1 It Depth to - .00
limiting
factor
~II`~ a g 5 S
Remarks: _
Boring # _ -
1 0-9 10yr413 none 1 2msbk mfr yw if .5 .6
92 9-22 7.5yr4/4 none sil Lmsbk mfr yw if 5 6
3 22-33 7.5yr4/4 none co s Osg ml yw na .7 .B
Ground
elev 4 33-88 7.5yr4/6 none ms Osy ml na na .7 .8
99-4 ft. -
t,^I - 1~- - -
Depth to
hmiling ll%%
facto
+88.. -
Remarks:
Boring # 1 0-9 10yr4/3 none sl , 2myr mvfr gw if .5 .6
5 2 9-86 7.5yr4/6 none IDS Osr, M1 Ina na .7 .8
I
Ground - -
elEMr
99.4 R - -
Depth to
limiting
facto+86^
Remarks:
Boring #
Ground
ele+
Depth to - -
limiting - -
facia
Remarks:
$80-83301R 05,92i
STEEL'S SOIL SERVICE
Gary L. Steel Bridgeland oev. Co. 1554 200th Ave.
CSTM2298 NASA S28-T29N-R19w New Richmond, WI 54017
MPRSW-3254 town of Hudson (715) 246-6200
lot ;#24-St. cROix EstATES First Addn.
~2 =40
Itop of 1" pvc pipe C el. 100.00'
t. BM.= top of tel ped(large) -2 el. 100.80'
to
T ~Q' gf ✓
It~e
P
q o
4 R
l_- V\ rJhy
Gary L. Steel
3-16-2000