Loading...
HomeMy WebLinkAbout020-1044-90-000 (2) Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No (ATTACH TO PERMIT) 597387 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: -7 MARK & WENDY STAHNKE TOWN OF HUDSON 020-1044-90-000 CST BM Elev: Insp. BM Elev: [jescriptiom Section/Town/Range/Map No: Coy, crzh_ 4e,4 &I/ 19.29.19.1771 TANK INFORMATION LEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark G--~, t-1N `o 3 .(10034 ELL~eX _ Alt. BM fflA _ Aeration Bldg. Sewer Holding SUHt Inlet TANK SETBACK INFORMATION SUHt Outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic T-! /V Dt Bottom Dosing Header/Man. ~•!fli Aeration e jo Q• zV / -Fees jt Holding Bo f. System Final Grade 1 brt t.t PUMP/SIPHON INFORMATION VA Manufact rer Demand St Cover GPM 42X! Model Number TDH Lift Fric n s System Head TDH Ft Forcemain Lengt Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth ! ( (y 2 DIMENSIONS 3 SETBACK SYSTEM TO `PP ~a I'll BLDG WELL LAKE/STREAM LEACHING Manufacturer: t~ INFORMATION Type Of System: ` - CHA 13 E OR L 1~-r /l{~, s11A^ fawluoc ~,32 Model Number ~ P~ DISTRIBUTION SYSTsr" Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake i ! Length_ Dia Length Pi 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 r Mulched Bed/Trench Center Bed/Trench Edges Topsoil E] Yes No ~I Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 338 BAER DR 1.) Alt BM Description = *V14 2.) Bldg sewer length - amount of cover = T Plan revision Required? Yes No I Use other side for additional information. Da nsepctor's Signature Cert. No. SBD-6710 (R.3/97) c e County Safety and Buildings Division ,S F 201 W. Washington Ave., P.O. BOX 7162 Sanitary Permit 4N. P j , W1 53707-7162 umber (to be filled in by Co.) $ P-A L" Madison55'73'9 7 11CGTL10I1 State Transaction Number 1 ipp .VIA. In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the aS is required prior to obtaining a sanitary permit. Note: Application forms for state15 submitted to P oject Address (if different than mailing address) the Department of Safety and Professional Servies. Personal information you provide may be used for s c~I ry ur oses in accordance with the Privacy Law, s. I5.04(I)(m , Stats 11 IN 1. Application Information - Please Print All Informat'~ Property wner's Name Otm el # 1, 6t"~i 4r rfN~« G J v - G q q - 70-- r✓d c Property Owner's Mailing Address q Property Location 19 7 1: City, State Govt. Lot 1-41 Lip Code Phone Number Section 14~ ~ jVr✓~ '/4, _ o6 o `,g ( SVbl/ ' I/ / '~K (circle one) 11. Type of Building (check all that apply Lot # T N; R E o~o or 2 Family Dwelling - Number of Bedr ms 3 Subdivision Name lock # /lAA 1,Y*-8 ❑ Public/Commercial - Describe Use ❑ City of ❑ State Owned - Describe Use CSM Number ❑ Village of i ❑ Town of l-tu~~` ~J 111. Type of Permit: (Check only ofie box on line A. Complete line B if applicable) A. - ❑ New System eplacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. El Permit Renewal El Permit Revision El Change of Plumber List ev, us Permit Number and Date Issued ❑ Permit Transfer to New Before Expiration Owner VV D 2 IV. T e of POWTS System/Con onent/Device: Check all that apply) Von-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ o mg'fank ie-r ispersal Component (explain) ❑ Pretreatment Device (explain) d) Design Soil Application te(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed t) System Elev_at on 1// 7orHolding Dispersal/Treat reat ent Area Information: / ~ 7 Capacity in Total # of Manufacturer Gallons Gallons Units 0-10 New Tanks Existing Tanks eL~ -46 rR _2 Tank V11. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber'' lgnature _ ,Il. MP/MPRS Number Business Phone Number ~y'75 ~~5 lea 5~~~=1 Plumber's Address (Street, City, State, Zip Code) VIII. ount /De artment Use Only Approved isapl Permit Fee Date ssue Issuing nt Signature Ow Zeason for Dcmal $ IX. Condtt»7il R Reasons fori Disapproval i . ' pbks glide ettlt~l:rt il~eT rt~" s&i ce" must all be se-i'Ag s er aspillifWiagement plan pta/ide1 by plumLe;. 2 1 .k mqurerwnis must tn.* r. Ks;rt, r i n per WkWs C46! I irkincti. Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size SBD-6398 (R. 11/11) c.. C i Q \ M ~ I I ~ j i C ySi yz 'x ~ ~ , ; i ® ~ ~ ~ ~ ~ J ~ L! d M - y 1 + f ! 1) c! Ov~ w c C~ CONVENTIONAL COMPONENT DESIGN Residential Application n. INDEX AND TITLE PAGE Project Name: (...Je_*_ 124 1dL V%%e_ Owner's Name: Max ( Malp k. Owner's Address: 331 Qa,e_r- Je Ny~~so-~. WT, . StiFot to Legal Description: 5 N~ St,G. C 29 ~9 cli Township: ~d0~0 County. Subdivision Name: Lot Number: Parcel ID Number: 020 000 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 11 Attachments: Soil Test & House Plans JPil~ ~~l Designer/Plumber: ZZ-..T 7577 License Number: AA, Date: G~Z$~17 Phone Number AS- 760' Signature Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01/01). Page 1 - -'y - A ~qj o ~ S ~ Q 0 ~ ~M 3 Zw a z Qi ll J V w J i L Z- 14 ~I N "t Vi m _ o ~ ~ 4 40 N I Ill 4J ~ r J 3~ ~ d I . Soff Absorption System Cross Section Mo f 4° Schedule 40 Final Grade PVC Vent Pipe With Vent cap Leaching Chamber System Elevation ft ft Soil Absorption System Pion View ft ft -3-ft Vent Or Observation Pipe Leaching Trench 1 Chambers 4° Dia. Trench 2 Header Leaching Chamber Specifications FEISA urer And Model _►(ka~..Gfe~Tw~aQ.~ ~~5 . sq ft per chamber Soil App lication Rate i7 gpd/sq ft w = ~ *7 Soil Application Rate ZD EISA = Z Chambers 2 rows of chambers each. Page of 111111111111 Oilick4 Quick4 Plus Standard Chamber ~VAVA 48' 34' I EFFECTIVE LENGTH Quick4 Plus All-in-One 12 Endcap PRESSURIZED PIPE DRILL POINTS LOCATIONS (2 PLACES) 6.8'INVERT Q 13 33' FRONT VIEW SIDE VIEW INFILTRATOR WATER TECHNOLOGIES, LLC (°INFILTRATOR'1 Quick4 Plus All-in-One Periscope InirroatorWaterTea.taoOMLLCSTANOMMUMITWDrai"fie,dWARRANTY (a) The structural integrity of each chamber, endcap, EZfI" expanded pdystylene accessory manufactured by Infiltrator (,,Units'), when installed and operated in a leachfield of an QUICK4 PLUS onsite septic system in accordance with Infitrator's instructions, is warranted to the original pur- ALL-IN-ONE PERISCOPE chaser ("Holder') against defective rreRerials and workmanship for one year from the date that the (360° SWIVEL) septic permit is issued for the septic system containing the Units; provided, however, that if a septic O permit is riot required by applicable law, the warranty period will begin upon the date that installa- tion of the septic system commences. To exercise its warranty rights, Holder must notify Infiltrator in writing at its Corporate Headquarters in Old Saybrook, Conriedicut within fifteen (15) days of the alleged defect. Infiltrator will supply replacement Units for Units determined by Infiltrator to be covered by this Limited Warranty. infiltrators liability specifically excludes the cast of removal and/ 12.7' INVERT or installation of the Units. Q (b) THE LIMITED WARRANTY AND REMEDIES IN SUl3PAR/VCf1APFt (a) ARE IXCLUSIVE. THERE ARE NO OTHER WARRANTIES WITH RESPECT TO THE UNITS, INCLUDING NO IMPUED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE (c) This Limited Warranty shall be void if any part of the chamber system is manufactured by anyone other than Infiltrator. The Umited Warranty does not extend to incidetal, consequential, special or indirect damages. Infiltrator shall not be liable for penalties or liquidated damages, including loss of 4 production and profits, labor and materials, overtnead costs, or other lases or expenses incurred by the Folder or any third party. Specifically excluded from Limited Warranty coverage are damage to 6 the Units due to ordinary wear' and tear, alteration, accident, misuse, abuse or neglect of the Units; the Units being subjected to vehicle traffic or other conditions which are not permitted by the instal- lation instructions; failure to maintain the minimum ground covers set forth in the installation instruo- - 9„ tions; the placement of improper materials into the system containing the Units; failure of the Units l or the septic system due to improper siting or improper sizing, excessive water usage, improper grease disposal. or improper operation; or any other event riot caused by Infiltrator. This Limited Warranty shall be void if the Holder fails to comply with all of the terns set forth in this Limited Warranty. Further, in no evert shall Infiltrator be responsible for any loss or damage to the Holder, the Units, or arty third party resulting from installation or shipment, or from any product liability claims of Holder or any third party. For this United Warranty to apply, the Units must be installed in affiance with all site conditions required by state and Io aJ codes; all other applicable laws; and Infiltrator's installation instructions. (d) No representative of Infiltrator has the authority to change or extend this Limited Warranty. No A, 1 4 Business Park Road warranty applies to any party other than the original Holder. The above represents the Standard P.O. Box 768 Old Saybrook, CT 06475 United Warranty offered by Infiltrator. A limited number of states and counties have different war- 860-577-7000 • Fax 860-577-7001 rarity requirements. Any purchaser of Units should contact Infiltrators Corporate Headquarters in Old Saybrook, Connecticut, prior to such purchase, to obtain a copy of the applicable warranty, and a 4 221-44 should carefully read that warranty prior to the purchase of Units. www.infi ltratorwater.com ww.i U.S. Patents: 4,759,661; 5,017,041; 5,156,488; 5,336,017; 5,401,116; 5,401,459; 5,511,903; 5,716,163; 5,588,778; 5,839,844 Canadian Patents: 1,329,959; 2,004,564 Other patents pending. Infiltrator, Equalizer, Quick4, and SideWinder are registered trademarks of Infiltrator Water Technologies. Infiltrator is a registered trademark in France. Infiltrator Water Technologies is a registered trademark in Mexico. Contour, MicroLeaching, PolyTuff, ChamberSpacer, MultiPort, PosiLock, QuickCut, QuickPlay, SnapLock and StraightLock are trademarks of Infiltrator Water Technologies. PolyLok is a trademark of PolyLok, Inc. TUF-TITE is a registered trademark of TUF-TITE, INC. Ultra-Rib is a trademark of IPEX Inc. PLUSOS 0816 0 2016 Infiltrator Water Technologies, LLC. Al rights reserved. Printed in U.S.A. I WN~ 4,` F LTRATOR" PlUSTM Series The Quick4 Plus Standard Chamber offers maximum strength through. its two center structural columns. This chamber can be installed in a 36-inch-wide trench. Like thek ` # M R L ' ;original line of Quick4 chambers, it offers advanced contouring A..°mw capability with its Contour Swivel Connection TM which permits turnsn up to 15-degrees, right or left. It is also available in four-foot lengths to provide optimal installation flexibility. The Quick4 Plus All-in-One 12 Quick4 Plus Standard Chamber Benefits: Endcap, and the Quick4 Periscope Two center structural columns offer increased stability and superior strength are available with this chamber, Advanced contouring connections providing increased flexibility in system configurations. Latching mechanism allows for quick installation Four-foot chamber lengths are easy to handle and install Supports wheel loads of 16,000 Ibs/axle with 12" of cover t7- Specifications Size Quick4 Plus All-in-One 12 Endcap Quick4 Plus All-in-One Periscope 34"W x 53"L x 12"H Benefits: Benefits: (864 mm x 1346 mm x 305 mm) May be used at the end of chamber Allows for raised invert installations Effective Length row for an inlet/outlet or can be 180° directional inletting 48" (1219 mm) installed mid-trench 12" raised invert is ideal for serial Mid-trench connection feature allows applications Louver Height construction of chamber rows with 8" (203 mm) center feed, as an alternative to inletting at the ends of chamber rows Storage Capacity Center-feed connection allows for 47 gal (178 L) easy installation of serial distribution systems Invert Height Certified by the International 0.6" 15 mm), 5.3" 135 mm Pipe connection options include ( ( Association of Plumbing 8.0" (203 mm), 12.7" (323 mm) sides, ends or top and Mechanical Officials 0APMO) APPROVED in 11 11 1 w-l-il'i SECTION: 3.20.065 , lKWZ/TV PUMPS ~//NCE lqyp FM1775 0809 Product information presented Supersedes here reflects conditions at time ~L j 1 0308 of publication. Consult afac- t t tory regarding discrepancies or inconsistencies. MAIL TO: P0. BOX 16347 • Louisville, KY 40256-0347 visit our web site: SHIP TO: 3649Cane Run Road •tou&tlle, KY 40211-1961 www.zoelter.com (502) 778-2731 • 1(800) 928-PUMP • FAX (502) 774-3624 ZOEMER ONSITE WASTEWATER PRODUCTS m • EL M71 11, G TWIST LOCK MECHANISM BY-PASS PROTECTION Inner cartridge is held firmly in place, but Sleeve remains in the outlet tee ( - can be easily removed for servicing. when the main filter is removed for servicing. Solids are prevented; N from leaving the tank. GASKETED SEAL LOCKING TAB Rubber gasket ensures that all effluent Zoeller invented the locking tab to prevent passes through the filter, not around it - the filter from floating out and keep the 4,;W- - i Provides protection in all commonly found' by-pass sleeve in place when servicing. 4" outlet tees. DEEP PLEATED CONSTRUCTION SUPERIOR FILTRATION Design adds more effective filter area than A(l 132 linear feet of 1/16" filtra- any other 4" filter on the market. Pleats tion is located below the water retain solids to aid in servicing. line, making the filter 100% effective. CLEAR ZONE ACCESS l Once installed in the tee, filter pulls effluent from only the "clear zone" of the tank. Available NSF t with sanitary I tee and filter complete. cPrtred I. ANSI-NSF 45 F Covered by US Patent Nos. 6,136,190; 6,331,247; 6,495,040. 170-0144 © Copyright 2009 Zoeller Co. All rights reserved. s ~ a Application: Single family homes. LLER SEPTIC TANK RISER AND LOCKABLE LATCH Filter Area: 132 Linear Feet of 1/16" filtration. Flow Rate: 1,000 GPD. Two or more filters may EXTENSION HANDLE be connected with a manifold for higher flow I applications. Material: All materials are noncorrosive in the septic SLEEVE OUTLET tank environment. Sleeve is PVC, primary filter FILTERING is polypropylene, and filter connection element is I CONNECTION ELEMENT neoprene. NOTE i 51, 4" SANITARY TEE I Easy to install or retrofit: The Zoeller Septic YOTAL LENGTH System Filter fits inside any 4" sanitary tee. Slide the filtercartridgeinto the filter sleeve. Slide the assembled cartridge and sleeve into the sanitary tee at the tank's outlet. Ensure the sleeve tab is pointing toward the 4" DRAINAGE PIPE outlet of the septic tank before filter placement into the tee. The drain field is now protected from solids greater than 1/16". SK1972 CARTRIDGE Adding an extension handle: A 1/2" PVC pipe can Eimothe ate and local plumbing codes may require be attached to the top of the filter with a stainless steel screw. Cut quidpenetration.Forexample,25'o-45'. uid depth or 9" off th e tank bottom. off to appropriate length below the lid. Easy to maintain: The filter can be maintained by rotating the cartridge counterclockwise out of the locking tabs and removing for cleaning. The sleeve should remain in the sanitary tee while cleaning the cartridge. To clean, hold cartridge over septic tank opening and rinse with a hose until clean, washing filtered solids back into the septic tank. In addition, spray off any solids that have accumulated on the inside of the sleeve. The Zoeller filter should be cleaned each time the septic tank is pumped or when the need is indicated by a high water level in the tank or slow flows from the house. The secondary filter sleeve should be cleaned whenever the tank is pumped. For installations that exceed the design flow rate of the filter or in applications where the septic tank is undersized, more frequent cleanings may be required. It is best when the filter is inspected and serviced as part of a regular septic tank maintenance routine. Troubleshooting, repair, and replacement: Follow the install and maintenance instructions above. For replacement components, call 1-800-928-PUMP. Lifetime Warranty: Every Zoeller filter is guaranteed to be free from defects in materials and workmanship for the lifetime of the homeowner/purchaser. Free repair or replacement, excluding labor, will be made on i+ return of the filter prepaid to the factory. This warranty is limited to product proven to be free from abuse or improper installation. ALL ZOELLER ONSITE PRODUCTS MUST BE INSTALLED IN ACCORDANCE WITH PLUMBING AND HEALTH DEPARTMENT CODES. Distributed By: ,i~Z-7 7 Y \ \ p Zz/ 1-800-928-PUMP www.zoeller.com © Copyright 2009 Zoeller Co. All rights reserved. ti M 00 rn 04 J ~ W M ^ ° M V- 0 ~ 8s ~s~ CANT M ° Zc`i O U - N C) co m 0- o co i C!1 0 ti N 287.62 v 3 284.75 N P-- 99'999 LO 90'9L9 C co e co cl, r LO M ~ ~ rn o O O M cl X33.2 ~ ~ V to oo 0 1~a cn co PG cz~ ~ ~P ~ 2~~ ~ ti X30 ` o m h It P~ rp 201.7 a cp. >9L6 N 6zz ~.00 Q~ z ti c, 0 - M zzz M co N 2 ti ON ) ° X 0) T- I ,C~ ^ cc ST. CROIX COUNTY SEPTIC TA\TK MA-D\7ENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Mailing Address 5 3 ~-7 19'w" bf've 144s' L-z Syu~ Property Address `3.3 -67 tL' Y~~Zr i tlJ 5 v tLC (Verification required from Planning & Zoning Department for new construction.) City/State Z41 d,5,(-V ~ is o ,!!~4c) tz,- Parcel Identification Number /'9 LEGAL DESCRIPTION Property Location 7 V4 V4 , Sec. T N R Jar W, Town of '14"' 5cv,L. Subdivision Plat: Lot # Certified Survey Map Volume Page Warranty Deed # (before 2007)Volume ,Page # Spec house El yes 0 no Lot lines identifiable 0 yes ❑ no SYSTEM NLALNTENANCE AN-D 0W--N;ER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper. maint_^rance consists of pumping out the septic tank every three years or sooner, if needed., by a licensed pumper. Vrrhat 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 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 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. Cer tTaoaiion stating that your septic system has been maintained must be completed and retumed to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. I/we certify that all statements on/is form are true to the best of my/our lmowledge. Uwe am/are the owner(s) of the property described above, by virtue of Tanty deed recorded in Resister of Deeds Office. Number of bedrooms 3 L?3, SI ATU-R.E 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 certi5ed survey map if reference is made in the warranty deed. (REV. 04/12) ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING 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) located at: $c' 1/4, ~ w~ '/4, Section /9 Town N, Range /It Town of 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 Comm. 84.25, and it (they) appear(s) to be i anctionin g pr oper ly. Most recent date of inspection or service /lam Did flow back occur from absorption system? Yes No _N, (if no, skip next line.) Approximate volume or length of time: gallons minutes Tank Capacity: Construction: Prefab Concrete, Steel Other Manufacturer (if known) : Age of Tank (if known) : Permit number (if known) AVae (Licensed k-,;:: er Signature) (Print Name) AL/ 61. '212, (Title) (License Number) MP/MFRS (Date) Form to be completed by licensed plumber (Dept of Commerce Chapter 5 and s. 145.06, ~ isconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 9/2008 wiisconsin Department of Canvnerce SOIL EVALUATION REPORT Page of Division of Safety and Buildings in accordance with Comm 85• Yft. Adm- Code /y 5 Cf2d lx Attach complete site plan on paper not less than 81/2 x 11 county include, but not united to: vertical and horizontal reference point M), V ED P I.D. percent slope, scale or dlmenstons. north arrow, and location and 'stance to nearest road. 02-0 Please print all information. F R Date Pemonel sa You povwo may be used for aqr L.ae~, T5.a`(tr(mJ/OU Owner j,-U6Y-/A-k- ,e K J) N YC (,J 1/4 S %-f T 29 N R I/ E (or) W Plm' Owner's Mailing Address Lot # Block # Subd. Name or CSM# -9:3 T Cb TA, A ► 4r 'd ad 1 16 Stale Zip Lode Phone Ntmtber ❑ Ciry ❑ e Town Nearest Mupso,.~ c ) ~so~ cro ''A" ❑ New Use J6Residential / Number of bedrooms Code derived design flow, rate GPD Reptacernant ❑ Pubic or oamteraal - Describe: P matuxial L e-rd Flood Plain elevation if applicable PA ft. General canrrrents and recomirneridations: La fkja< P"S'? JL5 MmCRY A»C - ~~~~.ft2faa Boring f P-1 9PBoring it Grouridsurface elev./40•Z it Depth m raiding factor > l 1 b in Sod ApOicatiort Rate Horizon Depth Dominant Color Redox Description Texture Structixe Consistence Boundary Roots GPD/ff in. MunseL Qu. Sz. Corte Cow Gr. Sz- Sh. 'Eff#1 'Eft#2 A -6 - sc. 654 1 ph 0.4 d.6 -!g MS CS/4 CS 1 m 6:1, / 0:7 UL t i Z so" # 2 Boring An0 Pit Ground surface elev. 10 .6 ft. Depth to limiting factor > rJ 1 in. Sod Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Rods GPD/fF in. Munsel Qu. Sz. Cord'- Color Gr. Sz- Sh. 'Eft#1 'Eff#2 Jo a s c n, t /41 a •A G M:S 56 i'h Ls 6--7 t Eflk*wd #1 = SOD > 30 < 710 rngrl and TSS >30 < 150 ' Etlkuent #2 = BM ,:5 30 mg& and TSS < 30 rrg& CST (Pleas!MAisd - - CST Nttrrtber Jtv Vdrf" ZZ7 7 Date Evakuation Ca"ducted Telephone Number i u11s~ 6-4 oZ 319 G 40 o Property Owner AHgt kE Parcel to # page Z ar rJ1 AF Boring # ° Boring Pit Ground sumacs eiev.160 -rc tt. Depth So tlM;6V tadar~* 7 b in. SOS ~ R Horizon Depth OominiaM Color Redox Description Texture S'fucturei Consiia Vnce Boundary Roofs GPDIff' in. Munsel Qu. SL Coat. Color Gr. SL Sh.b 1 'Efl#1 'Eff#2 -r /o z 5c / 6,6 /av fps S4 ref 1 - ,Z El /W ❑ pit Ground surface elev. ft. Depth to tinting factor in. Sad Rate Horizon Depth Application Dm* wt Gokw Redox Description Texture Structure Consistence Boundary Roots GPD/PF in. Mtunsell Qu. Sz. Coro. Color Gr. SL Sh. 'Eff#1 'Eff#2 a Boring # ° Boring ❑ pit Ground s wbw elev. ft Depth to Yrifirg tads in. Sol Rafe Hart= Depth Dominant Cobr Retiox Description- Texture Structure Consisferx~e Boundary Rooft GFUM in. . Munsei Qu. Sz. Cont. Color Gr. SL Sh. 'Eff#1 'Eff#2 Effluent #1 = BOD6 > 30 < 220 mg& and TSS >30 < 150 mg& ` Effluent #2 = BODS < 30 nxllL. and TSS < 30 rnWL The Department of Commerce is an equal opportunity service provider and employer, if you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SS"3Q(R W) ND~~ ScALI 1.36 ,J Env- ~no.8 ELEv- ~j 'V T 3 -j'4'p$p5z. gaGrtF'I &LL IZt 171. Ldu2T Ca Al 10 gG.~uCgI►QY-- `7i.J CUQ a/~ l f, E~Ev-106:L 1 X13' t ~y 3ooL'~,~ ~ ► G>A~ac,~s ~I ►JwCvc~,e2- Aee„-r,%apj-To r~,pYtti SEW vQ BE>w" laoLxc CL~~- ~03.9~. • e Form - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP SEC. r_ T _N-k_ W ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I?LHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM OVe,c S~ ~ .e y 70 N T1-! PaeaE'ty Lii.e>' `1 & = Sound . ~ 3, ~ ~ • P.~rxRrr L=.,,F 6 I vre S7x ue ti...~ ,:Ye PE , I c yo 7• G,vt t✓ /Deo GAL. J'FPTJC;. e EXZS rs,~G ' Tn ti/C 0 CAAAGE I 57~ 87 c., L x.rs-ri../ c ~ /Z~ssoL'ivcs 6VE(L /OD" To fu~rN C aePEn.TY Lx"a INDICATE NORTH ARROW /2'U SGN LE BENCHMARK:. Describe the vertical reference point used Elevation of vertical reference point: ,L1U124- Proposed slope at site: SEPTIC TANK: Manufacturer: Liquid Capacity:) Number of rings used: / Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front 10 Side ,Q Rear O (1 U feet '.From nearest property line Front,O Side ,O Rear, O feet Number of feet from: well building. ~ • ~ w (Include this information of the bove lot P plan)( 2 reference dimensions to septic tank) SEE REVERSR crnp Pulp CHAMBER Manufacturer: Liquid Capacity: Pump/Siphon Manufacturer: Pump Size Pump Model: Elevation of inlet: Bottom of tank elevation: pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: line: Front, O Side, O Rear, Q Ft. Number of feet from nearest property Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: AEf Trench:. ~1 Width: Lenith:_se Number of Lines: Area Built: b/l ~OS It Fill depth to top of pipe: ~C~ Front v O Side, O Rear,Pt Number of feet from nearest property line: v Number of feet from well: / Number of feet from building: (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, 0Ft. Number of feet from well: Number of feet from building: + Number of filet from nearest road: Alarm Manufacturer: Inspector: Plumber on job: Dated: License Number: 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION MABOXDISON, , WI ~NI 53707 BUREAU OF PLUMBING MA CONVENTIONAL ❑ALTERNATIVE State Plan I.D. Number. Ilt asstynedl ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER INSPECT14 I N DATE: Gene 9tahnke Route 5 Ct . Tk. A Hudson WI s - :3© BEtf rMARK (Permanent refe,encepo,nl( DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: 71 , PT. ELEV.. SE4 NW4 Section 19, T29N-R19W, Town of Hudson Name of Plumber. MP/MPRSW No.. County. Sanitary Permit Number: Gar Za a 3300 St. Croix 69624 SEPTIC TANK/HOLDING TANK: MANUFACTURER ` LIQUID CAPACITY. TANK INLET ELEV.. JTAN~OUTLET ELEVARNING LABEL 2~ ,1 C PROIDEDPROVIDEDBEDDINGV~,,•J / YES ❑NO ❑ NO . Id. I ALARM NUMBER OED ROAD: PROPERTY WELL: BUILDING. VENT TO FRESH L/ / FEET FRDM:. < o Q. LINE. / ~~~ll AIR Ip LEj. ❑YES ~ O ❑YES ❑NO NEAREST (J yV/+y DOSING CHAMBER: MANUFACTURER BEDDING. JLIOUIDCAPACIIV PUMP MODEL PUMP;SIPHON A if A(:IUHEH WARNING LABEL JLOCKING COVER PROVIDED: PROVIDED: ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO GALLONS PER CYCLE: PUMP AND Co. TROLS OP ER ATION NUMBER OF PROPERTY JWBUILOWG VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINI AIR INLET PUMP ON AND OFF) ❑YES NO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plow ulnnaF TEH MATE HInI AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until Ft3RCj the soil is dry enough to continue.) MAM NN CONVENTIONAL SYSTEM: ~I:D/TREIy ' WIDTH 11111T'It3 NOOF JDISTIL PIPE SPAI;IN1 COVFFH NSIDL DIA -PITS LQUID c C THE NCNFS ntATEHIAL' PIT DEPTT GRAVEL H FILL DEPTH DISTH PIPE UISTH PIPE DISTR. PIPE MATERIAL NO DIS t NUMBER OF 'PROPERTY WELL BUILDING. V NT TO FRESH BELOW PI P'S ABOVECOVER ELEV INLF I ELEV ENO PIPES LINE AIR IN ET 2 a . Sl 9 / NEARIEsT°"' u~ ~1~5 G3 6 MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- ❑YES ❑NO meets the criteria for medium sand. TIONS MEASURED. SOIL COVEIR TEXTURE PFHn1AN T MAI FH 0135EHVATION WELLS E ❑NO ❑YES ❑NO DEPTH OVER TRENCH BEp ID E PTH OVER TRENCH BE O OEPTII OF TOPSOIL Sf IIIOVIS SFEDTII J MULCHED CENTER EDGES / JN 0 ❑YES ❑NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH NO. OF j0T L ACING 77TH 111,1 PIPF FILL DEPTH ABOVE COVER BED/T~RENCH : TRENCHES DIMENSIONS MANIFOLD PUMP MANIFOLD IPE MA OL D M TEHIA UISTH DISTRPIPE DISTRIBUTION PIPE MATERIAL MARKING FLEV. ELEV CIA IPES OIA ELEVATION AND DISTRIBUT ION INFORMATION HOLE SIZE HOLE SPACING OHILLEDCOHR COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS ❑YES ❑NO ❑YES ❑NO COMMENTS PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: JBUILDING' FEET FROM LINE. ❑YES ❑NO ❑YES ❑NO NEAREST' SO( Sketch System On L,L 4eialn in county file for audit. Reverse Side. SIGNATURE. TITLE. / DILHRSBD67101R.01/82)