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HomeMy WebLinkAbout020-1053-30-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 597402 GENERAL INFORMATION (ATTACH TO PERMIT) 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: MICHAEL DUDINYAK TOWN OF HUDSON 020-1053-30-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: /DO GS 20.29.19.197E TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER t CAPACITY STATION BS HI FS ELEV. ♦ J Septic Benchmark LJ S r 3 , /6Cb /-.3 161. 3 /66 Alt. BM 4-4-11. 97~ a Aeration Bldg. Sewer 3.1 Holding St/Ht Inlet 7• a5 /~r 215 TANK SETBACK INFORMATION St/Ht Outlet 7,5$ C?5. 7 TANK TO P/L WELL BLDG. ent t it Intake ROAD Dt Inlet Wes Septic x 96 1 1141 1:5 Dt Bottom Dosing V Header/Man. 1 9 3 Aeration Dist. Pipe Q ` Z Holding Bot. System q• Z y~•IS Grade e~ PUMP/SIPHON INFORMATION Final 77> ( 9'` Manufacturer De and St Cover Z 9'T• 1 Model Number GPM TDH Lift Friction Loss System Hea TDH Ft Forcemain Length Dia. Dist. to Well J0~ yL SOIL ABSORPTION YSTEM 3.'lt q(o, S8 ength No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth BED/TRENCH Width 7%'4- DIMENSIONS L9 SETBACK SYSTEM TO /P/L BLDG, 1WWEELL`L LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR ~7• I ~w~--.rL Type Of Syste C ♦~7r~r w UNIT Model NumI;iRr • a„W a et / XV ~ G,F DISTRIBUTION SYSTEM 7,36a ZZ~ e. ~✓S Header/Manild it Distribution x Hole Size x Hole Spacing Vent~(o~4ir Iryta4 e Pipe(s) v~ Length Dia r Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Dept of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edgesi Topsoil ♦ b S Yes No YesI No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 464 JACOBS LA C' /tom 1.) Alt BM Description = [ C~ a ♦ ^ tJ,S 2.) Bldg sewer length 4`'k - amount of cover = Plan revision Required? ❑ Yes 0 (7 Use other side for additional information. SBD-6710 (R.3/97) Date Insepctor's Sign ure Cert. No. y fly RE~wj VED County \ ♦ Safety and Buildings Division (r 201 W. Washin ton Ave. P. I JUL 2017 9 O. Box 7162 Sanitary Permit Number (to be filled in by Co.) Illladis .~1/Vl 7C 76 o sroNAtig° uCROU(COU _NP 30 a.I• 1 ' _ Permit A V 8GZ3PEH 1 YX4C State Transactio rber In accordance with SPS 38321(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit, t~rote: Application forms for state-owned POW TS are submitted to Project Address ("if different ittan mailittg address) the Department of safety and professional Servies. personal information you provide may be used for secondary purposes in accordance with the Privacy Law, s. 15.04(l )(m), Stats. G~ L Application Information - Please Print All Information Property Owner=s Name Parcel # ` IJ U.1i ti hp~V (3,4 6x3 Property Owner's Mailing Address ~ `t ~b ~ ~ ~ .S ~ Property Locaiiand i9 7 Govt Lot Citv, State 1 u Zip Code Phone lumber Section A~__ _ r~ ~W W lJ Q ~rcle one) IL Type of Building (check all that apply) Lot # T r N; R E or w ❑ I or 2 Family Dwelling - Number of Bedrooms 3 Subdivision Name Block # c S)vi t. ` I' 3 I Q i ❑ Public/Commercial - Describe Use I9L ❑ City of ❑ State Owned - Describe Use CSM Number ❑ Village of 3 1 A- GJpt4 t f ` l 3 1~J v s 3 Town of 1l NO III. Type of Permit (Check only on box on tine A Complete line B if applicable) ❑ New System ; LReplacement System 0 Treatmenl/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) R ❑ Permit Renewal 1 ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration t Owner IV. Type of POWTS System/Component/Device- (Check all that app [ ! Y) f Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound = 24 in. of suitable soil Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) 1 V. Dix rsal/Trea ent Area Information: Desigtl I IQw (gpd) Design Soil`plication Rate(gp Dispersal Area Required (s) Dispersa Area Proposed ( System Elevation 50 's 106 1 VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units o a New Tanks Existing Tanks SZS a U rn u; CIO GT C7 ll. ' Septic or Holding Tank Dosing Chamber - VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's N me (Print) um 's Si a MP/MPRS Number Business one Number Ym gat aa~~ X11 -fib 4a Plumber's Ad°d~ress {Street, City" State dip Code) VIII oun /De artment a t?nl Approved ❑ Permit Fee Date ued Issuing nt Signature Own ven Reason for Denial ~ (J~ • $ `7 / 7 Ib. Conti" Weasgns for Disapproval lark t#fltasn; riftevnil 4A ' 3, 6 bi- loc.. a, +3b iersht ceft must till t&A S !t nl~ in -,K ,j1NM' ►en• Plan pro tided by plumber. ~.O M PW C~t€ / aditltlfm. Attach to complete plans for tLe swum and submit to the County only on per not less than 8 jr- s 1 i inches in sine SBD-6398 (R_ 11/11) 1Mti~l"~ s 4"OC44A'>n, WY 3-o,A5 L L f 4 y .F k t 6 { ~ ~hR ' it L/ TI, ti , ti L p-, . • 1 C.~ , Owns-",r's Name tl I __...w..._._,...._._ / S Como pas 1 fir.. 2 f 8Q r', 3 Papa Pago For~i'p We Fs n (:Y. I~acac~cl pa, I ~ ; '(tea+~;v O~iFa. 7 4a,.Q1 ~1 r,~~IrldtYl•~~C I' 4~snr,nf r,l Ca>>17r ;l~~tr~ira! rn, P11~i7:S VF;i5it9n ~,O ~`t,3i1,.9r ~fl~~~~,~,.~ f'sicje 7 I i VAX 1060 3x~,t~ ~ (3QO~o~M rs t H i I Nce~li1px TO? i i 4" Scilodtrle ? - - iY PVC vent pipe + In-a,} L3rSl+dF tnfif{~ Vayjf (lap Leaching 3'_'_-,1 f I M11 I M wilm"I"Emalfix"I Ma"u, LGavM-j!g Trench _ ~h+atYibc~:, ....E ; e Irancli 1, e-n' Or ©b-S--fvaticn Pipe } ~Trench i ~iatl'Iffackwer ARCl Model I~ PISA PiaE}n4_ SG} Pa,- chamber Soil- Ai"rcatio g~ t~es;9o, }=lover re R~f~ sAd~sq ft Snit Ap}3}ic8#iop Rate + Page of Technical Specifications PL--525 EFFLUENT FILTER WON CN ro1 ;ms's ( - EXCEPTS 6'SHD 40 it A1435 T FURI ETEXE'N7_N 57 L-S~aHNGERCEPT3 ' ~ SCH 4C d 5 Sl,ti 1G 1417, i._I 7-7- r- ~ I I, I ~I 5 23 33 A 44_x, 1894 PL-525 FILTER HOUSING PART N0. -30142-525 U ATERI AL A HOUSING • POLYPROPYLENE OUT-ET BUSHING -PVC 6,49kL -HDPE --ll L - 3GCXETEXCEPTSF,DATS~u TCN 1=~ 7 10 23 j 98 ExC°_ SC~l LEN 10,84 FOR «IM EX i1Cn 5 24 ca0'OFI"6'S'; M =r. 47 9.56f. _ - 9GJ(:T't XGEPTS 6.04 _ 3kL PUSH ROD OPENING _ - _ - , ~769 ~ i I i, 1 ~G NG 1 20, \ 1~L ~ I O i' c, ecz .a4~ i j, P POLYLOK PL-525 FIL7R CARTRIDGE II PARTNO,- 30141.525 MATERIAL -PCL PROPYLENE V o o I POWTS WHEW MANUAL & MARA NT PLAN FILE INFORMA-TIO N S'Y-Igr 4i SpI'>m]l l R! ~ ilnrnar I L~A Pv $opt;; lank -srwaclty fa dal i~ NA Permit $epft Tank Manuf-Agu4 mr V~3 ~ ~ S e IC M NA ii l~ i fii PAi . • . _ S pro P"tt«ar~lo9 t(f zszrGlf~At J 4 ( Gl WA Nvmhar of der!:rpvms 0 NA >aff4went Flit r Mod at s l"i MA Number of PLINIO Fpcilky l Trim ~ NA Pump T Rn c Cepaphy _~3 PEA Eemate~i Afi3w toverana? 360 lid rum Tank IMIRntaf=Ulfar M NA t Damon Tlovv lp klr irs2irfT d x 1.5) T ll~iPump Mtnuf Ctwrsr M NA ~ i MNA 2 p Mahal _ SolSoll; Ap plia'tlala l.Tis -W all I V P rri - ^ w s Pre'es'tment Linn l~ NA ti Stsnd>xr~l ir~~l~serrC/p~`!Ur'n't Q~ssil~l' iUt~rlrt[x, ~.vers(3n Pm, Oil & Cro"a Inia'} ?~Bf~ Cl »qnd/Gravsl Filter Pam HIM i Siachemi0al Oxvgon Demvd (REDS) ~2~tf MR/l- C NA Ca IUiatta47Tca! Aare-ton C1 W, 1%90 srlrn ~1 ri4ar 'CIF'O mg/1' s T 0-mi Swaper deg? r ills t i5~, 0 NA Pretrap-Ad -R~lrIaMt 4;?w01Y l1ltr~RGhly aver ~,e rllsper at el(ts} ' ~ic~fl- ~ ~ t~+in~~ wand {graui~l ~ In,>~ra4;nd lpreeot~frl~edi• 5iacheminal Okraon F~VmEnn (Suzi 0 Mawnd ~rgll 014A CI A«„~~trsds T n~ ai Sciepandad SaiYda f i } ( l ripJ Tna ENi 6h>ar. c eWal C~ii rt~x f rr~a ric pT} IT at,wf 7' m1 NAys t t~trerl ri tit&e INA a A Maximum ~u IA sr4t Pa~lcte Size ~ ~ CT ~iA `~»hert k Y r}:}tar: r Gtha----t- 1w N' r °`i~ditta~ gypiral 4~r syamrasagc tvnsrsuw~aY Intl a9lsttn "H;tk e~la.~rfi. . ii:tA4~'4'•~IY~!'~'1`' S'i~ki1~LSLi.L~ ;;~+~rtrt^a ~"3'~.~u~Ri";~. l 9 1~~."sca n t i i' t I i4 iv ID ~aaca; M NA i A inns crae ewaYl v1 e'r,s; Q NA inspect ezind*n cs'h3 *(Fl hi -a € ?uiTz Out c~nxentJ of tarrklak '•~fhQ?i cofrit~ined ah:tt+l?yp e~ acwrrY steals Yses :v fiG1 ii~a} d tank yQjwm'e p irsl~t~l2 } 4iV a~it Q ~s r&4 Q TWA At i^-Ak Mc 9116x} a ~ ~ ~r Si tnapact dispatol rmiita} t~ hE } M l4A At least OrMe snarly: ♦ ~n:t .der a3, Olean r~' iusrttfiitar - ~I rho rthl"} NA i A~ iaast ent~~ &vety: C v. N hspe pump, pump prartYbls alarm 1~ W;qI WA, J t Ai: 9aaat rnas eleat`t/; •I t{ 1. ( E1ii94r k&tarpla And pr9&EtJK iE9i R1G~ituy't '.l A ~3zilasi i At iaast i 6 FIVS } ;;ear 1s; HA 3 i 11 Ilar f I 11rZlarf4TjWA=r:14iS' AVO-riiCOS ifiSpsGt3r3ns o'( tT+ ; and d:isp2real cake erestl. he r,.:at}e Izy an individual urr g 0l1 csF X 43 ~ lirsvV.i ii nse r a~'r~i ica n - °A Qp'BGtfaCl' Master Plumber, Et>i,sfr`,~ar P]Umber Ramr'lotad S~vyrr; P3~FdT~ i~paattat ~ PC WTS MV l' cranks or team: ifispectfan rrust'crtrvltad fl ~ilstaef iraslsetHL on of ht 4a~1s} nfssing ar brwk~n h`&rU' rg, iden~iR7 arty u era f~h~ial~ rsr any prsrrdtnca raarrwra the rcrit+*^a sf ar 4V~1n xiwdre Rnd t3agTz ,srd to :".heck. for any haal 4r }na4StliYfg ~f di~l~tsrs" t}4} grrswnd aur'rapeo The disper~i ap'RIs) shzll ~e visuglly inspected to aYsrk •k'2 ef,luem Islrsls in -,hg ty~s+~ruati~t~ yij~ of $fff 1ar4, an the graWrtd vrtauw. 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