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Home My WebLink About040-1320-00-012 (2) Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: SAN-2017-216 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: DEAN & JULIE JAKUBOWICZ TOWN OF TROY 040-1320-00-012 CST BM Elev: Insp. BM Elev: BM Description: SectionrTown/Range/Map No: 13.28.20.2159 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Bench ma 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 l Holding Bot. System Final Grade PUMP/SIPHON INFORMATION Manufacturer Demand St Cover GPM Model Number ; TDH Lift Fr tion ss yste HeA TDH Ft Forcemain Length Dia. Dist. t II SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTE Q l /L BLQ WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) ! Length Dia Length_ i Dias paang ~1 SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil Yes No Yes No COMMENTS: (Include code discrepencies, persons present. etc.) Inspection #1: Inspection #2: Location: 302 CROIX RIDGE DR 0, c 1.) Alt BM Description / 2_) Bldg sewer lent - amount of c¢ver = Plan revision Required? Yes No _ r Use other side for additional information. ~ 64 Date Insep I I ~y ct& ,grtatS ure i Cent No. SBD-6710 (R.3/97) -7 O10 County Sanitary Permit Application ST. CROIX COUNTY WISCONSIN In accord with Chapert 12 St. Croix County Sanitary Ordinance PLANNING & ZONING DEPARTMENT G Personal information you provide may be usedJtMJD ST. CROIX COUNTY GOVERNMENT CENTER $t_ [Privacy Law. S. 15.04(1)( 1101 Carmichael Road X Hudson, WI 54016-7710 K6 ~P~ (715)386-4680 Fax (715)386-4686 ' -'ins for the system on paper o ss than 8-1/2 x 11 inches in size. Cou ty Sanitary l7e,,QR5J J Check if revisq'~JIS 0 n (7- 21 C _101010 ff t 1. Application Information - Please Print all Information Location: Property Owner Name 1 1~ , . ~2 7 !7 /1 (1. LL16 /4 1 /4, Sec D ¢ J a T N, R r,L 0 E (or Property Owner's Mailing Address Lot Number Block Number City, State Zip Code Phone Numer Subdivision Name or CSM Number II Type of Building: (check one) amity ❑Village own of NL 1 or 2 Family Dwelling - No. of Bedrooms: r~- ❑ Public/Commercial (describe use): ❑ State-owned Nearest Road ll. Type of Permit: (Check only one box on line A. Check box on line B if applicable) Parcel Tax Number(s) A) 1_®' Repair 2.0 Reconnection 3.❑Non-plumbing 4. ❑ Rejuvenation o q o 1,3 -70 Sanitation 1 1.4 r. ♦ o?y - G' I V. Permit Number Date Issued B) State Sanitary Permit was previously issued a ' LC k" cS C.~ 7 IV. Type of POWT System: (Check all that apply) 20V-C, ❑ Non-pressurized In-ground ❑ Mound ? 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 V. Dispersal/Treatment Ar Information: 1. Design Flow (gpd) . Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. System Elevation 7. Final Grade Q Required Proposed (Gals./day/sq.ft.) (Min./inch) Elevation O 2 3Q 8 A3 <3 S? w ~z l a( o ~(,,ZS VI. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic New Existing Gallons Tanks Concrete structed glass Tanks Tanks h ❑ ❑ ❑ El is ❑ ❑ ❑ ❑ ❑ VII. Responsibility Statement I, the undersigned, assume responsibility for repair/reconnenction/rejuvenation/installation of non-plumbing for the POWTS shown on the attached plans. A license is not required for terralift repair or the installation of non-plumbing sanitation system. Plumber's Name (print) Plumber's Signature (no stamps): MP/MPRS No. Business Phone Number 0 R IL f fit k cc_ if V"'c4 c" LO 1ls2 1 Z-? ? r a 1 i s- y - 3 3~ Plumber's Address (Street, City, State, Zip Code) Cir 4-, 7 N L 6 S' .4 d Itr~ lac VIII. County Use Only ElDisa z LID roved Sanitary Permit Fee D to Iss ed IsLSignature sta s) Approved Owner Gi tah4dueLge LZ L, ~ ~ rmination tic/ IX. Conditions of Approval/Reaso for Disapp oval: f it- low O-PP ("o'Jej'a+ A, 69,~e, OLb J~ l I y~. Rev: 8/05 \yt~ -z' p,1Z.~.bo+~,L~- 'JYvcE_~~n'~2hI~kO~~ QT& z,s~s (off -41 b~ 1 r J ~ O Z D ~i'D i Z1 obi pti"C u.. r c~ ~,:,a.~..r., ~ ~ ~ z.s~s aw~(o~ 5~.~~t 7,4z> \ 1 0~~ 'Q°rt4' x l o~rt Y- o c._K. 1-1- 3 6 y O Z o ctp 13K ~ 1~ Z.1 ab~ p~`t u Design Criteria Residential Wastewater Contaminant Load: 30 mg/L < BODS < 220 mg/L Anticipated septic tank effluent 30 mg/L < TSS < 150mg/L Fecal Coliform > 10,000 cfu/100 mL Fats, oils, grease < 30 mg/L k Bedrooms x 100 gaVbedroom/da x 1.5 Y ~ u-~ gallons/day hydraulic load Design Calculations In situ designed loading rate Z-~ gallons/sq. ft, per day Depth to estimated high ground water in. Depth to bedrock in. Cross slope at system % V Force main length ' ~ ft. of '2• in. 34 4 Manifold/header length ft. of 4 in. o <<a z Drain-back t 3 gallons Lateral length 4, @ S10.0 ft. of ,`/4- in. Lateral elevation 3 - o ft. @ bottom of lateral Lateral hole size 3/ I b in. @ 4 • o in, o ft.) Spacing 3 holes/lateral S holes total Lateral volume Z g gallons Total lateral discharge rate gallons/minute @ 2 S ft. head Network pressure compensation losses 0' ft. Elevation difference l q o ft. Friction loss ~ L ft. @ 3 S gallons/minute Total dynamic head z`g S ftPump/si on e 'c gpm @ ft. of head Manufacturer _'t o ~~leN Model # Dose volume l2. m gallons Lift/sipfion tank ~-r.~-n- (,o ~~-b gallons Septic tank gallons Effluent filter (~-~vv Measurement pump on and off O in. Height alarm from tank bottom in. Reserve capacity gallons specs calcs.res Page of 0% PA WE►TkERP%?wF LOCKING COVER ,3UNCTION MJG 6CW pvlcK a~calutCr-'1 C,. r- • 4vo Plot' 3' t4M 4NoiSTURUD \ Sol L- 24 4"4 o MMit1CLE Y E I!T Ma.t r - . G°wLLP q Ha:< oP►' ctovtD 2cc , o" 4" P A L CI~SKET Jb~rT'S BAF F L E RU.. Pim -s'~ 3' O-ro 4 GO► t~v E LT I O b sk 1 1 - l~Q Z 1' OH q.~ ) L04>40TLIM~ w U c C C 1 ( L GRVUKo ~4' ~ Oc•c ptkp BcoCK SEPTIC t _SPE:ClFI'GATIOKJS Q OOSC TAWKS MAWUFACTURCR: w M~"~ L IJUMEER OF DOSES: T PER DAB AIUK SIZE, GALLOWS DOSE VOLUME ALARM PIAAIUFACTURER: S~ F1a~~ro IWCLUOING OACK/LOW: X12'$4 GALLONS MODEL WUMDCR: `b CAPACITIES; A_ 2ci'0 wcHCS OR AL to►,s SWITCH TIP(; 8a PUMP MAIJUFACTURCR: IWCHES OR CAL L O U S 410 IULMES OR (ALIOU5 MOOEL WUMDCR; / D. a9.0 INCHES OR ` / 145,o g SWITCH TyP[; a..r~ ~A.'.ou5 -[?'----,4r' WOTE: PUMP AWD ALARM ARE TO 6E MIIJIMUM DISCMARCA RATC~;4 GPM INSTALLED OW SEPARATE CIRCL T5 VERTICAL DIFFEREWC1 OETWECU PUMP OFF AI,IO 013TRIBUT10W PIPE.. + niuIKUM uETWORK FEET I I SUPPLY PKjS$URE FECT4-0'-44 + FEET OF FORCC MAIM X 2~Sj FY100FEFRICTIOW FACTOR. FEET ! TOTAL DVWAMIC.• HEAD a FEET I►JTERQAL DIMEW610Wi Of TAIJK: LEWCrTH ;WIDTH 9 , ;LIQUID DEPTH r Wis nain -)epartnient of Commerce County. Safef and Building Division PRIVATE SEWAGE SYSTEM St. Croix INSPECTION REPORT Sanitary Permit No'. 506204 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal intormation you provide may be used for secondary purposes [Privacy Law, s15.04 (1)(m)J. Permit Holder's Name: City Village X Township Parcel Tax No Jakubowicz, Dean Troy, Town of 040-1320-00-012 CST BM Elev: Insp BM Elev. BM Description' Section/Town/Range,!Map No, GS 13.28.20.2159 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER , rr CAPACITY STATION BS HI FS ELEV. f Septic Benchmark Iz60 Sr ZS /os Axs Dosing ► Al M Go "Jo 0 4 Sao C~ J* 7 Z 4 7. b 5 Bldg. Sew & V CJ ir. 7~ /l. / ~ q3. orr Holding St/Ht Inlet rf' /l• 97 92 L8 TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic y t~ 6 ► 36 Dt Bottom T~ 17~ $g • Dosing Header/Man. >Z5 36 3U Z. o /e3. 2.:5 Aeration Dist. Pipe molding a /43. zs Bot. System Z . 7 /az . 55 PUMP/SIPHON INFORMATION Final Grade /4y z,5 Manufacturer Demand St over y Z u GPM Ce JG~ 7~ 7.z- '77-05 Model Number 3'h Cb s. zs i06 TDH Lift Friction Loss ystem Head TD, . 5. 2.5 LZ. it, bcA ~a! . t -S 1 Forcemain Lenptth Dia. Dist. to Well ^ SOIL ABSORPTION SYSTEM BED/TRENCH Width ► Length / No. OfTre hes PIT DIMENSIONS No. Of Pits_ Inside Dia. Liquid Depth DIMENSIONS /toe B SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer INFORMATION Type Of System CHAMBER OR tM y L:j /65 N , J UNIT Model Number ` 1 IQJ,N ~iJ /V DISTRIBUTION SYSTEM eo 44, Header/Manifold Distribution N x Hole Size x Hole Spacing ~ Ve Air Intake Pipe(s) ~t l-ength__-1 Length lad Dia /I " Spacing 3 1 r i SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only e-A ZGV-1 Depth Over Depth Over xx Depth of xx Seeded/Sodded jxx Mulched Bed/Trench Center Be /Trench Edges ` Topsoil. Yes No Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection 41: Z 5/ d 7 Inspection #2: Location: 302 Cove Ridge Drive Huds 154016 (SE 1/4 SE 1/4 13 T28N R20W) Cove RAige o} 120 T Parcel No: (3.28.20.2159 1.) Alt BM Description = ~t ki-A AZ c{ue 4-izj 4-foC. ril 40 2} Bldg sewer length = 3Q ~-.0-4r-S 6 f ~ ow • amount of cover Plan revision Required? Yes No L/p Z~Q b~ / Use other side for additional information. Date SBD-6710 (R 3/97) Insepcte S Signa re Celt. No. l fe onsin Department of Commerce PRIVATE SEWAGE SYSTEM county: o St. Croix Saf and Building Division INSPECTION REPORT Sanitary Permit No 506204 0 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 X Township Parcel Tax No. Jakubowicz, Dean Troy, Town of 040-1320-00-012 CST BM Elev. Insp. BM Elev: IBM Description: Sectionlrown/Range/Map No: >I`A GS 13.28.20.2159 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER , N CAPACITY STATION BS HI FS ELEV. I Septic Benchmark '5ZS /O` ~ ! Zab 7 J~ / Dosing AI M Co V eJ '4 SOO V C6 7 Z. 9 7. b S / TT Bldg. Sew r pt g3. DC! Holding St/Ht Inlet ~f' /1.97 9z L8 TANK SETBACK INFORMATION St/Ht Outlet ` I TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic 7 Zs / 4 36 Dt Bottom Dosing >Z5 A4- 3~~ Header/Man. Z, O lq3, 2.' 7 Aeration Dist. Pipe a /a3. zs Holding _ Bot. System Z.~ /az. SS Final Grade y z5 i PUMP/SIPHON INFORMATION ISO /a Manufacturer Demand St mover J~ , L GPM 7Z_ 17' O5' i Model Number / 4V !y ) 31; 6- .4*5 /Od TDH Lift, Friction Loss ystte ~ ea TDj~.,~. ~19 n, L 1~ teJ M ~E/ r ( t Forcema~in LenAtht DDia. I / Dist. toW ell A G 1' l` l 0'1 SOIL ABSORPTION SYSTEM ,1V1` BED/TRENCH Width Length / No. Of Tre s PIT DIMENSIONS No. Of Pits Inside Dia. irluid Depth DIMENSIONS ~ a - SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System ~ UNIT Model Number: ~V NJ +d' DISTRIBUTION SYSTEM Header/Manifold I/ Distribution Z, far x Hole Size Ix Hole Spacing / VerIft 11D Air Intake ` Pipe(s) Lengthy Dia Length 166 Dia Spacing 3 tp D -M. SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only A Z, e- V-1, Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges ` Topsoil ` Yes - No Yes r` No COMMENTS: Include code discre encies, /O / Z 5/ b 7 Inspection #2: / I ( p persons present, etc.) Inspection #1: Location: 302 Cove Ridge Drive Hudsoft, 154016 (SE 1/4 SE 1/4 13 T28N R20W) Cove R~Pot 12 Parcel No: '1(3_.'28.20.2159 1.) Alt BM Description = J' CLX"'.'kz ~ _ (4ue- 4-t:n, I I 2.) Bldg sewer length = 3o d0 r`et aL^j is amount of cover = / a C'O (cll. I I I If /s 'y ~dUs~. ~k. C'~ Y~^G. [pC.~YddCCOCC000JJL~~ G,.r Plan revision Required'? Yes No Use other side for additional information. L~G Z~ I Il SBD 6710 (R.3/97) Date Insepcto s Sign re Cert. No. l Safety and Buildings Division County " s 201 W. Washington P.O. Box 7162 5/ e-, rh Madison W] -7162 Sanity Permit Nutt _ D ber {to be filled in by Co.) Department of Commerce (608)266- 56 O Sanitary Permit Application State} Plan I.D. Number In accord with Comm 83.21, Wis. Adm. Code, personal information you prove J j j may be used for secondary purposes Privacy Law, s I "m) Project Address (idifferent than mailing address) I Application Information -Please Print All Informs 9 ~vF ca tic Property Owner's Name A Parcel Block It L`Ad _lut/i, kL,-,6d w Z Y ? 4 11'01 11 -/JX-ao- a N Property Owner's Mailing Address CfZ01x Property Location City. State Zip Code Phone Nu COUNTY ~ `L Section , clrel ,J 11. Type of Building (check all that apply) b> S ~ N; R E o la'l~or 2 Family Dwelling -Number of Bcdrtwms - Subdivision Name CSM Number ❑ PubiiaCommcrcial - Describe Use a,e eras qat t t~ vK. K CC) R ( ~ I i ---f El rig State Owned - Describe Use 146 '34A ~la ❑City ❑village r.e`ownship of_-Kec III. Type of Permit: (Check only one box on line A. Complete line B if applicable) i A. pyr" wm e ❑ 1Zeplacement System ❑ TreatmenVilolding Tank Replacement Only ❑ Other Modification to Existing System t B• ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. Type of POWTS stem: Check all that apply) O e r0 Mon -Pressurized In-Ground ❑ Mound > 2.t.in. of suitable soil ~ound < 24 in. of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized bi-Ground ❑ Holding Tank ❑ Peat Filter 11 Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter ❑ Leaching Chamber ❑ Drip Line ❑ Gravel-less Pipe ❑ Other (explain) V. Dis ersal/Treatment Area Information: 4 A. - Desi Flow d Design soil a f i (gp) gn Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation L-90 23og 23og ~ foci+5. ~ V1. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank Aerobic Treatment Unit Dosing Chamber . v' _ I V11. Responsibility Statement- L the undersigned, assume r for Installation of the POWTS shown on the attached plans. Pluutberts Name ( ) Pt bet's re MPIMPRS Number Business Phone Number ml ~ s 1~ 509 pis Plumber's Address (S City, State, Zip Code) GE " ys? h~u.~c /f1E'/l 7S Y VIIL oun /De artment Us On Approved (sapp Sanitary Permit Fee (includes Groundwater Date ssu Issuing ent Signatu o nps) iven ial Surcharge Fee) / O( ~ Ati t 5 6.~ iX. Conditions of ApprovaMeasons for Disapproval ~ 3) • Sam talk QMUInt filter and 1 eop dispersal cell must all services / ma as per management plan provided by plumberr, . 2. AN slettb wk requirements must be meWda tsd as pet spppceble code l oldlrtslacas. Attach complete plans (to the County only) for the system on pa r of lees SShan 81/1 x 11 Inches Is size cook]- Zc d-t:c c,ew 1 1, Blue nn{~, 5~j SBD-6398 (R. 01/03) 5 - Colt pt~u. poh~ a ~L • C u.,~ CZ: \ P 04- ('lay 1 ow.~., l V•o~ ~ / S'2lot 2.s'kS 0.wt_ ~o~ 5~.,,Kt ,,4z ZI.! s.~ +Q ' r I / l*4t v ec.~ / l.,Ln2~1~ SOyt~ ~ U~0.A / 1 AO • ~+l~o.+.v ~ O z a c~. fl ~ , `Yro4e- aA-L c. obi QA -t k