HomeMy WebLinkAbout024-1018-30-101
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-2017-223
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:
Justin Luther TOWN OF PLEASANT VALLEY 024-1018-30-101
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
v Co 0~ 16.28.17.98C-01
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic B chmark
3. /4; /ZYS
Dosing Alt. BM
Aeration Bldg. Sewer 71
Holding St/Ht Inlet
.3
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
Force
main Length Dia. Dist. to Well
SOIL ABSORPTION SYSTEM
BEDITRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION
Type Of System: CHAMBER OR
UNIT Model Number:
DISTRIBUTION SYSTEM
Header/Manifold Distribution x Hole Size x 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
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 codediscrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location: 1753 CTY RD N CL-0.;
1.) Alt BM Description = ' 1 11
~
2.) Bldg sewer length = /0
- amount of cover = 0 P
7 ~f L a n
Plan revision Required? ❑ Yes o I 7 z l '`°'f i/
Use other side for additional information. L ~I G j/ ~f►
Date IS5 Are Cert. No.
SBD-6710 (R.3/97)
IT - d a I ? 3
County Sanitary Permit Application ST. CROIX COUNTY WISCONSIN
` cord with Chapert 12 St. Croix County Sanitary Ordinance PLANNING i~ ZONING DEPARTMENT
TOO CIO information you provide may be used for secondary purposes ST. CROIX COUNTY GOVERNMENT CENTER
G [Privacy Law. S. 15 1)( 1101 Carmichael Road
Hudson, WI 54016-7710
L ril W n i G (715)386-4680 Fax (715)386-4686
gI lete plans for the syste -112 x 11 inches in size.
c~'~, C+ ry Permit # ❑ Check if revision to previous application
U 1" - Zb17- ZZ
1. Application nformation - Please Print all Information Location:
Property Owner Name
1U __T_'
/ /"C 1/4 1/4, Sec /to
S jl.~ _ _ r T N, R E (or
-114 Property Owner's Mailing Address Lot Number Block Number
City, State? Zip Code Phone Numer Subdivision Name or CSM Number
1 ' Chi Cpl - S
11 Type of Building: (check one) amity ❑ Village own of
❑ 1 or 2 Family Dwelling - No. of Bedrooms: 1N~
❑ Public/Commercial (describe use): item CL"
(/Ga
❑ State-owned earest Roa
11. Type of Permit: (Check only one box on line A. Check box on line B if applicable) a /J
Parcel Tax Numbe
1.❑ Repair 2.Reconnection 3.❑Non-plumbing 4. ❑Rejuvenation 0,211- /OI$- -161
A) vv
Sanitation 1j,, af;. 1-1. 9 8G' to I
B) Permit Number Date Issue qG
❑ State Sanitary Permit was previously issued 1755 J/ / p l)
IV. Type of POWT System: (Check all that apply)
❑ Non-pressurized In-ground ound ? 24 in. suitable soil ❑ Mound 5 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 Area 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 (Gais./day/sq.ft.) (Min./inch) Elevation
VI. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic
New Existing Gallons Tanks Concrete structed glass
Tanks Tanks El 0 El 0
❑ ❑ ❑
El El
VII. Responsibility Statement
1, the undersigned, assume responsibility for repair/reconnenction/r ' venation/installation of non-plumbing for the POWTS shown on the attached plans. A
license is not required for terralift repair or the ins tion of non umbing sanitation system.
PI ber's Name_(prip Plumbe s nature ( st s): MP PRS No. Business Phone Number
P
'1 llw~l ~ e' 33 7Ature
Plumber's A~d~dr~ess J(~S~treet, City, State, Zi .Co)d1e)
62V ° • Di a A GN `V"' -n W .J Syar v2
Vlll. County Use Only
Dis pp~re Sanitary Permit Fee Date Issued Issuin gent SigApproved Owner nitia erse 2Z. . a -712bj I
Determination 7
IX. Conditions of Approval/Reasons for Disappro at:
~-,J&,j: ~ wad Ncofle u va-c4.~.rc. Poca.
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ST. CROIX COUNTY
SEPTIC TANTK MA2,,7ENANCE AGREEMENT
AND
j OWNERSHIP CERTIFICATION FORM
Ov~nerBuyer !J v ~d-,' ~ y ~
bailing Address 17,55 C47 fl-~ /J
Property Address
(Ve--fication required from Planning & Zoning Department for new construction)
City/State Parcel Identification Number D Z~- /0 (9 ,30 - /a/
LEGAL DESCRIPTION y l
Property Location 1/4 % Sec. , T ZN R 1-7 W, Town of PlP,C~ 1/e~,
Subdivision Plat: , Lot #
oe
Certified Survey Map m l6 3 , Volume , Page S/ 7-3
Warranty Deed n 143 S 6!5 (before 2007)Volume , Page
Spec house ❑ yes ❑ no Lot lines identifiable ❑ yes ❑ no
SYSTEM MAL~=NTANCE ANTD OWNER CERTIFICATION
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper
ma.int-nance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What 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 - SL 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 ptunper 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. Certification stating that your septic system has been maintained must be completed and returned to the St Croix
Counry Planning & Zoning Department within 30 days of the three year expiration date.
Uwe cerffy that all statements on this rm are true to the best of my/our lmowledge. Uwe am/are the owner(s) of the
dee
d recorded in Register of Deeds Office.
property described above, by virtue of a Wily
Number of bedrooms
SIGNATU-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 R eziister of Deeds Office and a copy of !be certified survey map if
reference is made in the wa=ty deed
(REV. 04112)
0?;'19%2017 9E:38 7156943144 BOLDTS PLBG HTG PAGE 02
Business Office; 820 Main Street. PO Box 78, Baldwin, W1. 54002
(715) 684-3378 Baldwin (715) 356-4445 Hudson (715) 684-3144 Fax
Date: July 18, 2017 RECEIVED
JUL 7 9 2011
ST. CROIX COUNTY
30MMUNITy pEVELOpMENT
To Whom It May Concern;
An on-site investigation of the septic system on the Justin Luther property, located at
1753 County Road N, Hammond, WI was conducted on July 14, 2017.
The sanitary system appeared to be functioning properly and there were no signs of
system failure- Should you have any questions regarding this subject, please feel free
to contact this office.
Inspected By. ~ - /0/9
au
fi
SPECIAL NOTATIONS:
Plb. _106
Plan Identification No.
1
Construction Inspection of Alternate Design Sewage Disposal Systems
Wisconsin Department of Health & Social Services
Section of Plumbing & Fire Protection Systems
Owner's Name 2; , ,
Mailing Address M a n
A. Site Investigation at onset of construction
1. Name of Installer 6~t
2. County -Inspector ( ,45oBate L I b L0
3• Package #
4. Preliminary onsite made b / v,►~S ~"~7 Date la L z
5. Depth to limiting factor (50o unconsolidated rock or estimated ground
0
water level) 3 p
6. Percolation rate 61 0
7. County installation permit number 0 2--%>
8. Are percolation and soil boring holes evident? Yes N0
9. Is system located in area of soil tests? Yes 5 0
10. Is system located in area shown on state approved plans? Yes No
11. Ground slope in area of system J)as
12. Site data is correct as presented by C.S.T. and system designer? Yes
No
B. Inspection of Construction
1. Disposal site plowed and properly prepared? Yes _N0
2. Disposal site conditions wet or damp? Wet Damp Dry
3 . Type of f i l l material kAiym sk" Q
i
4. Depth of fill (I' Minimum) Lid
5• Is a crawler type tractor used? Yes__X_No
a. Blade- Bucket
6. Has site been driven on by any vehicles? Yes No
If yes, explain
1p
7. Trench width as indicated on approved plans? Yes No
8. Trench spacing as indicated on approved plans? Yes No
9. Have trench bottoms been properly leveled? Yes No
10. Trench length and number as shown on approved plans? Yes/-K--- No
H. Distribution piping proper diameter? Yes _K_ No
12. Holes in distribution piping properly sized? Yes_ No
13. Holes in distribution piping properly spaced? YesZ No
14. Holes in distribution piping in a straight line? Yes No
15. Distribution holes drilled straight into piping? Yes No
16. Depth of gravel below distribution piping
17. Depth of gravel above distribution piping :k-
18. Thickness of marsh hay covering 1--_
19. Permanent marker at end of each trench ~L
r/
20. Depth of fill over center of system 18
21. Depth of fill over outer trenches
22. Side slopes 6- ~
23. Type of fill used above trenches T Lott ry"x
24. Depth of top 'soil
25. Seeded? Yes No If no, has mulch been pl ced over mound?
Yes No
C. Pumping Chamber
1. Diameter of inlet
~r
2. Diameter of outlet
3. Head IF
4. Size of pump tank_,_-Z(jO gallops
5. Draw down or gallons pumped per cycle
6. Manufacturer and type of pump same as that indicated on approved
plans? Yes /1 No If no, indicate Mfg. and Model # of pump used.
7. Quick disconnect provided? Yes No
8. Diameter of manhole
9• Height of manhole above finished grade
10. Diameter of vent
H. Height of vent above finished grade
12. Pump tank located as shown on approved plans? Yes No
i
I
0. Septic Tank
1. Properly installed? Yes No
COMMENTS
1, the undersigned, hereby certify that the questions were answered ,I
on the basis of my personal inspection or knowledge of the construction
of this alternate system and further that all data and answers recorded
on this form are correct and to the best of my knowledge an
Name: ( hDm.3 C CtT on Si
Title: Q___,.e f+1y1 w V1.+{sti,,
WE HAVE INCLUDED TWO COPIES OF THIS FORM FOR COMPLETION BY YOUR OFFICE.
WHEN INSPECTION OF CONSTRUCTION IS COMPLETE, ONE COMPLETED FORM SHALL
BE RETURNED TO THIS OFFICE WITHIN TEN (10) DAYS AFTER YOUR FINAL INSPECTION
OF THIS ALTERNATE SYSTEM.
Date received by Section of Plumbing s Fire Protection Systems