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HomeMy WebLinkAbout028-1011-50-000 (2) Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No. (ATTACH TO PERMIT) SAN-2017-256 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: RAY & SUSAN GILLIS TOWN OF RUSH RIVER 028-1011-50-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: 10.28.17.59B TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark - Dosing Alt. BM , 11;111i}l 3, Io2.) Lf 1 Aeration Bldg. Sewer ~f r TZ C I O. Holdin St/Ht Inlet g w(+ /45 TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing / Header/Mark. Aeration Dist. Pi Holding Bot. S ste Final Gra e PUMP/SIPHON INFORMATION Manufacturer Demand St Cove_r_ GP M Model Number TDH Lift riction o ;Sy'st d Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS / SETBACK SYSTE P/L DG W LL LAKE/STREA LEACHING Manuf INFORMATION CHA OR Type Of yste " UN Number: DISTRIBUTION SYSTEM Header/Manifold Distributiofr x Hole Size x Hole Spacing 1 7 Vent to Air Intake Pipe(s) Length Dia Length f3t2 a SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over FBedp/Tench Over xx Depth of SeededlSodded xx Mulched Bed/Trench Center Edges Topsoil xx - Yes No Yes ill No COMMENTS: (Include code discrepencies, persons present.. etc.) Inspection #1 Inspection #2: Location: 405 CTY RD T o 1.) Alt BM Description = I 2.) Bldg sewer length = bb - amount of cover = 7 / i I Plan revision Required? Yes ❑ No Use other side for additional information. Efate Insepcto ' Cert. No. SBD-6710 (R.3197) County Sanitary Permit Application ST. CROIX COUNTY WISCONSIN accord with Chapert 12 St. Croix County Sanitary Ordinance PLANNING & ZONING DEPARTMENT f, Personal information you provide may be used for secondary purposes ST. CROIX COUNTY GOVERNMENT CENTER Privac Law. S. 1 1 [ Y $r1!~( )O s 1101 Carmichael Road Hudson, WI 54016-7710 (715)386-4680 Fax(715)386-4686 ST LO mplete plans 13CW4TMF6A65ZG 2 x 11 inches in size. ;,©JA County Sanitary Permit # Lj Check if revision to previous application 5A/J 2617 - 25 1. Application Information - Please Print all Information Location: Property O r Name A) L(~ 1 /4 S t-vl /4, Sec 09 N, AWR 17E (or) 0 Property Owner's Mailing Address Lot Number Block Number City, Stale Zip Code Phone Numer Subdivision Name or CSM Number 7rt;_-7- 7~ - 11 Type of Building: (check one) n J amity ❑ Village LgTown of A 1 or 2 Family Dwelling - No. of Bedrooms: ❑ Public/Commercial (describe use): C__~6,6,3 ❑ State-owned r Nearest Road Ill. Type of Permit: (Check only one box on line A. Check box on line B if applicable) Parcel Tax Number(s) 1.0 Repair 2. Reconnection 3.❑Non-plumbing 4. ❑Rejuvenation 6i 10R•CO-000 A) 1 0- Sanitation e. . 17. B) Permit Number Date Issued State Sanitary Permit was previously issued 5 J}•f~ z rL1 L ~C y 71 - _Z I - 62- IV. Type of POWT System: (Check all that apply) &rc x, ❑ 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 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 FX / 5 .f i/'-1 Required Proposed (Gals./day/sq.ft.) (Min./inch) Elevation ly VI. Tank information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic New Existing Gallons Tanks Concrete structed glass Tanks Tanks .t L' i Gf Grp FI ❑ ❑ ❑ ❑ VII. Responsibility Statement 1, 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 terraiift repair or the installation of non-plumbing sanitation system. Plumber's Name (print) Plumber's Signature (no stamps): MP/MPRS No. Business Phone Number X, ~Izn .06 ~ z 7~ 7 - sexy Pi ` ber Address (Street, City, State, Zip Code) (`i C i L c cJ _ F ht t cJ i y O Vill. County Use Only 17 Signa Disapproved Sanitary Permit Fee Date Issued l;4: tur o st s) Approved 2-15wnerGive ,all ~t Adverse C6 Det ion? IX. Conditions of Approval/Reasons for Disapproval: / ~N 6 V_1~ ~L 6- 17 6^ca, t%&,> kooa, W.0 I ea. Lm~ 10 0 ~Oje= Rev: 8/05 sang6ads~;d i % SOYSS tl1053NNW: SflOd73hRJ7Yv °IGhS IN'r~uow`u. 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SL30'ii(183'IOHM 1821{$ aply Sd~~i~ /~E1j j t1E8I1 c` d,y I O ~i p u C z \ G `c~> ~ C w / LLOP 1 e ~ci zn ! 3S7OH 0.:,,e ,5~ ~ A ni+C!A.LL w/J I o f l+~ ~ ' 1 ~ ~ ~ 5 j o` o oy ~ - 10 - U' a ; x ,iFE~ \ 1 LLJ W w Z o w c Ib ~f~ i i ,1\ lS^ a ¢ l d 'N f W U Z a' 'L W' OJ I_.~ { S;y4 W C Z Z Z 1 I F r o Judy Danielson Marko Septic inspection Aug 8, 2017,12:19:17 PM nelsonplumbinginc@icloud.com Marko 7WE;I 1092120th Street Roberts, WI 54023 715-749-3404 MarkoSeaticc-att.net STATEMENT OF SEPTIC OPERATIONS 1, Marko Septic LLC, Wisconsin License #2556, hereby state I have inspected the septic system located on the property described as follows: Raymond Gillis/Roger Nelson 405 Co Rd T Hammond W 54015 This system appeared to be in good working condition when pumped and inspected on August 7, 2017. Please note: 1 The septic tank was running at the top of inlet baffle/ 2 Outlet pipe needs to be cleaned or replaced 3 Covers need to be chained and padlocked 4 There is no filter Owner is responsible for disclosing all known septic issues including surface discharge. This is not a guarantee to the longevity of the system. This statement is an opinion, not a warranty or guarantee, and I disclaim all liability for any loss caused by the reliance on this statement. 8-8-2017 Matt Herink, Owner/Operator Date Marko Septic LLC ST. CROIX CO CTNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM RA,y -15-~t L15 Owner/Buyer __K"1__ _V S65-AN '1 t k Mailing Address p s,, CA ZON4--) __F -AA -n ►^n or,42b. Uj i Property Address b S C.. -1 `4c to &b _T A-wN m u 0.3 tti) i 5 ~eo / - _ _ (Verification required from Planning & Zoning Department for new construction.) " City/state- AYn bt,-,_b Lx_) Parcel Identification Number 02-b- I C l _50 LEGAL DESCRIPTION f'y Property Location W `/4 , r/a , Sec., T -Z-5-N R_~7W, Town of t,/ 517-1 Subdivision Plat: Lot # Certified Survey Map # Volume , Page # Warranty Deed # (before 2007)Volume , Page # Spec house D yes ~110 Lot lines identifiable, es O no / T SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance 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 - 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. I/we, 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 County Planning & Zoning Department within 30 days of the three year expiration date. l/we certify that all statements on s form are true to the best of my/our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a rranty deed recorded in Register of Deeds Office. Number of bedrooms 3 / /17 ICANT(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 certified survey map if reference is made in the warranty deed. (REV. Q4/I2) I i I ~ I T 17 I li 1A il! 1 VP~~ I t ~ ~ il J ~ I f i3' fI f ~ E i F I~, ,I, I ~F t 7,7 1-j L.J LL=l Ht UID ' 4 I % li IL~J iglu F 1i ~~1 \ II 4~fl ~l }sY I I i Ix~>=mar ` Y I I I[ILJL`J T ° : TO, I M X ~ 1 I \ I 1 IW ' i C 1 I I ( ~ ~ I U. 7- i n 2~. * i s I a n. _ I f 1. \I i I ( VI 13 tc i ~ •n S ._.4 syg" I ss ~ ~i. j ~~m sta. 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