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HomeMy WebLinkAbout040-1316-07-000 (3) Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 597473 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 DANIEL & TIFFANY WALRACK TOWN OF TROY 040-1316-07-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: 05.28.19.2063 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS l ELEV. Septic Benchmark r Dosing ' x Alt. BM Aeration y Bldg. Sewer 1 Holding St/Ht Inlet St/Ht Outlet G TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet i t Septic Dt tom Dosing Hk4&r/Man, Aeration Disft Pipe Holding Bot. System t~ -T Y PUMP/SIPHON INFORMATION Final Grade Manufacturer Demand St Cover GPM Model Number TDH Lift Frigtiofi ss' " c Sy terKHedd~ TDH Ft t~ Forcemain Length Dist. to Well SOIL ABSORPTION SYSTEM . i i L ud B De th PIT DIMENSIONS No Of Pits Inside Di a. q P . ' , EDITRENCH Width No. Of Trenches DIMENSIONS IMENSIONS Length - ~ • - SETBACK SYSTEM TO P/L a BLDG W WELL LAKE TREAM LEACHING Manufactu gp_ INFORMATION CHAMBER OR .w t " Type Of System r q ; , d UNIT Model N ber w DISTRIBUTION SYSTEM Header/Manifold Distribution ix Hole Size x Hole Spacing Vent to Air Intake Pipe(s) P' Length y 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 r Bed/Trench Edges Topsoilr Yes No ZF_ Yes I~ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 537 AUTUMN BLAZE TRL 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required? ❑ Yes F] No el rl 1 a rv ~t~>_ Use other side for additional information. t1 J ' Date Insepctor's Sign9tyre Cert No SBD-6710 (R.3/97) ST. CROLX COUNTY ZO' LNG 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: 1/4, 1/4, Section , Town N, Range W, 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 SPS. 384.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service Did flow back occur from absorption system? Yes No (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 jiumber (if known) (Licensed Plumber Sign, u e) (Print Name) (Title) (License Number) MP/MPRS (Date) Form to be completed by licensed plumber (Dept of Safety and Professional Services Chapter 305 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 2/2012 Industry Services Division County RECEIVED 1400 E Washington Ave 5T, C_Koi a`ir ,ice' Box 7I62 Sanitary Permit Number (to be filled in by Co.) ' P 0 ' 0' Ma 707 I b2 M 59-7,q 73 5T. Q Q State Transaction Number ~t App*~ ~OMMUN p l(,,t In accordance with SPS 383.21(2), Wis. Adm. Code, suhmission of this form to the appropriate gov cola( unit is required prior to obtaining a sanitary getout. Note: Application forms for state-owned POWTS arc submittltd to Project Address (if different than mailing a ess} the Department of Safety and Professional Services. Personal information you provide may be used for secondary p!Ms in accordance with the Privacy Law, s. 15.04 I (m , Stats. ^ I. A lieatlon Inforttlatton --Please Print All Information' 7 a Property Owner's Name Parcel ft -M. L i Tip -H kiAi-i 014C i7)i0--o-2--Coo. Property Owner's Mailing Address Property Location 5_7 -2 r :Z I _ Govt. Lot City, State Zip Code Phone Number Section Circ l e one ! Lot # T Z- i__ N: R E or It. "Type of fluild g (check all that apply) i or 2 Family Dwelling - Number of Bedrooms Subdivision Name 4GL Biock # C_'ebfw. 0 Public/Commercial Describe Use City of ❑ State Owned Describe Use CSM Number ❑ Village of t wJ / { , A Totcn of- - s - III. 'Type of Permit: (Check o ty one box on line A. Complete Une B if apple-cable) A. ❑ New System Replacement System El Treatment/Holding Tank Replacement Only Other Modification to Existing System (explain) B. ❑ Permit Renewal ❑ Permit Revision El Change of Plumber El Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner eat, ~~f IV. "I' e of powrS S stemfcom onent113evice: Check all that a 1y 7 Non-Pressurized In-Gro d © Pressurized In-Ground ❑ At-Grade 0 Mound > 24 in. ofsuitable soil ❑ Mound < 24 in. of suitable s ❑ F a ding Tank Other Dispersal Component {explain) ❑ Pretreatment Device (explain)--_ V. Dis ersairfrea nt Area Information: Design Flow (gpd) Design Soil Application 121 i: 111I Dispersal Area Required (sf) Dispersal Area oposed (sf) System }Irvatiofi 7 057/ VI. TTank Info Capacity m Total # of Manufacturer Gallons Gallons Units o New banks Existing Tanks pct v " 4 L L Q L`J, A ~ i<r P YbL 5'25 ` N Septic oAQ0Wi0g-T"Rk- Q 0.U n rn t= U )C 1 VII. Responsilzility Statement- I, the undersigned, assume res iiiiy or installati" of e i TS shown on the attacThed plans. Plumber's Name (Print) Plum s Srgrt re f ' um Business Phone Nrinthcr Plumber's Address (Street, City, State, Zip Cade) ^ LVI+11-:JXE~W7i 2- I 6A VY Coun tlAe artment Use Orel 7 - - Approved PermitF'ee Date Its d Issuing eat Signattu n Reason for Denial IX. Condi ea fo : isapprova! ur t 3 Pape t..Jod t i ,Z 5 6+~- t iwi cell must all to b.D Ils'itw ; orop,men! plan pfa4dett by plumbs!. Ad q,r1L, 2. A r rant*recoent must bE rumintr ire 4 vftl;IlAAt;! I. p da pert n' -Attach to complete plans for the system ands alit to the C my only paper not t . s' hall 8 Uzi 11 inches in size ~ Ilr'V8 o tr1 , j APJ SBD-6398 (R. 08/14) ~ h 1 Pie -Plot Plan Owner - - - - = eenoted) Legal l ~2- 111 lq x}61 ~9~IL! fr Orth 11 ~ F P Not" f V J ~'a PAGE 1 OF In-Ground Gravity Plan Index & Cover t Component Manual Design References: Version 2.0, SBD-10705-P (N.01101, R. I W12) P9 1 of Index & Cover Sheet Pg 2 of _ Plot Plan P 3 of Dispersal Area Cross-Section & Plan View Management Flan c( .q r-I LF) Attachments: Enclosures: PO S Application for Review Soil Evaluation Report & Site Map Project arse I Description Owner Name(s): L T( FFA," H _ UA CKPhone: Owner Address: !53,1 t,,Tu,,k)j i..;a~g -r._ Zip: Project Address: ( `~,IA& Govt. Lot: 1 /4 of 50,1 1/4 Section TAN-R 19 E ®or w Township: County: ti , c i-,e t Project Parcel ID 014_0 - J .3 r ( --c % - f) C)C Designer Information Designer Name: Ai7-,r1 ~_40 -N1-t ePLj?_T Phone:7,S -4)Z-6- t Designer dress: t w& ArTHaR-'s tff-, t~ _ikKV ws zip: -5`i8 0 E-mail: ~t0 f t sff_(Je5t a) p C01v1 - This spy 'char jt,ry`k' I storm p; `Y Y1 frfY License Number. { gs~ - oa i Remarks: 4r* I WF n " iVai. a tie 1 a rem uL lo f l Date: 0hu-nai r~ on subm&W copy. y Plot Plan' Page _o X Propeny Owner TLvLfG_t_ _71-, II"= 40fl. Legai Description , ~a (except ere noted) oe it S,5,1= tam ~ North g rEa~Q~~ CLP- X03 I'S rc e~ PAGE 3 F W i Z CO a `a c w 2 ID E ~ ~ • 8` ~ ~ ms's ~ -r- fit N CP c ' ® ° cry a It } _~f I " , E .0 < o t; Am- IZ3 CL 0 75 '77 72L I a u x c g a cc CL e% g U Vic` E-- -2 03 CL LU 0 CD ui C? co Z co CL 0 e~ + co 5 ~a s s s ' il. 3 s`~,^ t 3 a is "tt SS S y d r b t +GUT.e 5 a 2 t s _ 61 ~ x ~s r ,r , 1 t sue``' ;A.s - The Quick4-' Standard Chamber fits in a 36" wide trench and is ideal for curved or straight systems. It features the ° patent-pending Contour Swivel Connection- which permits turns up to 15°, right or left. The MultiPort- endcap allows multiple piping options and eliminates pipe fittings. The - chamber's four-foot length provides optimal installation; flexibility. 44 • Advanced contouring connections swivel up to 15°, right or left • Latching mechanism allows for quick installation ° Four-foot chambers are easy to handle and install r? • The Quick4 Standard Chamber supports wheel loads of 16,000 lbs/axle with only 12" of cover • Certified by the International Association 1AP of Plumbing and Mechanical Officials (IAPMO) gift - • Tear-out seals on inlet ports provide a tight fit to the pipe - _ , ° Eight molded-in inlets/outlets allow for maximum piping flexibility : • Eliminates pipe fittings Fits on either end of the Quick4 Standard Chamber - _ , . - - APPROVED in Chamber (T IVE LENGTH) ultiP P ii SIDE VIEW TOP VIEW FRONT VIEW TecNKXxM0kEs Typical Trewh View (a) The skucbxa v&srify & each pier: e:dcap and dtw ar y ff ad by Infftaaor (`U ASI wtli i installed and aperafed in a leadfoeld of an ores seie systern in MATA& afnncui a TOP-CAM ac dslce vim kaa retnr s +n.M d ors, s tva mied to tw ongaaal 1' ~ gyred ta- defective rnat pals w1d xv~jvnansNp br om year from ate daze DIA Me septc PeUrd V,, Units pfovwed_ t oc ver ntat if a sepal pmaA is trot re%xed by the septic systessr - r. taw. the tsarranty period to begin upon ft tw ShaL' of ft c SYSU- ap*aue /jam COVER BY•~ _ To a its tiuarranty ijii E nasF y In in wifing of its Corporate t nESK r an 0°k tviMssi F6teart(151 days n( the afleged defect ktfafar bat co+re~ed l4y tt-LOTA J } ikats far tktas by 42 aT - or aSvERT W-Yanty wwraws f2bilk, t ftre post of reoeoa•# ai>dkrir ' at Units- PER CODE— 3,1-- . U tIB~Stt•~ VMRMN AND FOMDES IN ` fit &t ARE K- 33' T}fEM EilE Aft t4O O1HER N1aFiftAKTFES WCffi REST'£CT TO 7TH tRdEFS.. ftsCLttG NO SMON G WFF?RAPU S OF At38M OR R ISSS FOR A FAMRULAR PtU*'0.5E M&pM (c) Tt> s tMUted Warranty std be void if any part of tle a system is rii3raft%red by anyaas other $tert kdarftc. The l.in jed yjananty does not ltd tD trzidentat ccrzegtiatfiat ' speCWorgxjraddanmW& sdaal not be liable for Pen2ifies Of fiquidaled damages size WW x 53"L- x 12'H ais~my trams ~oducs ~+d pass ~d--s, --head ems ar a"ver ks~ ~ (884 mm x )3445 fiT$yf x 3Q5 expe~s inemed by the Hokkv or mfg lhkd party- speur~y exaktded fnxn Ub4tad Warranty MM) ammege ape darnage to ft e ttrrTS due to ordinary w- Ed tear, acmdeRt (fwl*P- 48" (1219 mm) of ufe tfs~ Ve Muls being to vdjck~ kaffic or other rX 1S Tlhch Effecun Length we rot pernuded by rite' tdtte to fl"W rife rmwam " ground cmrxs sef form in the' - - U* placeinerd of knproper nu t+r ah sin fire sysIm LOUMHOWA 8" (203 mm) cdwg due tktitr faau e at ate Units or the septic spsfem due to onpoopw sAing orunfMper sbxmje capacity 43 gal (163 L) evaA not caised by InWhatw. Tt~ t,f; W be void a Me ~fGlIer m h aT Of ft U~= set iamb in dfs Li,xsted Warrifftty. Raft- in no, everd dal kt Worbe hWWt t 8" (224)3 MM) tor any lom or damage to to littk.vi um Uts- or any thad party restating fawn aUjabw or shipment or kM any product tiabaty s at Folder or aty fraud pady_ For ft 13emW Warrdfdy to apply. the Units aid be irked in accMd t' M -VI all sAe COn&MM regr:ed by stale and brat coda.:,, ad COW ap00111e 101M and IrMcalnrs is> a k5 tiF bOM ((ONO repm3MMM of wftoorfm tie aathwity to dMoge of co nd MMs Liaded wMarly No tray applies to any party COW than the on-WW Fbider. The abM reptwtts the S n dMd Lid Warranty offered by klfiWaW A Wniled mirnber of -t Park Poad semis and cowries t warranty regta~ttersts Any p of tkaTs d-M contact P.O.6= i'M LdBiraia s Corporate 6feadq~tas at Old Saybrook Cour t priortosuch Purchase- to Otd Sap6rook. GT65ta3 o9 s c at Uta appacabse ue-arlardy, arad stcdd amvkAy read that aam=,Ay Ww to Ute 86o-577-7000 t=ax 650-sSr`i 7lOtit pgdmse of (mss. T -4435 f 4,75ar-al: &M'?A 41: S,1S&4M 5-*6017: S,.ari.1li: SAM A50c 5511.903: 5.Tt ARt rs.%B,778: S.r19BA_U Csnafin Puwf*.=1.929 _2ADI..S64 OUie[p-ste t P&x*vB_ . arat ae aF HPa~TaSs- aatradnia-ulanfvano~k~lecoorWaxrYedrurogie9 isaregittrad~rk inF f Ao, GuxkQR• CkftC cF1W 5napt.nck Mv Eaadcaaatas40 tYaterTedegbgle'- t:cvatatr, PutStrswt. - a a vadenmt of P*Lok br- TM-ME is a of TUF-IM M &G. a tradett-k of r W- Zma kiftrAw Water Y LM AN iiyaMS Msarded- PSietad in Lt.SA. - _ C25=3 Liar 19 200 9t32nm Dan Weirack, RCR inc. 715. f49.41et P.1 ST. CROP COL MY SEjrfiC TAINMASH A`.dCrE AGREEMENT AND Mailing Adsirtsit d }go t'roherty :~t~t3c~Y ~ ~ ~ R '"°Lg~ (i'erif uttitrrt rcgttircd rrtastt i° rrsaing & Zoning i9epat2nsczfia fmr ac ev eaten sari.} cit y;Stme - P"art;el Identification Numba L AL OF RIP (dl~ Proitett1 Lw resort S., 9 T zFN RG!_ W -Town oS Subdivision Plat: , Lot N Certified 9evvy N Up mate lynT tiiy Deed (before 2007)Voiumo Page $F~ 3sOtese .,ass B,ociir~~identi#4ablt • ~ ra Impreprrsme and h"intenance of your sciatic sy'aeDm eatstd rasuii in its pevanatWz Yaiixere to iasachile w m Fmper nxa.iA ca misn of pizsrping out the scptic tank evcry thm y ors r, if by a liztnied pat . `§'idltat ym pti i:nsr 11tc aunt can off the futactioti of the di: tank a3 sir a in ft uaaate diagioW syUzni. ace sitiiit cs are 'f'eed in §Comm. 83-32(t) and in CbWwr l2'- St Craig County Sanitary Octliflarize- Tite pvpA ty owncr agrers to 60nut to St Cris C oucy L Isrining Zoning Depirrineti a mniGcatioa rams signori ty 14ir owner slid bq a trosicr plumber. journcy plumber. ream pl r or a limasod pumper vm-ifying Heat i i } the m4to waakwaterdrsposai s7Amm is in Nop orating txfDa andiv (2) aftw inspwicux and stumping Cif aryl. diesepti: Fame is less tb m 4.3 rutt of IbAOC. diver, 11ty undeysilptc4 have rears the abelve re quirententa anus sigme to mi im the private di tya wits IM s tra`edards set IoM, herein, as net by the Departmmar of Carwrt ice and ft Depwiment of Noxvat ~aDe saf ~I' Certifs. suing trust your septic s em has been trial must bt amWbud mid r to *a St Cwt Clamy Mooing ~ Zcnins Dept - e -akin 30 days of the th_ year saxgi date. Love cerdfy that all st~ntenis co tttiz'urns a wit to the best of m a knowledlic. Ehve anvszc ownetis of rise p:a ay dezcritred ctaavc, by b iatuc of a trarxanty worded in Register of Dew Mize. itdaasaa$sea• o t•tsos AO, t ! J say i s 1iW thFA is mi ented may restAt in the smitary pwnh ieiag smoked 5y dar wing Delmarmem. 00e include wits this application a s wasranty deed front, the FLepis or Deeds Office and* copy of Hte certifed survey snap it ie&xence is utacc is the WmUnsy d:ssd. (RLrr. VS) E' & 3E 't 2!.0 60 130 at WrsconnsnoecamentotCom,raae PRIVATE SEWAGE SYSTEM St. Croix Safety and Bu:Jirtg Drvtarm INSPECTION REPORT s3 utary Pem ft No 514839 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID Na Per>,ocai Worcratvn ycu prrw:da may be used rs secondary purposes tPrmacy taw, s 15 04 (t gmfl- v-erm1 Ho:aer's Name Coy Vi laje X Tc-n p Pareel Tax No Walrack, Dan $ Tiffany Troy, Town of 040-1315-07-000 CST 61J Elev ;nsp t}?tA @Ipv: Sk4 Descnpt~on. sectronlTa Rangelf lztp No Po t 66 7 05.28.19.2063 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACIYY STATION as Hl FS ELEV. * ) 'Be"cnmark -9 Gy py L ~p ~ $e'~}ttC f , / y G1 ~i.+.n.. , f Z.SC7 o e f ( ~U A • t 1 'K.J .aasu+g "L/ Alt. f3M / Z - `s' ~.":efa:icn BIC' 'g Sewer 2.35 JZI. V, t5sp g fSb'Hi tnfet $fx ~ ~I~.~ -I-ANK SETBACK INFORMATION 5UW Outlet z It .23 TANK TG Pl "'ELL BLDG. Vettt to Air bltaW FQAD Dt _Inlet ~ Dt Bottom Septic 5 ~J A- r I' Dasinq HeaderiPAan, d.~._`~ aeralton Dist. Pipe ' C' Holding Eot. System Final Gr PUMPISIPHON INFORMATION ~:tanufactuoer - -a®-~ Demand St~-,#jJ 1 z GEM 6 {Model Nu ber C) /t}/ 1 S TL:i-I t ift Frictton Loss Syst -ad T' DH Ft C.~ oreematn i er.gtrt Dia- _ trsl r© Ne, SOIL ABSORPTION SYSTEM q l zo -7 )-tv /b(o' S BEE)aRENCM VAe11h f Cengtn J NY Of Tw-hhus PI DIA75NSIONS No. 01 Pits ~ Ins,63 D:a. Licutd Depth DIMPNSIGNS La.T +3 i t iP. ✓4 SETBACK SYSTEM TO vds iL 9LOG V4ELi. LAKEISTREAM -CHING Manufacturer. INFORMATION CHAMBER OR t r 3N11 rdeiNumber 11 AM- ype T~ t) AiSe O -7140 t. iSTRIBUTION SYSTEM /1* I t Headerstanrtcta 1 Dut.irutx~ x Note siZe~ x Hoie Spacing Vent to ' la s wpets} e ~ /Z.~ lengti?_ :.onc~ihw D:a-_ `y._-- SRaGnr ________._m. Q. v1. SOIL COVER X Pressure Systems Only xx Mound Or At-Grade Systems Only ------ff G . p.F Over Depth O'er m Dep+h u( xx Seed d+Scdded xx 65ef`U~tF,,d I o N^ h &C r-ru.h l.enfi' } 3ec.'Trencn Sages O~ Topsoil `m,`a,• Yes i COMMENTS: (Irc;f de cede disc,epencies, persons present, etc.) Inspection 4Y~1_--_ inspection Locatlow 537 Autumn Plaze 7isd Hudsom, Wl 54016 (SE V4 SW 114 5 T28NN R19W) Cedar Woods Lct 7 Parcel No: 05.28.19.2663 S.p Alt 13Fol Dcaerlption .d-n ' 1-- Zy}•s.i... 'z i a1'. "Z- 5, 2.; Sddg se,l r teng3 N = 'L8 tn.l ,'(V~s (Z~. u-3 r ff am turd of co.e[ = ! r f•^A7G,i-.. r!3r r •pr. 2e4uired7 Yea t 0 d Z3 6 j" ! { use o t e- side for addiiioF d, r.format.on. Uate 1 InscytuT~ r.;abre r=n;t-NU B lot P&w or Site and Soil Evalualson e of 3 Property Owner G~ k- up 1" 40ft. c tJ North QD ti o~- I°{ 1 gyp= _ p• 7-0 }y a"~l 4 Site Location: t rte,