HomeMy WebLinkAbout161-1092-30-000 (2)
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County:
Safety and Building Division St. Croix
INSPECTION REPORT Sanitary Permit No
GENERAL INFORMATION (ATTACH TO PERMIT) 597497
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)] State Plan ID No:
Permit Holder's Name: City Village Township Parcel Tax No:
LAWRENCE & JEN LARSEN VILLAGE OF NORTH HUDSON 161-1092-30-000
CST BM Elev: Insp. BM Elev: 77 BM Description: Section/Town/Range/Map No
Sq 12.29.20.727
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing 6;..< -6iT;
Alt. BM
Aeration ~•j'V. ~ a
• Bldg. Sewer
k L4_-, 4Z~ AA NA
H
olding St/Ht Inlet
TANK SETBACK INFORMATION St/Ht Outlet
A 13 71r TANK TO 1~L WELL BLDG. ent Air Intake ROAD Dt Inlet
s ~ e
Septic Dt Bottom
Dosing Header/Man. od
Aeration Dist. Pipe Qrr .g
Holding
Bot. System
%I
9S 0~ O~
PUMP/SIPHON INFORMATION Final Grade 'C 4. 1 Mo. -03
Manufacturer Demand
St Cov r
GPM 00 aZ • 44
Model Number
TDH Lift Friction Loss System Head TDH Ft 01
Forcemain Length Dia. Dist. to Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Lengt , No. Of Trenches PIT DIME®NS No. Of Pits
Inside Dia. Liquid Depth
DIMENSIONS % Z
l te,~ ~ ~
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufa r
INFORMATION ctu
Type f System: ~ ~
Model mber: , A
J"6 / UNIT
1 03,
Z
DISTRIBUTION SYSTEM ZZ L; L, ~Z~__ /a
Header/Manifoll) / Distribution x Hole Size Ix Hole Spacing Vent to Air Intake
Pip9s)~ Di Spacing
LDia Length
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth of jxx Seeded/Sodded xx Mulched
Bed/Trench Center S Bed/Trench Edges Topsoil
No %__c,Yes F-i No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: 1 pection #2:
Location: 311 STATION LN N ` I J II
1.) Alt BM Description
2.) Bldg sewer length G111\4
- amount of cover O W
-
Plan revision Required? ❑ Yes )No /X 2 Ll -J7 7 _~71
Use other side for additional information.
S41~
BD-6710 (R.3/97) Date Insepcto Signatu Cert. No.
c -7
r 1 Y industry§et:=c Iii ;si 0 County
1400 E Washington Ave
'
S EP Ct. x 7 z -Sanity Pcimit Nu rn r
I"' ~ I qC,2~ ~ ~ tt, 37 71 ~ (to be filled in by CO-)
'OMMUNITY ten~s`gte Dgg4prmit ppli State Transaction Nurnher
la zccarda= c:ith SPS 383,21 (2), Wis. Adm. Code, submission of this foam to fire appropriate goce=en 't
is t utifcd lxittr to obtaining a sanita2y permit. Note: Application forms for state--os~ncd PORTS ur: sulm-fined to Project Address (ifdific cnt than maiPiag address)
the Department of Safety and Professional S"ces. Pcasaowl information you Prozidc may be used for iccres~ ry
i ' in accordance Nvith the PrivE Law, s_ IS, (1 trt}, Stats.
{l I. Application ltd-ormat utn - Piepse Print M ltaformation ~
f Pr0'rrCt'r}f ~5~.21CE' 31YCtrnc. aARtl
1t ( P - q
4 C% r Vv L r+u g
r
t .~r
} zy Qcsnc s ~Saii nl; Ad3resv
j ~ ~ Propx'xty l caatior , a y, (,1. 7
t uti S n C,owt. Lot
Zip C. d j Phoac Numb=
( C t}J - _ x Lp ti _ v, Section
(circle one
li. }'psc of Building (check all that apply t.ot
T N; R F
I or2 Family--Dwelling -Number ofBedrnt~s ~ Subdivision, Name
Block 4
Public/C'arrrzexcSal I:esctifxe L}sz
❑ City of
0 State 0,,,ncd Descnbc [1st CS I Numixa Village of r 4 by -
~ ~ Town.
111 Tike of verout- (C"beck only one box on line A- complete line B of app iicable) t~ dewSystent ¢R lacement 5 stcrt 1'rmatmenul$alding F..L Rcpiscz rrcnt On!v
Other Modification to Existing System (explain)
B Q Permit. Rtmv al Pcrm§r Revision Per xit?d trcr and ttstc Lcsu
ChanBc of Plumes El Pcmn€t Ttnnsier to New List Pr'Ni ed
~
Before E Viration r
VVlner ~,-41~; jf f :~,,*f .G~..:J-E~f .~3~ IV
I FIV. Type of i'+ONVI'S Syste »l onapoa utiDeviee Check all that a t1')
r
R Ikon-Press ritzd In-Grouad ?'resse i e l In-Ground C] A?_C T- ie 11 Mound- 24 in. of suitable son ~ Mound < 24 in, of suitable snit
t Ej 11aldinaa 'f: k 11 Other Dispersal E"ompoucut (exp- ~ lain'
I'rcbratxsseut t7c. ice (txpfsin)_
. a QCSaLf i'rea ; al Ama Info
j llcsig t Floe (9rd) Resign Soil Application Ratc(epdsf) Dispr sat Arr3 Rcquired (s0 Dispersal Area P~ (s£) System Fleu2lioa
Tank Info Capacity in
Total Of tbltrlU~vttL'C7
fsalion Gallons Units
c
t K7c Tanks 3:.-Zonng Tanks w o 'a
Sr tckiti#trtg'':a'
gllll_ Responsibility Statement- t, the uasrlcrssmued xsaarne resp+ousab lits for [a ` dou of the P TSi 7S showu on the attached Puns
i 4'fumt cr's $Na me (Print) Plumber's Sig, atuzc
t (f L PP` s rvsnbcr Business Phone Number
(Street, Ctty, State Zip Code)
1'111. t oa.ntyh)':!! r€wn ut list ftnl
A
X
gprosed ❑ gzorc, lrc-nuit Fee ;Date ds to ci Issuing V eat Sirs a4ure 9/00/1 T'
, oaditions cnf etiltprovallRe-asons for Disapproa'al ~_e
SYSTEM OWNER: pre, 3L1wt<.S air*, J6 Ott $
l~~~, ~
1. Septic tank, effluent fitter and ~1iv ~o ~tFt~GC[R! '
it dispersal cell must be. serviced / maintained •
as per management plan provided b lumber.
se ac requirem peel
~X
~ii°IE sysnx>R ud stxbmtf Ya t • _ -ty ..1y au pager eat? 8 t!a x 11 inches in s4c
as per applicable code/ordinances.
in-G.round Gravity Plan PAGE VE 1 OF 4
Coinponent Manual R, fe,,&rjces:
Versiio 2? 0, S u-1070 - rE., fit ~ . 10/12
2 of 4 1 Ian
4 Dispersal area # cjs- tiorj , plan fie
Pi,
i = er t Plan
Pinar Gannister.Specs POWTS App
lica'don for Review
Filter Spec _ oil Evaluation Report c Site dap
lnfiltr atx Specs _ Warranty Deed
Septic Tank maintanance Agreement
vvner Name(s): LAWRENCE J. JE L . LAR E Phone:
- -
Owner ~ fires 11 Station Lase N., Hudson Zip: 54016
Project Address: (same)
Govt. Lot: NA SE 1 /4 of SW V4, Section 12
Township: ~ Viiia of North Hudson
Fli'laject an'ce? to 163 1 - 1092 - ,:sip - 00
5_ 4 v_ r7`
Designer Address: 28497 King Arthur' Court, Dan bury, W i Zip. 548
ofl
License Number: 1359-007 ~~y~✓~ ~,,p Yp Y
ay $ p8
Remarks. y j Red p'.
q RUPPERT
a s
1
'Ub.s f d~ s
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o , h sawmitteI ccpy'
~s IL, .t
/ t
OWNER
ADDRESS
._-_.t12. r 1'-# k>+ 1~ E t t ad,,..-'t~ y4
SUBDIVISION ~ CST
LOT
SECTION
` R N7, - 0
ST_ CE Oi" COUNTY, SCCPt~SIa~
PLA~V VIEW
3HOW HPIG Utz HIN 100 FEET 0. SYSTEM,
TES`
_7 im
Jk S F r
Lf' d~dc P 1 v E~tTS U
I
t
a t
A lo Provide
S ~caGh and G't/3 _on jnf ll may _ cn on revers
~ Pt'o
-vide dimonsions
3r
y1
o
Z co
. z
L) > 43
CL C rJ
50- .2
0 47
(0 z
r o E Lo
fie. z i 'C U w
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PAGE 4 OF 41,
g s i-ground Gravity Management Plan.
if is T" NT-
The owner of this in-ground gravity syst-ern shall be responsible for its perpetual operation and maintenance pursuant to
regaairerrler tw of ,'v"Disc, drrrir. a:3e. Pu,.5uarit to SP5 '83.52 Wisc. Admin. Code, this system shall
be considered a hurnan health hazard if not maintained in accordance with this approved management plan,
curthemmore, ail inspection and maintenance activities shall be performed by a registered POWTS Maintainer in
r ccordanc:E vv th P 383.52 ; Wisc, Admin. Code.
Maximum Dispersal Area O tin limits:
T wi n Flow 600 ~ g SOD s!5 220 L"; SS < 150 r r' 9L"; FOG :5 30 L-'
inspection Checklist INSPECT EVERY a YEARIS
c type of Use
age of > Ifr E
nut~ance factors odors, use, CC)mpi r
mechanical m aifunction (i.o , pumps, valve's, vt c' , 10'-Ts.
a ma=:2rial fatigue (i.e., leaks, breaks, corrosion, etc.)
o ` rls volume in anaerobic treatment tank(s) and any ctistributi cr +3 wJ t ibui}Lt r . :`,cp boxes°},
o neglect or improper ? i (i.e., exceeding design capacities, prohibited a ivi'i' r.s, etc,)
c -extent of ponding in distribution cell prior to dosing
dosing irregularities - if applicable (i.e., pump re-cycling, float switch settings, etc)
electrical components - if applicable (i_e., :wing, connections, svoicdres, controls, timers, alirmc-, , ic.)
distributlon lateral or lateral orifice plugging (measure lateral distai pressure - compare to design sfpe j icatioH i i
o surface discharge of effluent or sewage backup into structure served
tr ,;i rre e e ii~t MAINTAIN EVERY 3 YEARS or when necessary)
_F,tac and dose tank(s) shall be pumped by a eerti}ied septage servicing operator licensed under :s. 231.143 Vvi5.
~yjhen the volume of sotids in the tank(s) exceeds sane-third (1f3) the liquid volume of the tank(si c;r
quired by l~cai card} ~;,c Disposal of contents shall i pursuant to N1- 113, Wisc. ,admin. Code.
viuenal L is shall inspected eY.`,w y 3 dear and shall be cle.a, G i"`eer, rrecessar ro ::a °tJve any
2CCLimUlatE9d `<C( -G t aifl' o- U.cCt.3r T' flfcflu:. k
S sped rIt ilea„ hod 11411 a''"»ays oe Jla'n t"
stern rile inten nce reps s shall be subi-ni ted to tai proper local go verrim ni unit in accordance with
SP 383.55 Wisc. Admin. Code. Report any Component failure or malfunction to:
f,iame of individual or company: Advanced Septic installation Phone: 715--1703-8337
Local government un t: t. Croix Community Development Phone: 715-3864-680
Local government wait address: Hudson, i zip: t0
Any defective part of this system shall be repeir d. replaced, or removed pu,° taant to SPS 383,51 (1}, misc. Admin.
Code. Repair or replacement of failed or malfunctioning components sh;=zil comply with SPS 383, Wisc. Admin. Code.
No pro cuc,i f~crr »("aemica l or n . -i1 restoration cf c. tr-P0-, v rFS m a,v t3. '!s "J", 11 s, . t} ? 'a. ed, D,l the Gepa fi" furl i2't
ill tilt..' event that call} . ,z . 4asem corripot en't 0 is..., , 3' ~ : _ C'aor".ri >r
1 lr t be rE."ja aced UUi 1rii to
Z H an c, n,
a! H a J 4e .ui:w at ';rC r d d;` CQ^ C tre _ i act`y
c r.r,dC 7 and' .'e.olr;ce{j by a, cvu' rornp;yin(i dis `c sal ti .l vt't• kl, in a feral dt~terrnin r area of s"'itabie soils.
if use of this POWTS is discontinued, i, steal' be c`7bando. ed 'dn accor(:clr:`.. o a'334.r7 SP S 383.33. Wisc, r'idrnin. Cc,,,'.;.
STC - o4
SANIT wty SYSTEM REpORT
t
P RSSr
r
rt
} SUBDIVISION CSMP
SOT
CTTO 3 a
- -T N-R
ST. CROI COUNTY, WISCONSIIN
-4-
Y PL;;
SHOW EVERYTHING WITHIN 100 Fu T OF
E
a 3 Pte,"
f
( I.
( j [ 1
I NDTCATE NORTH ARRO ~
j zQV ? set-back and elevation information on r£"Jrcrs 3f this forlR.
Provide 2 dimensaor,s t center of ser
a
i
r
CHI
f L 1 t . ~c
SEPTIC TANK ~ PUMP CHAMBER 11-OLD LNG TANK INFORMATION
Manufacturer: r y
Liquid capacity:
s Setha &w r in Wev House
P:.':iit Manufacturer-,
Float seperaticn Gallons/cycle•
:alarm L Dcation
I
SOIL ABSORPTION SYSTEM
}J! Width: _---Length I ~ - Number of trenches
f
Distance & Direction 'Lo nearest prop. line: f I
Setback from: well; 2Q Hlouse Other
i
ELEVATIONS
Building Sewer,,~ T a n1 et .
ST€ outlet J00 40
PC inlet--- PC bottom___::~_ Pump Off
z _ Bottom of system
E A,``tinq Grade Final grad, ,
~ti Tyi ry ,v i '
a
1
PLUMBER r ;
liCENSE NUMBER: INSPECTOR:
a/93 : jt
a