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HomeMy WebLinkAbout020-1099-30-000 (3) Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 600223 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: JOHN HART TOWN OF HUDSON 020-1099-30-000 CST BM Elev: Insp. BM Elev: M Description ^ Section/Town/Range/Map No (V1 xfw) -~o 0~ S ~1 C W I filler 33.29.19.399C TANK INFORMATION ELEVAT N DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM Aeration ab-PLAt&D Bldg. Sewer C Holding ^ J St/Ht Inlet $ n TANK SETBACK INFORMATION In~ d!9, t Outlet 1 5. TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing eade an. 7 Aeration Dist. Pipe 0-1 Holding - ® Bot. System 66 ' tp/ 7 Final Grade PUMP/SIPHON INFORMATION 3.-7 L70-17 Manufacturer Demand St Cover GPM Model Number s~ TDH Lift Friction Loss ystem Head TDH Forcemain Len Dia. ell SOIL ABSORPTION SYSTEM 4- fi BED/TRENCH Width //ff 1 Length No. Of Trenches PIT DIMENSIONS No. Of P s Inside DLiquid Dept DIMENSIONS f-1 ( 5 r / / 14 SETBACK SYSTEM TO P/L BLDG WELL LAKE/STR LEACHING Manufacturer: / N lt/I INFORMATION CHAMBER OR T pe Of System: L` UNIT Model robe. n~. in bOV fiiav '✓5 I LilL 1. J RI UTION SYSTEM Header nifold Distribution x Hole Size I Spacing _ Vent to Air Intake Pipe s h/Psf e Length Dia Leng h Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only De th Over TBed/F Over rench Edges Topso P . J F)7-Depth of xx Seeded/Sodded Depth O er Center c.0 i - _ s # J `7 I 2 [ Yes No Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 652 BRADHURST DR 1.) Alt BM Description = `~q A S Qt ~M. 2.) Bldg sewer length = - amount of cover = ~ N Plan revision Required? ❑ Yes ~o O n Use other side for additional Informs off n. Date Ins&sSignature Cert. No. SBD-6710 (R.3/97) Gr- , St~►'t0 QUi 7 3 y / esvtts Division County I }40(} P.0- Washington Ave 'Cl ttrtS` if~f ~0~'1 x 7VG Sanitary Permif number (to be f i lled in by Co.} IP7 ST. CR3 g r,r.A~A1{1~~TY~ A • ~L } GC~ State Transaction Number € ~~1~FUaFtce with SPS 38321{2), Wis Adm. Code, subrnis on ofthis form to the - i' ~ is required prior to eabtainin a sanitary ProPriaie governmcm'~ri uctit ~ the De g permit. Note, Application fortes for state-cnNned POWTS are submitted to Project Address (if different than nauling address) pertinent of Safely and Professional Services. Personal information you provide may be used for secondary n in accordance Information t e wilt the Priv Lativ, t5.0 } to Stats. ~Z n r ~d rS~ C. 1. fiction - Plea I All Information Proper ty 0laner's Marne °r Parcel # ....e (V .rail Properly thtrEer's Mat}mg Address t _ Property Location qq C 1 City, state Govt_ Lot ' Zip Code Phone Number 1~`=a~ r~~ IJ..t~~`',~~~~.'., /fl~.✓~ ~ ~ ~ r„r V. >4`V 'f, Section 11. Type of Building (check all that apply) Lot # {circle a ~;~,1 E0W } or 2 f'arnity 3:lsreliing - Number of T3edroa ` Subdivision xlarrte I .lock # j ❑ Public/Cammercial - Describe Use of ❑ City of ❑ State Owned Describe Use CSM Numbs ❑ Village of Y n I'fl11gT Of ',A #.t La„x,.~ LI) III. Ty pc of Permit; (Check only a box on line A. Complete line 9 i$applie abler 11 1. © New System Replacement S7-stem ❑ Treatment/Holding "['arcz Kepiacemml Only ❑ fh}ser Modification to Existing System (explain) B Q Permit Renewal ❑ Permit Revision List Previous Permit Number and Dale Issued ❑ Change of Plumber ❑ Penn it "Transfer to }Vc1v Before Expiration V. T . o> POIVT5 Svstem/CoM nent/Device: Check all that a & Non-Pressurized In-Ground ❑ Pres<urixcd 1n-Ground 11 At-Grade El ,,c urA > 24 in_ of suitable sail C1 Mound < 24 - of itabfe sail L ❑ Hordingg 1~~'r Di,persal Compor«nt {explain} - ~s"f0► - ❑ tatment Device {explain} V. toss. csA : rentm n' Area, Ia rsaat; a I~3ign ftow (gfd) Design Soil Appli n ~ Distx Arm Required {sf} i}ispe-rsal Area Pro s System EI i Tai. Tank Info Capacity in Total # of Manufacture e Gallons Gallom Units ti New Tanks E sling Tans Septic } K/ C v rr tz r: a Dosing Charm: K t . t,' { 'c~ . Z i~° Vll. Responsibility Statement- It, the unde ed, assamme responsibility for iustalMdOn 'Of the POVV S shown on the attached plans. ? Plumber's Nytne (Prat) Pturnbef's Sigtare IN, IT Business Phone Number )tr Plumber's ALLItesS (Sires C ~ ~ ; le ef4 ;q 717 V111 _taun rtment Use Only Approved ❑ rt;y>e. Permit Fee Date f' ued - Iscuin I g t Signature « . . fln to ,gy~ Dmial $ 4$S' °b 16 /'D LX.. Condit . b t4 pp ark, trim 1 a roe'al dKpem-*t ti=ll must d1l be seR• t' as per ipnaragement plan pro sided by plumber. E 2. A& sedwk recWper'ten,s must Lm maint-.ir.ed n W WknWit ctx~ l trdinanrs,a. A~asYs te, cccu~?-cc ~Saas far i°..xe s}sfc~ ~eai stt~ssnxt to f#PC taaxttp czsxty oa cs r ;xr s i esx 41-:us S L2 s d r az~Pa~ m s¢e SBD-6348 {R- 08II4} l~/? mar-/ o JOCLt~.CJ ~Jr~,^, C.~~~!~ r, Pe'~Z; r! /7,7 !ts IC t t ~O Y1 h ) p % I morel cc P, j~ 1~ In-Ground Gravity Plan PAGE I OF 4 Index & Cover Sheet Component ti.9 r wal oesign Referc_nces: Version 2. S M-10705-- (N.01/01, R10/12) log I of index & Craver Sheet of Plot Plan of Dispersal Area Cross-Section & Plan View of Management Flan Attachments: Enclosures: infiltrator r Specs PU IT Application for Review rev'Ous Sanitary Permitfinspection Report Soil Evaluatl rt Report Site Map Septic ~"r~treerner~t [ Warranty Deed reject Name / Description Owner me ss: jOH . RT Phone: 71 _ 31 w 11 Opet ner Address: 5 2 Bradh urst r,, Hudson, k,'JP - is 54016 Project Ad'dress: (s rr.e; Govt. Lot: NE 33 _1I4 of ` 114. Section € - 19 Ell or J Township: Hudson T 29 County; St. Croix Project Parcel I : 0120 - ",01-19-30-000 Designer Information Designer Name: Mary Jo Hu rt Phone: 715. 426- 1775 Designer Address.: 284/ 7 Krim Arthur-°s Court, a ,ibf try Zip E-mail: hoflisterdesign@outlook cow «63tl Y 1~'... License Nujielb,-r: -0, 7 Remarks: 'W! Tank & filter to be inspected, a9. Signature: i 1 flue: -2, 217 ngira@eaG~ re rq~re ar x sut mutedko~;. 1617 ` 5ca/e : 5th' r q`y. 9 i OP 1 ~ I 2 X55 cote c = ~ r p` q t . --pper+ PAGE 3 OF Q f l Z E / r.. r h ll v zt3 ~ p ~ s ,ry L { ~'3 ~ q) c-» ~ ~ -fig <a v cx 5T s u s 43 - c~ r= Us' _ ;;1 CD T LAS CV f ¢g ~P LCI f Q . Lull) ~ c m y E U) ? } It 3 n^ C LL" -LZ Jo ~ C;~ c ei ro. li ~ .d f V y 4 J U . J ^~f Ljj e r v- ti CY L4 - { & -10 c F- o co 0 ~ r- I { in-ground Gravity Management Plan PAGE 4 OF 4 ripe owner of this in-ground gravity systern shah be responsible for its perpetual operation and maintenance pursuant to requirements of SPS 382-384, Wisc. Admin. Code. Pursuant to SPS 333.52 (2), Misc. Admin. Code, this system shall be considered a human health hazard if not maintained in accordance with this approved management plan. u hermore, all inspection and maintenance activities shall be performed by a registered POW TS Maintainer in accordance with SFS 388.52 (3), Wisc. Admin. Code. Maximum Disloersaf Area erati- Jimits: Design Flow 600 p R s < 224 rngL"; T :5`t 5f3 rage-'; FOG :5 30 m fr vection Checklist INSPECT EVERY 3 YEARS 'type of use 3 are of system o ni isance factors (i.e. tears, user complaints, etc.) .0 mechanical malfunction (i.e., pumps, valves, switches, floats, etc.) c material fatigue (i.e., leaks, breaks, corrosion, etc.) Q solids volurne in anaerobic treatment tank(s) and any distribution appurtenance(s) (i.e., distribution ! drop boxes) o negiect or improper use (i.e_, exceeding design capacities, prohibited activities, etc.) o extent of ponding in distribution cell prior to dosing c dosing irregularities - if applicable (i.e., pump re-cycling, float switch settings, etc.) r7~ electrical components - if applicable (f.e_, wiring, connections, switches, controls, timers, alarms, etc.) * distribution lateral or lateral orifice plugging (measure lateral distal pressure - compare to design specification) u surface discharge of effluent or sewage back-up into structure served ik,;ntenance hoc list MAINTAIN EMERY 3 YEARS (or when necessaiy) Septic and dose teaks shah be pumped by a certified septage servicing operator licensed under s_ 281.88 Wis. Stats. vvh€n the volume of solids in the tank(s) exceeds one-third (1131 the liquid volume of the tan k(s) or as required by loyal ordinance. Disposal of contents shall be pursuant to NR 113, Wisc. Admin. Code. Eff3umr rmt fi##er{st shall be inspected every 3 years and shall be cleaned when necessary to remove any accumulated solids according to manufacturer's specifications. A servicing period will always be greater than 12 months. System maintenance reports shall be submitted to the proper local government unit in accordance with SIPS 383.55 Wisc. Admin. Code. Report any component failure or malfunction to: Name individual or company: Advanced peptic Installation 715-703-8337 Phone: _ Local government unit: t_- _ Croix Community 3 v l p _ _ Phone: 715-386-4 80 Local government unit address: Hudson, 6 54016 - Any defective part of this system shall be repaired, replaced, or removed pursuant to SPS 333.51 (1), Wisc. Adrriin. Code. Repair or replacement of tailed or malfunctioning components shall comply with SPS 383, Wisc. Admin. Code. No product for chemical or physical restoration of the POVI]TS may be used uniess approw.;d by the depa,-tment in accordance with SPS 10!';sc. Adrn';n. Cc. e. Contin e Plan In the event that any fail d tr e i nent :;a;rnpone?-r`t (i fl,-" PvVV' cannot bc i" a plans submitted to tyre appropriate agency for review end approval. A failed in ground dispersal Vcomponent may b- abandoned and replaced by a code-complying dispersal cornponont in a pre dcaermired area of suitable sci(s. System bgndnment If use of this I'Jlrt i S is d.s ont+nuLd. it s flail be ais3n'> t7 i tt a4i, fi -1:° vt ti. C,-~ 363, r C' r f I t .n ~ v d % -n V oa 11W g J F ?.w # Y 4k 4 y A a z The Cuick4-" 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 o toms up to 15', right or left. The iiultiPori°a endcap allows n~ multiple piping options and eliminates pipe fittings. The chamber's four-foot length provides optional installation flexibility. .A F • Advanced contouring connections swivel up to 15°, right or left 'A • Latching mechanism allows for quick installation • Four-foot chambers are easy to handle and install e" • The Quick4 Standard Chamber supports wheal loads of ~ • ~r G I G,000 Ibslaxle with oniy 12" of cover s Certified by the International Association of tol;ln-,,bifng 2nd i_chn ic2l 0,;t 1"MC) u a J dear-out seals on inlet pcrts provide a fight fit to the pipe ° Fight molded-in inlets/outlets allow for maximum piping flexibility )VI - Eliminates pipe fittings Fits on either end of the Quick4 Standard Chamber APPROVED in