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Home My WebLink About040-1324-31-000 (2) Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No (ATTACH TO PERMIT) 600256 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: William & Jennifer Bowman TOWN OF TROY 040-1324-31-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: 00, V'Q_ 01.28.19.2186 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM Aeration Bldg. Sewer ~ J v{Q Holding S n 1w Cov G9.22 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 i' Dist. Pipe Holding A Bot. System Final Grade PUMP/SIPHON INFORMATION Manufacturer Demand St Cover GPM Model Number TDH Lift riction Loss I System Head TDH Ft Forcemain I Length Dia. Dist. to Well SOIL ABSORPTI SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. LDIMENSIONS SETBACK SYSTEM T P/L BLDG WELL LAKE73~TREAM LEACHING Manufacturer. INFORMATION _ CHAMBER OR Type Of Syste : UNIT Model Number: DISTRIBUTION SYSTE Header/Manifold Dis bu x Hole Size x Hole Spacing Vent to Air Intake Pipe Length Dia Length Dia Spacing - --------O--------------------------- SOIL COVER x Pressure Systems Mound or At-Grade-Systems nly- Depth Over Dept,_,Quarl--- xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center ed/Trench Edges Topsoil U Yes ❑ No Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 570 GERMAN CT ec U► (Z Se v I U ' " 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = HT' D4' Plan revision Required? ❑ Yes o p T Use other side for additional information. Date nsepctor's Signature Cert. No. SBD-6710 (R.3/97)~~- A -7 3 -7 '3 County Er F.1 y Safety and Buildings Division ST CROIX r t ~S I 201 W. Washington Ave., P.O. BOX 7162 Sanitary Permit Number (to be filled in by Co.) P ~I ~r I Madison, WI 53707-7162 tpp~~~N eY,mit AppliC ALA-" State Transa lion Number In accordaneCith SPS 383.21(2), Wis. Adm. Code, submis: ntal unit is required prior to obtaining a sanitary permit. Note: Applic MOMZY arty Project Address (if different than mailing address) the Department of Safety and Professional Servies. Persona....___ 2HH v~WYG 6ZR ary ur ses in accordance with the Privacy Law, s. 15.04(i)(m), Slats. 1. Application Information - Please Print All Inf n Property Owner's Name Parcel # William and JENNIFER BOWMAN 040-1324-31-000 Property Owner's Mailing Address Property Location CP f • a 0196 570 GERMAN COURT Govt. Lot City, State Zip Code Phone Number NE NW Section 01 HUDSON WI 54016 612-991-8535 (circle one) T 28 N, R 19 9(or W IL Type of Building (check all that apply) C31 ECl or 2 Family Dwelling - Number of Bedrooms 4 Subdivision Name G Block # COTTON WOOD SOUTH 1 ST ADD. El Public/Commercial - Describe Use 00 tr 5 Alill- 4 El City of P~ ' CSM Number ❑ Village of El State Owned -Describe Use q(Town of TROY III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. ❑ New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only Other Modification to Existing System (explain) B. El Permit Renewal it Revision Change of Plumber El Permit Transfer to New List Previous Permit Number and Date I ued Before Expiration wner ~00' IV. Type of POWTS System/Component/Device: Check all that apply) ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil E3 Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dis ersavI'rea ent Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required 00 Dispersal Area Proposed (sf) System Elevation 600 .4 1500 2813 100 VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units 4 0 'o„ New Tanks Existing Tanks o y av ~ y ~ iwc7 a Septic or Holding Tank 1 1200 WEISER Dosing Chamber 1 800 COMBO X VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber'sSi}nature MP/MPRS Number Business Phone Number PAUL R KOEHLER ~j~ 25410 715-246-2660 Plumber's Address (Street, City, State, Zip Code) F ount /De artment Use Onl y 17 pproved Permit Fee Date I sue ) Issuing ~atur 4277iven Reason for Den' I $ ell) rG~ / IX. Conditions of A pp rova [/Reasons for D proval X e4oov C, Attach to complete plans for the system and submit to the County only on paper not less than S 1/2 x I I inches in size SBD-6398 (R. 11/11) RECEIVED ~ . -s,,~evi %/,Z, OCT 31 ZU1 i ST. CROIX COUNTY DEVEZOPME ` ~e ".2s~39 ^,OMMUNITV .arou o /ihC / • S70 German Crc !mot 3% p/<~ of C~Ztsn cod w~ lea -e-56 1,6 77A St. 'u7 /~G y r1 L.J ` .5c C G'r ~lc~,y Jades dl3rkS~28~. -East/of~-o ~ ~ 4T.o'~- h~ o X67 82 / f~ - - - _ - ' - Af Lo, \ e,Q' .63 3 8S A _ - ~cLWCa,n Rr osze✓/ 5F 74, 17',ysrr/SDI A 0tl 1~~ 5v'cec~r ` 9/~Q~ d.sn~~sc/Cr11101accd0n97 Z`n4'/t~l lll St{rr4Ce <lee be/a0.6,0 74 /a6eralc44', %R",r7f~1S'-y 'vr,4'ces;4ce f3oposccluJ~esErC crt,~t S`~' 5.r1l0d.. ype/yZIA' AszS yl,~U f,Vji,"t 4.16,-e-~- 3,- ac~lt . ,1f'5c,4, ,loAsTa1-01765;440e 4 CXS~~~ irl.foct'of2 441 le 6 w QfS%cllKLG 1 1 tea. a 4C MOIL, o t~ Document Number Document Title St. Croix County Affidavit for a single POWTS servicing Two Structures via Private Interceptor Main Name - (Owner) Typed or printed being duly sworn , states, under oath, that: He/she is the owner/co-owner of the following parcel of land located in St. Croix County, Wisconsin, recorded in Volume Page Document Number St. Croix County Register of Deeds Office: Recording Area Name and Return Address A parcel of land located in the '/4 of the 1/4 of Section T_N,R_W, Town of , St. Croix County, Wisconsin, being duly described as follows (include lot number and subdivision/CSM or detailed legal description): Parcel Identification Number (PIN) As owner of the above described property, I acknowledge that a Private On-site Wastewater Treatment System (POWTS) serving the primary residence is sized for bedroom(s) with a design wastewater flow of, gallons/day (DWF is based on 150 gpd /bedroom a 2 persons per bedroom). A maximum of _ occupants are permitted; if the number of occupants exceeds the maximum for POWTS design, the system will be undersized to accommodate increased wastewater flows and/or contaminant loads and may be subject to premature failure. I understand that disclosure of this information will be made to any parties interested in purchasing this property in the future. Dated this day of AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) )ss. St. Croix County ) authenticated this day of Personally came before me this day of (year) (year) the above named x to me known to be the TITLE: MEMBER STATE BAR OF WISCONSIN (If not, person(s) who executed the foregoing instrument and acknowledge the same. Authorized by S 706.06, Wis. Stats.) THIS INSTRUMENT WAS DRAFTED BY x (Signatures may be authenticated or acknowledged. Both are Notary Public, State of Wisconsin not necessary.) My Commission is permanent. If not, state expiration date: Date: "THIS PAGE IS PART OE THIS LEGAL DOCUMENT- DO NOT REMOVE" This information must be completed by submitter: document title, name & return address, and PIN (if required). Other information such as the granting clauses, legal description, etc. may be placed on this first page of the document or may be placed on additional pages of the document. Note: Use of this cover page adds one page to your document and $2.00 to the recording (ee. Wisconsin Statutes, 39.43. County. St. Croix Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Sanitary Permit No: Safety and Building Division INSPECTION REPORT 5820 (ATTACH TO PERMIT) State Plan ID No: 2655702 GENERAL INFORMATION Personal information you provide may be used for secondary purposes [Privacy Law s.15 04 (1)(m)I Parcel Tax No: Permit Holders Name: Clty Village Township 040-1324-31-000 William & Jennifer Bowman TOWN OF TROY Sectionlrown/Range/M01 28 19 2186 CST BM Elev Insp. BM Elev: BM Description ELEVATION DATA ELEV TANK INFORMATION STATION BS HI Fs MANUFACTURER r' CAPACITY TYPE Benchmark Septic , Z I Alt. BM Dosing Bldg. Sewer Aeration SUHt Inlet Holding St/Ht Outlet TANK SETBACK INFORMATION G. Van t Air Intake ROAD Dt Inlet TANKTO (L WELL Dt Bottom Septic *7& 1 V7 -46 Header/Man. Dosing t 7 Dist. Pipe Aeration Bot. System Holding Final Grade PUMPISIPHON INFORMATION Demand St Cov Manufacturer o e,t t GPM 3.l0 97. S Model Number V J Head TDH Ft TDH Lift Friction Loss system / to Well Forcemain Length Dia. Dist. Z SOIL ABSORPTION SYSTEM nside D Liquid1pth PIT DIMENSIONS No. Of P t®_ No. O rich BED/TRENCH Width Length DIMENSIONS 'k; . Manufacturer. LAKE/STREAM LEACHING SETBACK SYSTEM TO P/L BLDG WELL CHAMBER OR INFORMATION Type UNIT Model Number: stem. A.jD SYSTEM x x Hole Size Hole Spacing Ven Air Inta e ; Header/Manifold Distribution Pipe(s) Dia Spacing Length Dia Length SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only a Mulched xx Depth of xx Seeded/Sodded Yes No Depth Over Topsoil Yes No Sri Depth Over ged/Trench Edges Bed/Trench Center Inspection 2' present, etc.) Inspection #-7 j$ / n COMMENTS: (Include code discrepancies, persons Location: 570 GERMAN CT 1.) Alt BM Description = 1~d\ ~a~~ /nom( 2.) Bldg sewer length - amount of cover ired? ❑ Yes C No Plan revision Requ Cert. No L~ I Insepctofs Signature Use other side for additional information. - pate-- - - SBD-6710 (R.3/97)