HomeMy WebLinkAbout004-1051-40-300 (2)
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division INSPECTION REPORT Sanitary Permit No:
son-2017-358
GENERAL INFORMATION (ATTACH TO PERMIT) 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 & ANITA GOKEY TOWN OF CADY 004-1051-40-300
Ins BM Elev: BM Description: Section/Town/Range/Map No
CST BM Elev: p. 22.28.15.342A-20
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic _ r• Benchmark
Dosing Alt. BM
Aeration Bldg. Sewer ` 5
Holding SUHt Inlet
SUHt Outlet
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Dt Bottom
Septic
Header/Man.
Dosing
Aeration Dist. Pipe
Bot. System Z
Holding ~
Final Grade
PUMP/SIPHON INFORMATION
Manufacturer Demand St Cover
GPM
4
Model Number
lForcemain Friction Loss System Head TDH Ft
Length Dia. Dist. to well
SOIL ABSORPTION SYSTEM
PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
BED/TRENCH Width Length No. Of Trenches
DIMENSIONS
1- > , 4 -CEACHING SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM CHAMBER OR Manufacturer:
INFORMATION Type Of System: _ UNIT Model Number:
I i
DISTRIBUTION SYSTEM
Header/Manrfold Distribution x Hole Size x Hole Spacing Vent to Air Intake
Pipe(s)
Length Dia Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
De th Over Depth over xx Depth ::::of xx Seeded(Sodded xx Mulched
p Bed/Trench Edges Topsoil U Yes No E] Yes No
Bed Trench Center
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location: 262 310TH ST
(...t. f~ r,t,2
1.) Alt BM Description
2.) Bldg sewer length r-,
- amount of cover =
Plan revision Required? E] Yes E] No
Use other side for additional information. <3 2
Date InsepcTorsS atu Cert. No.
SBD-6710 (R.3/97)
.tea `i
_ .F r.
County Sanitary Permit Application ST. CROIX COUNTY WISCONSIN
In accord with Chapert 12 St. Croix Co nt Sanitary Ordinance PLANNING & ZONING DEPARTMENT
♦ Personal information you provide may be u`E s ST. CROIX COUNTY GOVERNMENT CENTER
IA-Ulp [Privacy Law. S. 15.04(1)(m)] (MWD 1101 Carmichael Road
Hudson, WI 54016-7710
7tlQ 4 i 0 c OCT 182011 (715)386-4680 Fax (715)386-4686
Attach complete plans for the system q;W t I h n 8-1/2 x 11 inches in size.
County Sanitary gPermit # ❑ Cf 9 n
it~ " GU IlVd71~
n:
1. Application Information - Please Print all Informati rLotN
Property Owner Name 1/4 1/4, Sec Z Z
I
k'(' N, R E (or) Property Owner's Mailing Address ber Block Number
vision Name or CSM Number
City, State Zip Code Phone Numer te
I Z6 $ 3g
III Type of Building: (check one) z Ql~ n, ❑ Vill Town of
[ 1 or 2 Family Dwelling - No. of Bedrooms:
❑ Public/Commercial (describe use): 1! Cif'~N
❑ State-owned arest Road
Permit: (Check only one box on line A. Check box on line B if applicable) 31 V
11. Type of
l Tax Number(s)
1Repair 12. 4 Reconnection 3.❑Non-plumbing 4. ❑Rejuvenation
A) Sanitation 6,6 ,1-/CJ5 / - - 3 6c'
B) Permit Number Date Iss d
❑ State Sanitary Permit was previously issued Z 5 ~t*
IV. Type of POWT System: (Check all that apply) x
❑ Non-pressurized In-ground Mound ? 24 in. suitable soil ❑ Mound 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) Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. System Elevation 7. Final Grade
Required Proposed • (Gals./day/sq.ft.) (Min./inch) Elevation
VI. Tank Information Cap icty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic
New Existing Gallons Tanks Concrete structed glass
Tanks Tanks /iS ❑ ❑ ❑ ❑
❑ ❑ ❑ ❑ ❑
VII. Responsibility Statement
I, 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 terralift repair or the installation of non-plumbing sanitation system.
Plumber's Name (print) Plumb 's Signature no stamps): MP MPRS No. Business Phone Number
1
~JG S l f C,+"i!r r' , -C%1 74 _ - c' 7 - / U
Plumber's Address (Street, City, StaW,Zip Code)
VIII. Coun Use Only
ved Sanitary Permit Fee I D g);d Issuin entSignature stamp
Approved Owner G' ni rse 1 U16 . ~ /b
mnation IX. Conditio V easons for Disapproval: c 1
1 & lark, emuCtr Lift and t
di ipemni cell must all be sn=fc$s ! r,,a +~t ec
as per mar.agement plpn p o 4deh by plumber.
2. 'All mftwk requiMr.'ten s must w mamta ive•1
as per P.Mlicnbl9 c:nd~ / , rdi,ianca.:.
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ST. CROIX COUNTY
SEPTIC T<41\7K MAIl\TTEI\_ANCE AGREE_N~TT
AND
OVdNERSHIP CERTIFICATION FORM
i
OwnerBuyer ~ l ~ a ~ ~,1 ~ U ti/
Mailing Address . 1c) e 1A_~ , ( G g L ! ~Zo, 7
Property Address 1i(o~ 11> A^` 64-~Le~-
(Verification required from Planning & Zoning Department for new construction.)
City/State Parcel Identification Number 6b4 - !b-51-- J16 -360
LEGAL DESCRIPTION
Property Lc)cation Sec. , T ' S 'N R W, ToR,n of (`t
Subdivision Plat: Lot
Certified Survey Mapy Volume Page TL„L
'Warranty Deed N 6 j T to (4e (before 2007)Vo1ume , Page 4
Spec house D yes D no Lot.lines identifiable D yes D no
SYSTEM KA-L TTEINANTCE A -D 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. ''hat 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 ce-rdfication 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.
Uwe, 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 Natzal Resources,
State of "iVisconsin. 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.
Uwe certify that all statements on this form are true to the best of my/our lmowledge. Uwe am/are the owner(s) of the
property described above, by virtue of a w 76 ty deed recorded in Regster of Deeds Office.
Number of bedrooms
SICrNA OF APPLICANT() DATE
***_kny 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. Q4/1Z)
ST. CROIX COUNTY ZONING 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, .~t, 1/4, Section , Town N, Range W,
Town of St. Croix County Wisconsin.
Upon inspection,1 certify that 1 have found the tank(s), to the best of my
knowledge, will confonn 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: i'P A
Construction: Prefab Concrete Steel Other
Manufacturer (if known):
Age of Tank (if known):
Permit number (if known)
r ,
(Lic,nsed Plumber Signature) (Print Name)
(Title) (License Number) MP/MFRS
(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
Ryan Yarrington
From: Josh Turner <j_turner@hotmail.com>
Sent: Tuesday, October 24, 2017 10:17 PM
To: Ryan Yarrington
Subject: Gokey
Attached will be a house plan. Please reply to this email to verify you received this. Let me know if anything else is needed.
The system seemed to be working as it should and showed no evidence of ponding or having any other issues.
Thanks
Josh
1
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County St. Croix
Safety and Building Division INSPECTION REPORT Sanitary Permit No: 488259 0
GENERAL INFORMATION (ATTACH TO PERMIT) to Plan to No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)). S ¢ I t "
Pernit Holder's Name: City Village X Township aicel Tax No:
DiBona, Tim Cady, Town of 004-1051-40-300
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
,a ' Co-t) s l C? = CsrS # I 22.28.15.342A20
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURE CAPACITY STATION BS HI FS ELEV.
tr ~ csD
Septic Benchmark
Dosing It Alt. BM t~
Aeration Bldg. Sewer •q ..0 t
Holding SYM Inlet '73 72- 3 qZ 3 3 t
St/Ht Outlet
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic Dt Bottom r t
Dosing Lit Header/Man. V0,5_ 102. ZS 7'
Aeration Dist. Pipe . G r D ~~Z
Holding Bot. System O/• SO t
PUMP/SIPHON INFORMATION y 1~e %
Fi all Grade 47t.
Manufacturer Demand St Cover ~.d •"•'W'S 5•Zo O~~O r
GPM 4 • {r'•+ Model Num
ber rn V •
~Q Lift Friction Loss , System Head TD i Ft
Forcemain Length ZZ Dia. i• Dist. to Well , :?St
SOIL ABSORPTION SYSTEM
ED Width Length No. Of "renehe$, PIT DIMENSIONS No. Of Pits Inside Dia.
ENSIONS / I g t LL~
SETBACK SYSTEM TO PIL 1 BLDG WELL LAKE/STREAM LNICBEG acturer.
IN FORMATION CHType Of System: (C' > odel Number.
DISTRIBUTION SYSTEM o
Header/Manifold / 4 Distribution r t! x Hole Size „ x Holte /S_pacing Vent to Air Intake
Length 3' • Dla l Z ngtn 8Wla Spacing 3'O 3/b 7.
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Mulched
Depth Over Depth Over jxx Depth of jxx Seeded/Sodded
Bed/Trench Center Bed/Trench Edges Topsoil O Yes Q No Q Yes 0 No
y
COMMENTS: (Include code discrepencies, persons present, etc.) Ins ction #1: ri► Inspection #2:__=7=_7=7
5 NA Lot Parcel No. 22.28.15.342A2
Location: 262 310th Street Spring Valley, WI 54767 (SE 114 NE 1/4 22 T28N R15 ) NA Lot 3
C,,:,l. 6 0 r. s cwkrs AU +,.-Q_ t~ e•. 4 ►ti}?er~
1.) Alt BM Description = S rt,,, i 1 . t .
2.) Bldg sewer length = eft
- amount of cover = 47-
Plan ba~~
• ( ']Z~
revision Required? A Yes No
Use other side for additional information. - - _