HomeMy WebLinkAbout020-1016-60-000 (4)
v+==~' ~)ec~a„cm or0^^m°r^t' PRIVATE SEWAGE SYSTEM r'apt' St. Croix
$adety and Bu Atl fiq JivisDn
INSPECTION REPORT S:m:L'u' Permit NO
(ATTACH TO PERMIT: SAN-2017-391
GENERAL INFORMATION Scnr vlnr: Ic No
peso-a' ml:mnub:m You aronde meY dC u-,m for :e+:zndr: y Im :>ne+_s lvnvacy Law, s. is Oe i I:('n;l
11emHt-16onr'¢NUrt,e Gfy Vllaan Tnwnse¢ P:nccl'nx No.
ROLLING RIDGES, LLC TOWN OF HUDSON 020-1016-60-000
CST BY Elcv: h,::, Bvi Eler: 6U DC :criroti:x: 3caio°a'n~n'Kange':HaG )'3.29.19.731
TANK INFORMATION ELEVATION DATA
IYF'_ Ir1ANi.FA;:Il1Ki=h CAPACITY STATION DS HI FS F FV
Septic ClenchmarK
Dosing AII. Bid
/ l
Aeration X~ I -'r'vr:r
Huldctg Su. It Inlet
TANK SETBACK INFORMATION ;ifL• 11 Outlet
LANK TO Pll 144L L Li-D6 :°'t t, r'+: trnaie W)AL [A Inlet
Septtr. DI Bottom
")os,ng icarleulylan
Aeration DIST Pipe
Holding Hot. System
Final Grade
PUMPISIPHON INFORMATION
Manulacturer Demand it Cover
G 'Id
Mooel Nurobel
TDH I. ITT I notion Loss System Head -r0H F1
Forcemaln l enptn D:a. Fic.l 1, 'bell
SOIL ABSORPTION SYSTEM
BEOfTRENCH A.dih Longfh No CY -Tenches PIT DIMENSIONS N, If ~ I, Its. C -ria _gwtl Dcp:n
DIMENSIONS
SETBACK SYSTIEM T WL BLOc LAKL:S! RLAid l FACIIING T....... r.:4u<r
INFORMATION CHAMBER UK
1':':)I fi~slrrr UNIT I.lodel Numocr
DISTRIBUTION SYSTEM
~eacehl.lawfold U:sinb.Lon -.~ae'r::e r itlc :pac -a em !o ho lriaKC
Plpe;s'r
_eng:h _ Lencr D::
SOIL COVER it Pressure Systems Only xx Mound Or At-Grade Systems Only
DevVi Orr De Del Ovo- u Deptr m •ede11,-naAnA n 1./.... c:f
BedrI "C hCeWm Bcd'Twmh F,Lle:: Topnll Vcs Nn YC? NC
COMMENTS: onowle code dlscrecencies. persons present. etc.: Inspe: Nan #1 Inspecilor 92.
1AA1 t
~Gi
Location: ri(iS ALLxANDCR RD 1. \ d r SLOr'V~
1 ; All 91d Description = Y v ii "
2 ; Bldg sevmr length - ~l~ b~l a
- amount of cover = s ( , 3
Plan wv,sion Required'r - - Yes No
U v othct side for additional information. -,7y
riate In-poor -enat, ':en. No.
$6C-6-17 P sravf
Jt1V'U - ~c.7 -
,r County Sanitary Permit Application ST. CROIX COUNTY WISCONSIN
with Chaped 12 St. Croix County Sanitary Ordinance PLANNING 8 ZONING DEPARTMENT
h-lfiiSofl9 information you provide may be used for secondary purposes ST. CROI% COUNTY GOVERNMENT CENTER
(Privacy Law. S. 15.04(1 m)( 1101 ,Wl 401Road
~ 11 Hudsonn, WI 54016-
(715)386-4680 Fax (715)386
1366-4686
m I a plar PNOTD2HERAF26 2 411 iucries in site
ARGly' atlon
^1C -ZOI
1. Application Information P Inlorma kin Location:
Property Owner Name J? NE 1,4 NE tin, Sec 13
Rolling Ridges. LLC 1 29 N, R 19 E (or)
Property Owners Mailing Address Lot Numbe Block Number
City. State ip code Phone Nunief Subdivision Name or CSM Number
!w r lJ/G -
I Type o Building: (check one) r7~ ity ❑ Village LRTown of
)F7 1 or 2 Family Dwelling - No of Hedruoms. 3 Itr`
❑ PubliG'Comrnernal Idescube n;xeL Hudson
L! Stateowned Nearest Road
1. Type of Permit: (Check only one box on line A, Check box on line B it applicable) Alexander Rd.
arcel Tax Number(s)
'I'M A) 1 ❑ Repair ' . Kl Reconnection ❑Non plumbing - (.1 Rejuvenation 04.17 COO
Sanitation 020-1016-60-00@ /i. `1' • 1C
1. 7 31~
B) Permit Number , Dale Issued
❑ State Sanilary Permit was previously issued ll z D / 9
IV. Type of POWT System: (Check all that apply)
Q' Non-Ixessuriicd In ground ❑ Wind a 24 in. suitable soil ❑ Movnd 24 in. suitable soil ❑ Mound A-0
❑ Sand Fiber ❑ Constructed Welland 1.1 Peat Filter ❑ Drip Line
❑ Pressurized In ground ❑ Holding Tank ❑ Single Pass ❑ Olhcr
❑ At (trade ❑ Aerobic Treatment Und ❑ necirculatinq
V. Dispersal/Treatment Area Information:
1. Desigg How (glxl) 2. Dis(xssal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rare 6. System Elevation 7. Final Grade
Required Proposed (Gals:dayisq.fl-) (Min inch) Elevation
450 643 1000 .7
I. Tank Information Capaicty in Gallons Total p of Marro clure Prefab Site Oon Steel Fiber- Plastic
New Existing Galons Tanks Conae(e strucicd glass
Tanks Tanks
e G cxT> !tom `-s r ❑ ❑ ❑ ❑ n
I.Responsibtlity Statement c)
,
1, the undersigned. assurne respofmihilily for repair fewrinenctionriejuv natiominstallalion of non plumbing for the POWTS shown on the attached plans. A
license is not required for teralift repair or the it - allation t nmr plln ing sanita n system
Plumbers Name (print) PI m SI e " o ps)' MRMPRS No Business Phone Nunrlxi
Keith Knudtson 648443 651-0/0-1737
Plumber's Address (Street. City, Slate, ip .a1e)
927 150th St. Roberts Wt. 54023
III. County Use Only
11-i rl~ Sanitary Permit Fee D- to Issu Issuir Will Signalu o s ys)
Approved Owner aiv nilial ,q z7~ /7
D ation l{{ L )
Condition AftmWW sons for Disapproval: 1\ ' , Vn~
1 J \ I t _ x
K7 q (2y Vim-- t S O M'V ~
V J lwJr
1. Septa lark, etll nine- an 1 J\
aster ;41 nu>t all bey s •..-,r_,_-a~ M. f ~
4s p r -nar a emen. plLC r cube-. 1 !Jd.,rvs ~0.t-~ ice--' 1~ ) N."oq
2. -AA serback rec~.iwtr any mrr„t uc ar„ i e4 / Q I/
as per,Kiic b crA i:n ianr= . 6i,- 6JX4
Rev' 8.'05 J
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KNUDTRIN PLU.....
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QT CROIX COUNTY
AA
PLAMING Z®N - G
Dear Homeowner:
It you own property that is served by a private on site wastewater treatment system
you are required to provide proper maintenance on this system as per 145.245(3)
Wisconsin State Statutes and Chapter 12.7 of the St. Croix County Ordinance.
Proper maintenance will help to ensure the longevity of your private sewage system
and avoid premature failure.
This maintenance program requires inspection of or pumping of the private sewage
715-W-4680
r;drwtinn system at least once every three Years at the owner's expense- Inspections may be conducted by a licensed master plumber, licensed journeyman plumber, licensed
J~nd 1nG,onation a restricted plumber, licensed POWTS maintainer or licensed septic tank pumper.
~'fa!s The inspection shall certify that the system is in proper operating condition and the
715-386-4674 septic tank is less than 1/3 full of sludge and scum. If the inspection reveals sludge
and scum volume to be greater than 1/3 volume of the tank, a licensed septic tank 715-3M-4677 8'pumper shall service the tank. The St. Croix Count Planning and Zoning
Department is required to track maintenance reporting so our coo Hen-r'rnR greatly appreciated. y cooperation is
715-396-4675
Please return the information below to: St. Croix County Planning & Zoning
Department, 1101 Carmichael Road, Hudson, WI 54016.
-
ST. CROIX COUNTY SANITARY MAINTENANCE CERTIFICATION FORM
System was installed in
ii The private sewage disposal system is in proper operating condition.
k~- The septic tank was recently pumped by a licensed septic tank pumper, or it was
inspected and is less than 1/3 full of sludge and scum.
ii The effluent filter has been inspected and/or cleaned. All septic systems
approved after July 1, 2000 were required to have an effluent filter installed in
the septic tank. If your system was approved before this date, you are not
required to install a filter, but it is usually recommended.
Describe any other maintenance that may have been performed.
Signed by: -Title: License Number: Date:
Signed by Owner: Date:
Parcel lD Numberz c_-~ _ ~Cy>
Property Address or any changes: ' 7/ J~ ! r _
i/. CHO/X COI/NI Y 6OV1R1VA1rW (.6NN: K
1101 OWNICIN/I ROM) 11ad50N. W1 54016 715386'4&HG FM'
ST. CROIX COUNTY
SEPTIC TANK MAINI UNANCE AGREEMENT
AND
N0~ o~N OWNERSHIP CERTIFICATION FORM
j4Or 9Wg Ridges LLC `
Mailing Address ` r W\-" 3~
1 Zy j/
Property Address
t Veritication required from Planning t@ /oning I )eparttneul for new :on trueIion.)
Citv'State r Parcel Identification Number 020-1 016-60-000
LEGAL DESCRIPTION
Property Location NE NE Sec. 13 t 29 N R 19 w, Town of
Subdivision Plat: Lot r
Certified Survey Map # Volume 24 Page 4' 5743
lWarranty Deed # (before 2007)Volume . Page
Slice holtse ❑ yesow Lot fines idem i liahle DyesOno
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
improper u,c and maink:nancc "l"our,optic system conf.t re,uh in its premature ftilure to handle "a,te,. Proper
maintenance Consist, ,I pumping )ill the ,optic lank cvvey three Near, or owner, it needed. by it lieeu,ed pumper. What you pill inn
the ,"stmt can affect the function of the eptic lank as a treatment Gage in the waste disposal system. Owner nmintenance
re,lnm,ihilitics ;u•c ,pecilicd in §SPS. 3S3S21 I) and in Chapter I? - St. Croix County Sanitary Ordiu:ma•.
The property owneragrees it, stihinit to tit. Croix Cm m Planning & /oniog Department a certification tbrot, signed by the
owner and by a master plumber, iotimeym:m phmlber, re,tricied pluniher or a licensed pumper verifying that (1) the on-site
wa,lewmcr disposal system is in proper operating, condition and. or 12) after inspection and pmnping (if necessary), the septic tank i,
Ics, than I i Iidl of sludge.
hove. lite undcrcigned have read the above requirements and agive to maintain the private sewn-lc disposal system with the
,autclanl, let forth. herein. as set by the Department of safely And Prolesional Services and the Department of Natural Resources.
slate of W'iseonsin. Certification atatinr, that your septic system ha, been maintained must he completed and rcwmed to the Sr ( roil
county Planning & Loniug Department within >n days of the duce year expiration date.
I!we ceriiA- than all statements o/MT11,11,11, t arc talc to thehe,t o in om knoMcdh c Iwe :mvare the owner(s) of the
propclly described above, by virtue of a eed recorded in Rc;•.i,trr o(Dc. d, OfN.e.
Numb'., oT bed onts 3
L! U
t.4'fURI(OI' APPLIC;\NT(S) DATI•:
"""Any information that i, misrepresented may re,ull in the ,auiwry permit heina revoked by lite Planning & Toning Department. xa
Include with this application a recorded "a nun" decd [fain die Register (it Weds Office and a copy of the certified survey map if
reference i, made in the warranty deed.
(REV. 114+12)
Wisconsin Departmenl of Comserce
Safety and BiAdxlgs Division PRIVATE SEWAGE SYSTEM uurrty
INSPECTION REPORT St. Croix
GENERAL INFORMATION (ATTACH TO PERMIT) Sam Wry Permit NO.:
Personal infomwGon you prrvice may be used for secondary purposes (Privacy Law, x.15.04 (1)(m)). 353119
Permit He ei s Name: City ❑ Village Town o : state Plan ID No.:
Girl Scout Cam of SL Croix Valley, Town oCHudson 2 (i'{21 cs (p• ik
C TOM Elrv : t Insp. UM [ evr . BM Descnp6om. f Pence Tax No
W_•9 _ t tr¢e• -CST Bkclt~ 1 020-1016-60-000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
71
Septic3'I tO9,01.tr5 tf$T) Benchmark "I"
9 j trp Q Alt. BM
ItI O.
Bldg. Sewer
tt I"0'D St/Ht inlet tq. 2-1 .Z r
TANK SETBACK INFORMATION G • r Z
St/Ht Outlet 14. 44 9.Sr
TANKTO P/L rWELL,,
BLDG. A
u Intatoke ROAD Dt Inlet
V'T
Arr
Septic I .suo' NA Dt Botto
m
NA Header/Man. /o.ec q$.r/Qr
^ 3 Syr` NA Dist Pipe jO• U /
~3 S 8 2.
Holdin -lot, SY gY_~ r stem 11. G
z r
PUMP/ SIPHON INFORMATION final Grade _ +4- t'l 99-5:
s Manufacturer man cover a b 4? 148err
kB Model Number 8 `I GPM C.- j.}- 5{t(, F Ild ,gD 9!• 4z
DH Lift Friction .ea. System
V TDH ps~ft
a1 H
Forcemain Length. Dia. zp Dnt. To web 10.$O c)~.bz'
SOIL ABSORPTIO SYSTEI (o. 1 I I- D
THE C W,ct3, I gin No T nches PIT - o. Of Pits Inside Dm liyurd Depth
SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Na. aaure~ rs„
SETBACK
INFORMATION l-- r r - CHAMBER model Nunn r:
- top 3 , ~rao _ OR UNIT
DISTRIBUTION SYSTEM
HeaderrMamf Id nlribut.onpipez - I x HOesve ix HO espacing I Ve. nt TO 3QAivr intake ~
Length t _ Length paring _
SOIL COVER Tit Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over 4 4 Dept Over I xx 'o.1 D.pthOt xx Seeded/Sodded ax Mulched
Fl"d Wrench Center ppJ rTrench tJges Topsoil (1 vex t-I No Fl Yes E) No
COMMENTS: (Include code discrepancies, persons present, etc) Inspection f(I:of10VOC'Inspection #2: -/-7-
Luca on: _ 965 Alexa ROO d Hudyop, WI 1/4, Nj1 4~~CCtion j3 Z29N•RI~W~~)„-,139r19.73 - taaiw ~A1r.,n of
s,,t7{-I~-~ /1 jUQN"_~_-~~1-.~- d, op
® 5"'A 40a¢ w r i 1 y Q,,t.~F~"lI rX•a ".6"` w.alz -..P `-u' ' r, ~-~t
Plan revision required? ❑ Yes No
Use othersldeforadditionalinformatlon'y - Li CO _ L
SBD-6710(R.3197) POW 11 - rs (I 't inspector's siynatu~e Cert No
A-Y
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MAIN LEVEL FLOOR PLAN
n21 .._ql I ~~~-rr'
_ DLOFC_ °L'JPE _
+1] $'2 51L
Ft i /
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ROOF PLAN
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LOWER LEVEL FLOOR PLAN
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Safety and Buidinga Dwrition
*"sin SANfTARYPER SIC Po~2»~«Awme
In accord with II 1h r~ittV` qpt, yn 5370 7-7302
Department of Connierce - WD
E L ~I
• Attach complete plans (to the county copy only) fort e~stent, on paper p)atrfess C unity
than 8 in x 11 inches in size. (`?j SF (1 7 1 1 3 C
• See reverse side for instructions for completing this a lI ton BT CC. X ateSam1.,y Permit umber
111 ' "
Ftc,~ 3 53 (~9
Personal information you provide may be used for 9eGdfsdary purposes Z(TNLNtx a alM
o;" appa
revision to a
IPnvacytaw,s1604(1)(m)). _ State Pion lD Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INF MA ZY' Z
Property Owner Name Property t oretwn
LD C OF a %4 a, S T 1 N, R E (or
Properly Owner's Mailing Address Lot Number ~J Block Number
City, State Lp Code Phone Number Subdrvnion Name or CSM Number z V
L 4rly- /,0 Z I" )
11. TYPE OF : (check one) ❑ State Chemed u v'7 age -y2( y Nearest Road
Public 1 or 2 Famil Dwellin - No. of bedrooms town Or
IV a OX O
III. 'BUILDING USE: (If buddmg type is publK. check all that apply) Parcel lax Number(s) I1) (J v'r j-r ^~_L i
l _7 ` /
1 p Apartment/ Condo Z0 - 10 -40
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash
5 ❑ Hotel/ Motel 9 ❑ Office/Factory 13 ❑ Other: specify
IV. TYPE OF PERMIT: (Check only one box on line A. Check box online B, if applicable)
A) 1 New 2 ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. C] Repair of an
System System Tank Only Existin~System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one) Q,ZZfi S
Non-Pressurized Distribution Pressunifed Distribution Expenmental Other
11 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 410 Holding Tank
12 Seepage Trench 22 ❑ In-Ground Pressure 42 C] Pit Privy
13 ❑ Seepage Pit 1- , d 43 ❑ Vault Privy
14[]System-In-Fill L 7)" 72012 Ar~ye nVAcir
VI. ABSORPTION TEM INFORMATION: (2 0j' 11X
1. Gallons Per Day 2. Alnorp. Area 3. Absorp. Area 4. Loading Rate S. Per,:. Rate 6. SSystem Eley/ 7. Final Grade
wired (sq. ft.) Proposed (sq. hJ (Gals day/sq. ft.) (Min /inch) -TF/ 0,7
d ✓ Elet
Q 4 Feet (►t'eel
VII. TANK Capacity
in gallons Total # of Prefab ^ her Plants rxper
INFORMATION Gallons Tanks Manufacturer 'sName Concrete Con- steel lass A
New Existin structM 9 pp
lank% T nk
Sept,( Tank or Holding Tank Z YAW I E
Lift Pump Tank r ❑ El ❑ ❑ I
VIII. RESPONSIBILITY TATEMENT Ev/ Z/7SG' /Ca'
1, the undersigned, assume responsibility for installation of th onsite sewage system shown on the attached plans.
PlumbersName (Pent) %umber's Signature No Stem salP)MPHSW No.: Business Phone Number.
= ie _l6s'6 -
umbersAddress(street. City. State. Z (ode):
'Lot "'fAtz 0-3
IX. COUNTY/ / D PARTMEN USE ONLY =,gnature ❑Disapproved Sanitarys'ermK tee ~"s"ab GrwMasu+ (NO Stamps)
A roved PP ❑Owner Given Initial Ad.CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL:
rli5 era.c)'~ Gr~7S r.Crdfe(4 ~rCakSr -~~.t S a ~ILCu/ er•s~
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~ 00• p. -Janoa aloyuew )fuel a[>aas )o saluao of sluiod aauaaajal leluozuoy omy
c ~g b~. kw o wals& ag, 30 laaj 001 u!glim &14VLana 8mmogs pla:is main uefd V
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SOIL DESMPTION REPORT
PROPERTY O\WER peps .2 a 3
PARCEL LDJ
Boft1 Halt! DepM D=*r Odor ebN" Taft" SWUM"
CorrYMw BaetlYy Roole
h ww" Ou Si Corn Oda Gr. BE 6h.
Bed . Trweri
f -?IVIS-Ax AI FA 05
p • - 1' t L
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Doper b •S" -A .7
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Boring p
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elev.
Doper ID
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Hodtm DepM I I Dartwd ccw ►ladlec Tmdue sm ck" ConsWUrm Bae>Ilary Root
h /Anaw Ou. 6c GM* cow or. $2. &L Bed . T
Boring 1 •
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Doper b ` - .
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LOWER LEVEL FLOOR PLAN
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