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HomeMy WebLinkAbout030-2027-70-000 (2) County: St. CfOIX Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT Sanitary Permit No SAN-2017-379 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: JOHN EVAL TOWN OF SAINT JOSEPH 030-2027-70-000 CST BM Elev: Ins p. BM Elev: BM Description: Section/Town/Range/Map No: 22.30.20.439J TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM Aeration Bldg. Sewer Holding St/Ht Inlet 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 Dist. Pipe Holding Bot. System Final Grade PUMP/SIPHON INFORMATION Manufacturer Demand St Cover GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist to well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS LEACHING AMBER OR Manufacturer: SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM CH INFORMATION Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header/Manifold Distribution IX 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 Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil Yes [ No ❑ Yes; No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 1436 TRIANGLE DR 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required? [ Yes [ No Use other side for additional information. Cert . No. Date Insepctor's Signature SBD-6710 (R.3/97) G 24 21'7 1 A, V X C G vt N ,471n P. unty Sanitary Permit Application ST. CROIX COUNTY WISCONSIN Vool `Tr5 a=rd with Chapert 12 Si- Croix County Sanltary Ordinance PLANNING & ZONING DEPARTMENT Per; rill information you provide may be used for second pu s ST. CROIX COUNTY GpVERNMENT CENTER [Privacy Law. S. 15, m)? 1101 Carmichael Road +~r~~,~}~ 4n}1~ L Hudson, WI W15-7710 ugrZ2EEjjt4QP (715)388 4680 Fax (715)386 4686 complete plans 66EV _ ",an &1!2 x 11 inches in size. ®M NVitary Permit# - k if revision to previous application 4517 1. Appiicatlon Information - Please Print rmation Location: Property Owner Name 114 J V4, Sec ~ fe:7, YI.~ ~y`f:RL T 3© N, ~v P. E (or) (Z7 Property CCh/vneer's Mailing Address ~-7 Lo` er Block, Number City, State Zip Code Phone Nume, Subdivision Name or CSM Number ,VC FIX 11 Typa of Building- (check one) I~ity zavs own of 1 or 2 Famlly Dwelling - No, of Bedrooms: Q(L d0 ❑ PubliclCommercfal (deaoribe us--). n~K ❑ State-owned Nearest Road II. Type of Pormlt: (Check only one box or. line A. Check box on line B if applicable) Parce! Tax Number(s) A) 1.0 Repair 12.,k Reconnection 3.❑Non-plumbing 4. ❑Rejuvenation :::~3 „ 7~~C3z>'><> Sanitation r C. B) Permit Number Q 7 Date lssu ❑ State Sanitary Permit was previously issued 16h~ IV. Type of POWT System: (Check all that apply) ❑ Non-pressurized !n-ground Mound ? 24 in, suitable sell ❑ Mound s 24 in. suitable soil ❑ Mound A+Q Sand Filter 0 Constructed Wetland ❑ Peat Filter ❑ Drip Line, ❑ Pressurized In-ground 1❑ Holding Tank ❑ Single Pass 0", ❑ At-grade ❑ Aerobic Treatment Unit ❑ Recirculating IT we-, ; V. DispersallTrsatment raa Information: 1. Design Flaw (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 5. System Elevation 7. Pinal Grades Required Proposjed (Gals./day/sq.ft.) (Min./inch) 7 Elevation VI. Tank Information Gapaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic New Existing Gallons Tanks Concrete strutted glass Tanks Tanks a 1- I-woo Jr. Lo ! e ❑ C1 ❑ ❑ >4- Zoe* El VII. Rasponslblllty Statamont 1, the undersigned, assume responsibility for repairfreconnenciion/mjuvLnationfinstallatlon of non-plumbing forthe POWTS shown on the attached plans. A license Is not roquirod for terralift repair or the installation of non-plumbing sanitation system. plumber's Name (print) Plumber's signature (no stamps), /MARS No. Business Phone Number Plumber's Address (Street, City, State, Zip Goda) III. County Use Only Sanltary Parmft Fee D e Issu Issuing nt Signatu a (N amps) gpprpvdd Owner nitialRdve 7z ;P ination!/ IX. Conditions ofpprovallRoasons for disapproval: 4,V 7,01-7- O Jo4l.,01 "4A f aov% A4 0: G.fM-d~• Al 410,AY-r P4 e ~--o 4_0 Rev: 8lQ5r GaJ P.C,. ak ~ J ~ g0.J 24. 2017 10,59aV "t Croix Co Govt Cents, . 4i1~'j F. 4 ST. CROIX CO1 NTY ZONTNG OFFICE. CERTIFICATION STATEMENT FOR UTILIZATION OF E' XISTING SEPTIC TANK(S) This is to certify that I have inspected the existing septic and/or dose tank presently searing the following residence: (Street address) c13G % ;+~r`'cated at: 1i4,`~ i%4, ;o, Section , T'ovim~d N, Range a W, Town of Ale, , St. Croix County Wisconsin. Upon inspection, l certify that 1 have found the tank(s), to the best of my kmo,wledge, will conform to the requirements of SPS. 384.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service ley- flow back occur from absorption system? Yes No Did (if no, skip next line.) Approximate volume oz length of time: gallons minutes Tank Capacity: IzWlldd Construction: 'Prefab Concrete k Steel Other Manufacturer (if known): Iv ; 4 e _ Age of Tank (if known): _ ;?,o s" Permit number (if k-novvii) (Licensed Plumber Signature) (Print Name) C/ Ile) (Title) (License Number) MP/MPRS (Date F omi to be completed by licensed plumber (Dept of Safety and Professional Services Chapter 3)05 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 2./2012 /l 140; 40 ru,~r rot, zi, J~ '54-nU pa 4. • 5 V CD + Ire ft-_ d + 'S1• + + o-,, O + y sa o sb s oec + + b° s B s e Y ll~ } dpi as d s a o A' + \ } + O 3 as + 191? 9964 e,1 + O + 19 , p°"~'~e Y9 . y O + 0 .1p d~O A9K 4 z 13 p T C y srr s" O O `os0 °d °J t y °b t t r- f(1 N + ° 7~ U), i3 (n elp 9t $ $ M + t O ° O ac' Az * °9v sr C5 + ° R, s s O °9~ ° r?O r2 sp? + O ' t 6-0 No + ro SO NN m'N~~Qa OD CD 'O w E-r OQ O•= cL + + 7 °°rs 6 ;U J~ ° r v'r a I w ro ro S !n ^D O. /fl 0 O(D N O N ro M WO CD O ro ro 7 CD S O (D ' m 'O t0 cp n w O CO OD r- CD O- O. .O 0 0 0 0 O n fL] C`• 0 Q. 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