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Home My WebLink About004-1039-95-000 Wisconsin Department of Commerce County: St. Croix PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 0223 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: Robert Heath TOWN OF CADY 004-1039-95-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: 17.28.15.268A TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM Aeration x 5 Bldg. Sewer 71 Holding St/Ht Inlet ~ U 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. III GPM Model Number X TDH Lift Friction Loss System Head T DH Ft Forcemain Length r--T ist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM 06 Header/Manifold Distribution ix Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Dia 11-ength_ 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 I Yes ]No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 2820 CTY RD N 1.) Alt BM Description = ] 2.) Bldg sewer length = jc - amount of cover = ? Plan revision Required? i Yes No Use other side for additional information. Date Ins ctor's Si ture Cert. No. SBD-6710 (R.3/97) EC IV 17,IJ-976 301 County Sanitary Permit Application ST. CROIX COUNTY WISCONSIN 5CT'y In accord with Chapert 12 St. Croix County Sanitary Ordinance PLANNING & ZONING DEPARTMENT Personal information you provide may be used for secondary purposes ST. CROIX COUNTY GOVERNMENT CENTER Cod T' (Privacy Law. S. 15.04(1)(m)) 1101 Carmichael Road DEAL PME Hudson, WI 54016-7710 (715)386-4680 Fax(715)386-4686 Attach complete plans for the system on paper not less than 8-1/2 x 11 inches in size. County Sanitary Permit # ❑ Check if revision to previous application Z 1. Application Information - Please Print all Information Location: Property Owner Name - /I Gc.,) 1 /4 J`4~ 1/4, Sec U 6,- ~ ~ ~ .Z& N, R /,:!S- Property Owner's Mailing Address Lot Number Block Number z?.z() 61 X~/, W do City, State Zip Code Phone Numer Subdivision Name or CSM Number 11 Type of Building: (check one) amity ❑ Village wn of Ii; 1 or 2 Family Dwelling - No. of Bedrooms: C~ ❑ Public/Commercial (describe use): ~e~ ❑ State-owned Nearest R d J' 11. Type of Permit: (Check only one x on line A. Check box on line B if applicable) . G T7' RP, NAJ Parcel Tax Number(s _ A) 1Repair Reconnection ❑Non-plumbing . ❑Rejuvenation f -WO Sanitation B) Permit Number Date Issued State Sanitary Permit was previously issued 5 S~ ~s S Z IV. Type of POWT System: (Check all that apply) ❑ Non-pressurized In-ground ❑ Mound:' 24 in. suitable soil ~nd 5 24 in. suitable so' ❑ 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 Dispersal/Treatment Area information: 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. System Elevation 7. Final Grade Elevation Required Proposed (Gals./day/sq.ft.) 5,,-) (Min./inch) p 4 1,g it I. Tank Information Capaicty in allons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic je Existing Gallons Tanks Concrete structed glass s ,Ta.ks lL/?~ / "e S ' r.Cf Ca ❑ ❑ ❑ ❑ CsM b~ ❑ ❑ ❑ ❑ It. Responsibility Statement 1, the undersigned, assume respo rsbility for r air/reconnenction/rejuvenation/instatiation of non-plumbing for the POWTS shown on the attached plans. A license is not required for terralift or the stallation of non-pl nitation system. Plumber's Name k=!/,r flumt~4 s Sig /MPRS No. Business Phone Number 5~' rvl~pff ~,Pz,). 7T6 LLrneS , Plumber's dress Street, ityy, St ip CPde) K VIII. County Use Only Disapproved Sanitary Permit Fee Date Issued Issuing Agent Signature (No stamps) [jf Approved Owner Given Initial Adverse rh Q Determination IX. Conditions of (Approval/Reasons for Disapproval: ` Rev: 8/05 POWTS - Existing Residential Mound Reconnection Index & Tilte Sheet Project Ownership Project Name: Heath residential mound reconnection Owners Name: Robert Heath Owner's adress: 2028 Co. Rd. N, Wilson, WI 54027 Project Location Site address: Same Subdivision or CSM: Na Legal Description: NWuaSWua, Sec. 17, T.28N., R. 15W., Town of Cady, St. Croix Co., WI. Parcel ID 004-1036-60-000 Page 1 Index and Title Sheet Page 2 Site Plan Page 3 Existing Dispersal Cell Evaluation Page 4 Existing Septic Tank Certification See original State Plan Approval &Sanitary Permit #552354, issued May 5, 2012 ted Service: Jams Thompson Dep't. of SPS Credential 300321 Mater PI oberRestr' Signature:- Date: z ;Z,:0/5 Page 1 Of 4 Q~642~ /lca-t~ rq~. ;LeA~ Co. 4 0 G (s on, c.J ! Ss<o z 7 56. ( IV 4 (o q -C A0A L'o✓~! o✓/~iA46 55.8~Cc5~~ EJr, nn 4.t11 4t~in S~ccf`cy~ icT~ / Grade ow- 5,T7,1lef = 9•/, 3 C, (0-dea-o-0b;le t4~ ate= 9/. woa-0 C. 2s: Sa'x85, \Co ~ ~ upd b,% {nowt c, 02' Si o%hC~ t 6x,~5 SCWfr"f~ C=4P~ ~ I J An4rust 27, 2015 A.C.E. Soil & Site Evaluations James K. Thompson 340 Paulson Lake Lane Osceola, WI 54020 Department of Safety & Professional Serviees Credential #30021 Master Plumber, Certified Soil Tester, Plumbing Inspector, POWTS Maintainer, Erosion Control Inspoeetor DNR Certified Small Water System (O'1`M/NN) Operator #62095 RE: Heath Existing Septic System Evaluation, 2028 Co. Rd. N, Wilson, Wt., NWv4SWv4,Sec. 17, T28N., R.15W., Tn. of Cady, St. Croix Co., Wt., Pcl. #004-1039-95-000 1 have conducted an inspection of the existing mound septic system that serves the residence at the above address. This inspection was completed August 25, 2015. Records obtained from the St. Croix County Zoning Office indicate that the system was installed October 24, 2012 under permit #552354. The system consists of a 1,000/650 gallon Wieser Concrete combination septic tank/pump chamber and a 6.93' x 65' dispersal cell contained within a mound at 25.50' X 85.75' with 18" of sand lift. The system was installed as per codes in force at the time of the installation. An inspection of the observation pipes show no signs of effluent ponding within the system dispersal cell. There were no indications or evidence of effluent discharge to the surface of the mound or to the surrounding area. This indicates that the system is functioning properly and is able to absorb and dispose of the wastewater that enters it. James K. Thompson Dep't of Safety & Professional Services Credential #30021 Cc: file 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) 2820 Co. Rd. N, Wilson, WI, 54027 located at: NW '/4, SW '/4, Section 17 , Town 28 N, Range 15 W, Town of Cady , St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, 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 August 25, 2015 Did flow back occur from absorption system? Yes No x (if no, skip next line.) Approximate volume or length of time: Na gallons Na minutes Tank Capacity: 1,000/650 gallon Construction: Prefab Concrete X Steel Other Manufacturer (if known): Wieser Concrete of Tank (if known): 3 years, installed 10/24/12 Permi number (if known) 552354 James K. Thompson icensed Plumber ignature) (Print Name) MPRS MPRS #30021 (Title) (License Number) MP/MPRS August 27, 2015 (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