HomeMy WebLinkAbout020-1161-90-025 (2)
rotSCmi:v,-¢pal eni Gen -m cc PRIVATE SEWAGE SYSTEM c.;onry p
$ataly ..-ind Bmlcina Uivisan St CFOIX
.
INSPECTION REPORT S:milary Permd No
GENERAL INFORMATION (ATTACH TO PERMIT 600350,
State Ploll ID No
nmsona. ^lounaton yuu provide mey:>rscd for secondary pwposcs lPn•scy Law. S.15 74 (tirmij
Pa^m l lblderS N:rmrz ty Village To,,s-a 0:nrel Tax No:
Steven & Katie Koets TOWN OF HUDSON 020-1161-90-025
C5T FN EIC, Insp BN I Imo. B6• Jn;cripnon
p SeCtioNT:ra R,d^3eA,laP No
o L j pi 23.29.19.926A
TANK INFORMATION ELEVATION DATA
TYP= MA.%urAC'ORFR •~'S CAPAil IY STA710N R$ rl P$ FIP/
Sep!,c r i• 9enchmmk
Q"Ugj
r-, I At, p (D It-- s All P.Id
Aeratinn 1 Bldg. Smv.f G
Holding S Z5 /a •a 9(0 • ~
SUHt Inlet
TANK SETBACK INFORMATION SUHt Cutlet
to ys . c~9
TANK 1'J P4L vCLL BLDG. Air Iw ke, RC AU DI Inlet
I
Septic ZS
7 L Z<7 'TO 5 Dt Nollcm
Dosing 70 Headel7Mat e ) \
'G"sf i O'xrJ~
Aeration Gist Pipe
Holding
Bel. System
PUMP/SIPHON INFORMATION Final Grade
Idanofacturr Drmaod St Cover
GPM
Model Number
TDH Li. Friction I oss System r•-• FT
F ornemain Lvn7ltlr - is Uisl w r..
SOIL ABSORPTION SYSTEM
BED/TRENCH :MCIh Lnnp:h NI :3, a•nohus I I "DNS Nn is Pqs Insde Uni Ligwd 11,14^
DIMENSIONS -
SETBACK SYSTE10 r:L BLDG LL tAKE'$TRLAId LEACHING Manufact..tcr.
INFORMATION
Type On CHAMBER OR
UNIT Noce' Nun::c•
DISTRIBUTION SYSTEM ~T
i•uacar'Llamnan 7isrlbuvn° -
SOIL ICIe Sze A Hoe ~y>aring ens. Io r..i In:ake
P oc
II - e",is,
pt,
' Dia _ uu
SPa, I
COVER x Pressure systems only xx Mound Or AI-Grade Systems Only
Japlb Con' UepSi Over xX Ueul^ of
Betl:-m...f, Ccrter ECV:Im"::h E'~CS xx Seancd:Gpddcd tix Nuichai
'opSitl
I 'r'os Vo r'e5 Nn
COMMENTS: ilnGude rode dlstxepencies, persons preserl, elc ) Inspection #1 I Inspection p2
Location: 832 KIT LN f / J L011pr•0 W~SGIC~.Js
I 1 All Ulvt Desorption
2.) Bldg sewer length
- amount of cover -
Plan revision Required? Yes No Q L I g t7/'
Use other side for additional inlorma n'
SBD 6710 R.3,97) Date I^scpclv5ti:vwc Cat Na.
Js _I rr _ O4a
i ruerrLVL - - Comm
~ fir! .
'
~ FREE? Industry Services Division St Croix
} ~`0 $ 3 `l f, 1400 E Washington Ave Sanitary Pcrmit Number (to be tilled in by Co )
` P $ P.O. Box 7162
Madison, WI 53707 7162
2 9 CN3
666350
L Mmn4
1 rvl U SWIG Trwtsadlgn Number
NnT
Sanita"r~uPermit Applica 'YY ew~MQ
In accordance with Sf5:37k3;21f'h 3ils,:\dt¢i:oult..wbnussion of this turn V E _..nk
- -
is required prig tooblmnmg a sand rv pernut Note: Apphxabon I, N6` ..c ,ubmitied I.
the Department of Satet) and Prolessnmai Sen ices Pcrsonal in of ...,t nc ua-d lie aondarv Ptuject Address (if dilTercnt than mailing address)
purpncs in mcnnianec w.uh the 1'ri%xy I aw, s I S IW(I Hm). Slat 1 Same f~
1. A licatiun !Dior 'on - Please Print All Information "3Z'
Properly Owncr's N the Parcel N
Kock, Steven R Katie 020 1161-90-025
Propcny Owner's Mailing :Wdre s Propcrty la¢ation
832 Kit Lane
Govt I.ol
City, Slate Lip Coale Phone Number SW Y., SF Section 13
l lud on , W1 54016 (c`icle one)
T29N R 19 P. ore;
IL Type of Building (check all (hat apply) -
® 1 or 2 family Dwelling - Numiscr of Be-d".. Subdivmon Name
L Pox Valley 1st Addition
❑ Public Commercial - Desenhe l i,e 19 Cv& Block 0
❑ Slmc (Tuned [escribe Csc ❑ Village of
CSM Numfx~r
® l2own of I lud,un
IIL'Iv of Permit: (Check only one bux_ online A. Complete line B if applicable) Q _
A. ❑ Ncw System ❑ Rcplaccmcnl Syxlcm Z lrcalmentil lolding lank Kepl:a:cmcnl Only ❑ Other Modilicmem in Lxisung S)'sicnt Iexplainl
H. - ❑ Pemtil Kcnewal I E] Permit Itcv isnm E] C'))angc of ❑ Pcmtit Transfer to Ncw List Prcvoms Permit Number and Date Issued
H iirc Pxpiratloll Plumber (honer 168682 111/4!1996
I V. Type of PO\\•TS SystenViFotnponent'Devicc: (Check all that apply)
1 ❑ Nan-Pte,mired In-Gmmnd ❑ Piensuri/ed [it-Ground ❑ At-Grade ❑ Mound , 24 in. of suitable sail ❑ Mound 24 in. of suilflble soil
❑ l o me ank Other Dispcnal ('omp ncnl (explain) ❑ Ptrrrcalmcm Device (explain)
\r . Dis rsal/Treatme o Area Information:
Design Plow Igpol Design Soil Applicaliun Dispersal Area Required Dispc"l Area Prorxe ed (s System Elevation
45{1 Rate Ygpdslj 563 570 91.50
0.8
VI. Tank Info Capacity in - -
1 GUIIgG o O
I Dial tY of
Manulitclurw
;Gallons ' Units •'u E c v 5! Z
i New took. 1[x{vbne funk.
I
Septic of l lolding Tank /0(00 I(NN) ~_l OlHl 1 Midwest Precast ❑ ❑
IA)sing Chwnhcr _ ❑ ❑ ❑ ❑ -
VI I Responsibility Statement- I, the undersigned, amume responsibility for installation of (he POW TS shown on the attached plans
I'lumhcr's Name (I'nnl) Pluribi{ 1 • urc MPtMPRS WnnM1cr Busme>, Phone Nwnbcr
John tichmitl 223760 - 715-760-0486_-__
P unttrcr's Addrea lSUCCI. City. Slate- Lip C de) V
616 15(10" ,\ve. Soniersel. WI 54025
V Ill. C univ/De artment Use Only
Approvoxi asap 1-until Pa; ! Dale I tied Issuin gent Sognaru -
- rGival Kcawm for . I I $ ! ~~LI. lLCl _'3 3~J/~
IX. Cond' Reasons for Disapproval \
1. ,tw*, elwU4m like-cthf 3J
u:%4w: cell .qua dll be sa_rc^s pit ;-ec .vl. .A
ds P'N ,:oar aywne pl""n p':, lcel b) Niu ne.. \~>S~..tv ✓L Ir n+V£ • t
2. N attba•:k rK'rr"Bn,S m l.:t Lc Z. CS. it E
caper.appe bl+.cM.:~r:t 75
libeh in rumpkm planx fur ibr.).ten and whmii 1o t6e l OUR only oo W rw thine a vx x 11 inrhe. r vac
yQ 1/~ re
SBD-6;98fR01, I1) D
CONVENTIONAL COMPONENT DESIGN
INDEX AND TITLE PAGE
Project Name: Koets Tank Replacement or Relocation
Owners Name: Steven & Katie Koets
Owner's Address 832 Kit Lane
Hudson, WI 54016
Legal Description: SWl/4, SE1/4, 523, T29N, R19W
Township Hudson
County: St. Croix
Subdivision Name: Fox Valley 1st Addition
Lot Number: 27 Block Number
Parcel I.D. Number 020-1161-90-025
Plan transaction No.
Page 1 Index and title
Page 2 Plot Plan
Page 3 Septic Tank Specifications
Page 4 Effluent Filter Information
Page 5 System Evaluation
Page 6 Management and contingency plan
Page 7 Existing Tank Certification
Page 8 Septic Tank Maintenance Agreement
Page 9 Warranty Deed
Page 10 CSM or Plat
Attachment 1 Soil Evaluation Report
Attachment 2 Addition Plans
Designer: John Schmitt Licnese Number: MPRS 223760
Date: 3/26/2018 Phone Number: 715-760-0486
Signature:
In-Ground Soil Absorption Component Manual Version 2.0 SBD-10705-P IN. 01/01)
Page 1
IM-1060 General Specifications and Illustrations
IP INr.'.IIW Y:Ilt. .l =1`f a, 1,N11FT'N
iIY1t Kl AItrIKi r~ K.11
The IM-1060 is an injection molded two piece mid-seam
plastic tank. The IM-1060 injection molded plastic design 3T_~ - r 4 ti i
allows for a mid-seam joint that has precise dimensions
for accepting an engineered EPDM gasket. Infiltrator's - s
gasket design utilizes technology from the water industry
to deliver proven means of maintaining a watertight seal
The two-piece design is permanently fastened using a r 1;
series of non-corrosive plastic alignment dowels and
locking seam clips. The IM-1060 is assembled and sold
through a network of certified Infiltrator distributors-
TOP VIEW
am
'TbrkiCapacity 1287 gal (4872 L)
Ai,space 16.5% I- II 1 Tit".
Length 197" (3226 Tom) vAt1O]✓ I 'fI 1 a 14x,,7
- - ItMYYi /1, 154 III a JJ j~!
Width 62.2" (1580 mm) ~l
Length-to-Width Ratio 2.3 tot All,
Height 54.7"(1389 Trim) END VIEW
t cuid Level 44" (1116 mm)
Irvert D'op 3" (76 mnl) oul°4, 07.16101 ACCts>uIV•IACS'N1uuOwxOLd u;
_ WCO•N•S 'l
IT d'rmp-Aar
Ftoerglass Supports muntt XO1,xLLW° l u."<unu T
CouTpartrients
I aetn
,IN I;^ I
Bunel Depth - 48" (1219 mrn) NAT
Maximum ruix
PAlmmum Burial Depth 6 (152 rnrn) ~ ~
P.laximum Pip[; Diameter 6" (152 mm).ccwdwss - _ Ilral Iuua.lA.
I xxll'J - ':WNNrI
_ - Uf✓111 r•Yr1Ull
N MGpi FIF
5'veigrt 320 lb,; (146 kg) Neu Nnul I
nrc:.nK ll /
SIDE VIEW
~I 1
'ANN -OP ----i-- CONTINUOUS
1IA F j ` 4ASKFT
IANK
IN7FgIOR J1 J~ SEAM CUP
Al IONMFNI
DOWFI
INK BOI IOM
Ll'I
J Ousi^a,:e: Pah Wav is
P.O. Mx 7tilt
d (Ad S.I GT 1+N/5
ain-5r.-7rso-1860577 ToyI MID-HEIGHT SEAM SECTION
d F I L-I R AT O R 1-300-221-4436
www.inti1tratorawate4.lx m
U5. Pmmts: d,759.%q 5,017.OU; 94(6.488; S.;xi 011. !:,un. 116: b. l A59: 5,511 5 716,165, 5.588178 5.839.844 Cyatiyl PalarC 1,329959, 2.001.%1 QM W1,Its prulrr; ImI 0,1 tuu.im,
O.Ikkd,vr::'i0xV.5rx:w aeregrwlxl xarlnmaMSMI^nllratrx VlKw 1yJ'r%AWA h+'IUUrcx'I>are{js(vW °vlwnark in rrv'ee, 1,441 tw WI Tech,xixJix gaIwistvN 11 Vy..
✓✓'a1' Nej°LrcUn°.PW/TUII, CTTI 7C n1rF-Tp9C9. AIW.A'rxl, h:eilir:h, QIrxRA f}Iii NI r. $T.v ,NkkI Yxyyna•FSm MR.a1°-Walt TrehrTrx~rc.
I`aytua'c v b~'•era<ol Pd~r,r~, b aC : a r~IrrvM ba.MnnM 0 IUe - nnY INNC. . CNle-TbL Iz:. Lualvrevx v11PCS he.
s :aid Ir•M.rtv Via!n I xn,daArez, LLC. NI'iryrL rrvveil. R nbJ ul LLS.` 11.102 1'19
Page 3
'DX
n Area#. Gulvge j Zalvl
Cr;M~ L', + P Ciro-n of FN.¢k
- .I
the PL-525 Filter is rated (or 10,1100 (;PD (gallofu per day) making it one of the largest filters in its class. It has
525 linear feet of 1/ 16" filtration slots. Like the Polvlok PL 122, the Pulvlok PL-525 has an automatic shut-off ball
installed with every filter. When the filter is removed for cleaning, the ball will float up and temporarily shut off
the system so the effluent won't leave the tank.
Rated for 10,000 GPD (gallons per day). AlarmSwitch
- f (Optional)
52, hocar feet of 'I/'16" filtration. K000 GPD 7
Accepts F PVC
Accepts 4" and 6" SCHD 40 pipe. Gxtem wri I Iand L•
Built in gas deflector.
Automatic shut-oft hall when filter is removed.
t\lann accessibility. 1 I Rated 1,
10,0110 GI'U
Accepts PVC extension handle.
525 Linear Fl
Weal for residential and commercial waste flows up to
10,000 gallons per dal' (Cpl)). ..r ur I r 1~"
Fd [ian"n Slop
1. Locate the outlet of the septic tank.
2. Remove the tank cover and pump tank if necessary.
3. Cauc the filter housing to the 4" or 6" outlet pipe. It S( lit) Ill pipe
the tiller is not centered under the access opening use a
Pulglok Extend & Lok or piece of pipe to center filter.
4. Insert the PI -525 filter into its housing.
Gertified to
5. Replace and secure the septic tank cover'
:0
NSFiAN51 Standard 46
Fi:
r9r
I lie IT 525 Effluent Filters will operate efficiently for -
several years under normal conditions before requiring
cleaning. It is recommended that the filter be cleaned
every time the tank is pumped, or at least every three
years. It the installed filter contains an optional alarm,
the owner will be notified by an alarm when the filter
needs servicing. tiervicinb • should be done b - CW. Drtlec n,r
- V a certified
septic- tank pumper or installer. Auh,ma Lc
Shut-Oft Fail
1. Locate the outlet of the septic tank.
2. Remove tank cover and pump tank if necessary.
3. Do not use plumbing when filler is removed.
4. Pull PL-525 cartridge out of the housing. i4
5 Bose off filter over the septic lank. Make sure all Or `
solids fall back into septic tank.
6. Insert the filter cartridge back into the housing making;
sure the filler is properly aligned and completely inserted.
PolYlok, %atwl .@ lied filters aaxrpt Easily installs
i. Replace and securesephc Link cover. Iha•SnmrtFiltcexiswitchandalarn, into extshng tanks.
Pc9yluk, lire. 3 Fairfield Blvd. Wallingford, CI OM92 Toll Frce: 877.765.9565 Flux: 2114.284.8514 wuw.polylok.con1
Page 4
!CHMITT & SONS
586 Valley View Trail
Somerset, W154025
schmittandsonsexcavating.com
(715) 760-0486
March 26, 2018
to Whom It May Concern:
An evaluation of the septic system On the property of Steven and Katie Koets
located at 832 Kit Lane, l ludson, WI was conducted on March 26. 2018. At the time of
the evaluation the soil absorption area appeared to be functioning properly. The soil
absorption area has trees growing on it, or close to it, which could affect the perfortnance
of the system. The lower trench has 6 inches of ponding and the upper trench is dry.
At this point the septic tank will be too close to an addition and will be moved or
replaced so it will meet code. This evaluation does not in any way warrant or guarantee
future functioning or operation of the system.
if you have any questions or concerns. please lee] free to contact me at
715-760-0480 or ischmittid,somtel.net
Sincerely,
John Schmitt
Master plumber Restricted Service #22'760
Page 5
PAGE 4 OF 4
In-ground Gravity Management Plan
IMPORTANT:
The owner of this in-ground gravity system shall be responsible for its perpetual operation and maintenance pursuant to
requirements of SPS 382-384, Wisc. Admin. Code. Pursuant to SPS 383.52 (2), Wisc. Admin. Code, this system shall
be considered a human health hazard if not maintained in accordance with this approved management plan.
Furthermore, all inspection and maintenance activities shall be performed by a registered POWTS Maintainer in
accordance with SPS 383.52 (3). Wisc. Admin. Code.
Maximum Dispersal Area Operating Limits:
Design Flow= 450 gpd; BOD5 220 mgL"; TSS :5 150 mgL-'; FOG 30 mgL-'
Inspection Checklist INSPECT EVERY 3 YEARS
type of use
age of system
nuisance factors (i.e. odors, user complaints, etc.)
mechanical malfunction (i.e., pumps, valves, switches, floats, etc.)
material fatigue (i.e., leaks, breaks, corrosion, etc.)
solids volume in anaerobic treatment tank(s) and any distribution appurtenance(s) (i.e., distribution 1 drop boxes)
neglect or improper use (i.e., exceeding design capacities, prohibited activities, etc.)
extent of ponding in distribution cell prior to dosing
dosing irregularities - if applicable (i.e., pump recycling, float switch settings, etc.)
electrical components - if applicable (i.e., wiring, connections, switches, controls, timers. alarms. etc.)
distribution lateral or lateral orifice plugging (measure lateral distal pressure - compare to design specification)
surface discharge of effluent or sewage back-up into structure served
Maintenance Checklist MAINTAIN EVERY 3 YEARS (or when necessary)
Septic and dose tank(s) shall be pumped by a certified septage servicing operator licensed under s. 281.48 Wis.
Slats. when the volume of solids in the tank(s) exceeds one-third (1/3) the liquid volume of the tank(s) or
as required by local ur,5nance. Disposai of contents shall be pursuant to NR 113, Wisc. Admin. Code.
Effluent filter(s) shall be inspected every 3 years and shall be cleaned when necessary to remove any
accumulated solids according to manufacturer's specifications. A servicing period will always be greater than 12
months.
System maintenance reports shall be submitted to the proper local government unit in accordance with
SPS 383.55 Wisc. Admin. Code. Report any component failure or malfunction to:
Narne of individual or company: Schmitt _ and Sons Excavating Inc 715-760-0486
_ Phone:
Local government unit: St. Croix County Community Development Dept Phone: 714-386-4680
Local government unit address: 1101 Carmichael Rd, Hudson, WI ZIP: 54016
Any defective part of this system shall be repaired, replaced, or removed pursuant to SPS 383.51 (1), Wisc. Admin.
Code. Repair or replacement of failed or malfunctioning components shall comply with SPS 383, Wisc. Admin. Code.
No product for chemical or physical restoration of the POWTS may be used unless approved by the department in
accordance with SPS 384, Wisc. Admin. Code.
Contingency Plan
In the event that any failed treatment component of this POWTS cannot be repaired, it shall be replaced pursuant to
a plan submitted to the appropriate agency for review and approval. A failed in-ground dispersal component may be
abandoned and replaced by a code-complying dispersal component in a pre-determined area of suitable soils.
System Abandonment
If use of this POWTS is discontinued, it shall be abandoned in accordance with SPS 383.33. Wisc. Admin. Code.
Page6
ST. CRO[X COUNTY
Sl-TI'IC TANK MAINTENANCE AGRL-LMLNT
AND
OWNERSHIP C'LRTIFICA] [ON FORM
Owficl Ruvet Steven Katie Koets
Mailing Address 832 Kit Lane
Piopelly Address 832 Kit Lane
I Verification required lionh Planiung & AIIIIII " Depmnocnt for new c'onstructiun.)
;t~ st1Lt Hudson, WI Parcel Identification Number 020-1161-90-025
LEGAL DESCRIPTION
Property Location sw SE . Sec. 23 .1. 29 N R 19 W 'I Own of' Hudson
Subdivision Plat_ Fox Valley 1 st Addition 27
- - - .Lot #
Certified Survey' Map # Voltaic Page it _
Warranty' Deed # (before 2007)Vulurne Page +
Spec house ❑yespta 10( Imes ide•ti liable El)°es0no
S1'SI EM MAI.NT'ENANCE AND ONN'.NER CERTIFICATION
Improper use and maintenance of your optic ,ystcrn could result in its prenBq ure IEI lure ru hart ~ tI,isrc.. P: p.::
rcutten:mce consists of -pumping out the septic tank every three years or sooner. it needed. by a licensed pcr.rpr.-. h, tar •,:~u r1.:1 Iri,l
the -.y stem can aftect the auction of the septic tank as a treannew stage in the waste disposal stem. u c .cr 1 r. . rosx
,,.ponsibilirics are specified in ASPS. 387.5_111 and in Chapter I_ - St. Croix County Sauildy Ordinali
The propeuy owner agrees to submit to Sr Croix ('aunty Planning S: Zoning Department a ccrMlicariun ibi m, ,i, nrtl I~~ t~w
owner and by a master plumber, journeyman plumber. restricted plumber or a licensed pumper verifying 1Lnt (I I Aic on-,31c
IA a,Teweter disposal sysicrl is in proper operating condition and/or (2) after inspection and pumpim! I it necessary the septic ;arik i,
Ica, than 113 lull or sludge
I: wr, the undersigned have read the above regmrcutents and agree to maintain the private sewage disposal system will rlr
<randards set forth, herein. as set by the Department of Safety And Professional Set%ices and The Department of Nanut:t Rccow:a.
Sure of Wisconsin. Certification suiting that your septic system has been maintained MUST lie eonyrlered u:id rCwrni d to rCC
Comity Plammng.k. Zoning Department within 30 days of the three year expiration date.
I+wc ccrtnly that all statements on this form are true to the h«T of my CUT knr A ',Lec. I.',ec :n-r AC m: (I'A ts{ tit ihr
prrocny desctihcd above, by Vrtue ofa warranty deed rely.-Led in ft: cr:Ter of D~ r~fa 1 )Ilicc.
Numberol'bedrooms 3
SIGNATUREOI. APPI.ICANT'(S) DATI
"'Any infbrmaaon that is nturcpresented pray result in the sanitary pernnl icing revoked by the Plami C Zoning Department
Include cvth this application a recorded svannnly decd hom Inc RCPisicr of Decd, Q1fiCe and a copy of the .crtified ur sep nk'-Ih -f
e.hrc is rM& in the warranty decd
Page 8
wisconsinuepartmentofIndustry, PRIVATE SEWAGE SYSTEM County:
L.``or and Hyman Relations ST. CRO1X
SaRty awd Buildings Dbision INSPECTION REPORT
(ATTACH TO PERMIT) Sanitary Permit NO:
GENERAL INFORMATION 268682
Permit Holder's Name: ❑ City C3 Vi age Town o State P an IDNO.:
IVERSON, JIM HUDSON
C TBM Elev.: I Insp BM Elev.: BM Description. Parse Tax NO.:
i
/60;00 oU•OJ i tti• J.
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic j ~LGCT. y h/D7 Benchmark AWJ d 9' /Op, 00'
Dosing IwI
/ r89 .84' io0• ov
Aeration Bldg. Sewer p G 4G• 6d '
Holding St/Ht inlet *v?.
TANK SETBACK INFORMATION St/ Ht Outlet /✓o b6
TANKTO P/L WELL BLDG. Vent to ROAD Dt Inlet
Air Intake
Septic yp. NA Dt Bottom
Dosing NA Header/Man. ~~;ya 5v v~
Aeration NA Dist. Pipe 51 qa•n<
8.c v' q„_s
It, 579
Holding Bot. System 1,Sq' 93.3,
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand f a'
94, ra'
Model Number GPM
System TDH Ft
TDH Lift Iction
1 Head
Forcemain"- Length Dia DM rower
SOIL ABSORPTION SYSTEM
RED/TRENCH Width I urylh No Of Trenches PIT No Of Pns + Inside Dia Liquid Depth
DIMENSION5- -DIMENSIONS SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manuacturer:
SETBACK
INFORMATION Type CHAMBER Model Number:
System: -tjA .4,4/ > 70 OR UNIT
DISTRIBUTION SYSTEM
Ileaderi Mann old Distribution Pipes x 11nlesile I x Hole Spacng I Vent TO Air Intake
length Dia Length Dia Spacing
SOIL COVER It Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over DrprhOwr I I xx Depth Of xx Seeded I Sudded xx Mulched
Bed/Trerch Center Bedrlrendi Ldyes Topsoil r] Yes ❑ Nu ❑ Yes [I No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HTIDSON.23.29.19W, SW, SE, KIT LANE !
11-1?i- 9G Qu
4_5'_ 94 %
~(~'ul 1' •`sk - Y)I1~ _a~.9 5 d•vH< o-. ~s i/, -
qjN
Plan revision required C] YeQ I 7 6 L
Use other side for addi tional inf~nat`ion p;T 4/-Z L .4 4
SOD 6710(R OS191) ns U Date Ins ctor's signature Cert No
Safety and Bmlmnys 1)"'T Oil
ILIIR SANITARY PERMIT APPLICATION 8ureau of RU.Iding Wall, Systems
201 k. Washington Ave.
In accord with ILI IR 83 05. Wis Adm Code P.O. Box 7969
Madison, Wl 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less county _
than 8 112 x 11 inches in size. 57. 1 t-
a See reverse side for instructions for completing this application slate l r Perm/iL_ Number
V 4~--
The information you provide may be used byother government agency programs F) Chool, it revision to previous application
[Privacy Law.s 1504(I)(m)I
Slate Plan 10 Number
1. APPLICATION INFORAIIATION -PLEASE PRINT_ALL INF RMATION
Property{~w ner Name Prolxily LO<oliun
JI~ Svc soN lra SE va,S a T.2f ,N,R I ~(or)W
Property Owner's Mailing Address Lot
NumBlock Number
037- L eU
07,
City Sta66e lip Coce Ptgne Number Sutsdrvision Nameor CSNINusmpe
u-a45 rv 54014, ( 1 ox & 1
11. TYPE F B ILDIN ((heck one) ❑ State Owned a Nearest Road
Public 1 or 2 Famil Dwelling - No. of bedrooms 3 r voage
f , - S R 1~ L
111. BUILDING USE: (1+ buildmg type npablic, check all that apply) Patel lox Number(s)
1❑ Apartment /Condo 0 ZG 1 154 - a00 0 0
2 ❑ Assembly Ball 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 U 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 S. ❑ Repair of an
System System Tank Only _ Existing System ExistintgSystem
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non Pressurized Drstrbution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 210 Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 (Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 43 ❑ Vault Privy
14❑System In Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2 Absorp. Area 3 Absorp_ Area 4 Loading Rate 5 Perc Rate 6. System Elev. 7. Final Grade
Required (sq. ft, Proposed (sq. ft.) (Gals/day/sq. ft (Min./inch) atI q1.S Elevation
4 s o ?ot,< I t're'k e' eet
VII. TANK Capacl
INFORMATION in gallons Total X of Manufacturer's Name Prefab Site Fiber- Plastic Exper
New Existing Gallons Tanks Concrete Con- Steel glass Apo
Tank tanks Tj nvctad
Se•pt.c lank or Holding Tank 1~ ~n ® ❑ ~ 11110 11
Litt Pump lank /Siphon Chamber n ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage s stem shown on the attached plans.
Plumber's Neme.(PrinQ Plumber's Signature ( oStamps) M" PNS o: Business Phone Number:
CL r 9 l!4.1 e Claw P -7
S- S - 2175
Plumber's Addis (Sir ce4 city, State. /tp Code):
7 T j
IX. COUNTY / DEPARTMENT USE_ ONLY
❑Disapproved S ni twyPermit Fee ar"s"'r'~'Oi"b"0.+ etc sloe kwon 4gent Signature (No Stamps)
~A roved
PP ❑OwnerGrvenlnitial
Adverse Determination lJ
X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL:
son 048(H:1,10) oitialasiTillN fxy.mlin (ovnp nn-o,Pe TO tnlYiy aand.Pr4rr Dir.;,>n, 1>n"a. PlumGm
Wisconsin Department of Industry, SOIL AND SITE EVALUATION
Labor and Human Relations Page .L_ of
Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Adm. Code
Attach complete site plan on paper rat less Man 8 12 x 11 inches in size. Plan must County
include. but not limited to: vertical and horizontal reference point (BM), direction and t o 1, h
percent slope, scale er dimensions, north arrow, and location and distance to nearest road. Parcel I.D. a
0-7c) I / -aGODO
APPLICANT INFORMATION - Please print all Information. Reviewed by Date
Personal information you provide may be used la socondary purtxrses (Privacy law, s. 15.04 (I) (m)).
Property Owner - ( -
_ Property Location
T, vyl Cr Govt. Lot S i,rJ 1/4 S e 1/4,S,:~ 3 T N,R 19 (a) W
Property Owners Mailing Address Lot M -Blocks Subd. Name or CSM#
City state Zip Code Phone Number ❑ City V-11" Town Nearest Road -
UIIN W, I S 4o7-L (715-) -f l
New Construction Use: ® Residential / Number of bedrooms Addition to existing building A9 A-
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow _4~ao _ god Racom mendod design loading rate ---bed, gWFC).ie -trench, gpd1W
Absorption area required bed, h2_ r trench, h2 Maximum design loading rate - bed, 9p1rftz,trench, 9pd ft2
Recommended infiltration surface elevation(s) 171 T r .~i,(o J fw lr/~✓//,,, s~✓ h (as referred to site plan benchmark)
Additional design/site considerations In/T,cl ~v.S tfM ~yctT. e„rG__Sy~rc~n QITei,,,>'c S~,S~n w,f) cs yrroaLn~_
Parent material Flood plain elevation. if applieablo F'j A_ _ h
IS = Suitable for system I I Conven0°nal Mound I i-Ground Pressure AT-Grade System in Fill Holding Tank
u= unsuitablo for system DOS DU ®s CJ u s U u ❑ s u ❑ S X] Li ❑ s O u
SOIL DESCRIPTION REPORT
Boring It Horizon Depth Dominant Cola Mottles $/NCIurO GPD/ttz
in. Munsell Ou. Sz. Cont. Co1ur Texture Gr. Sz Sb. Consistence Boundary Roots Bed , 7rendl
I o-r' 7.5 YR 3/g S ~msh~ rnuf • Uf_ 0.~ 1)10
4 Ground
sr4,s~Gw 1vtg"St~- 4 Fj 3 SY2gf S lb (!hs)>1t c (,j VV A
Depth to 5 r 6S q,
limiting
factor
> 9+ Remarks:
Boring # I, p r
1 0 4 7.5 Y2 -31 3 S' a2 ri! ~ Ihv7r $ 2UT
2- 9-22 75 La 0.
X23 Ya1-3
Ground 4 -4 4
s,r l3 sr s i cb 4 v~ c w
40-8S)rfZ && _ Syr X11_ Cw - G. 0_
G_ 9 71
5YR
0.
Depth to
limiting
VI -'o
amarks:
CST Name (Please IIPrint) Signature Telephone No.
Qr H-CSo _ _L_dd~4. IS-4 _ -21
Address Date CST Number
042- OZyt' Fars W; S4raz io-2-9G c r~ro
SOIL DESCRIPTION REPORT
PROPERTY OWNER -.ZJJ~ =±V6vS 0Page of
PARCEL I.D.iI O2OI - '~O
Boring # Horizon Depth DorninaM Color Mottles Texture Structure Consistence Boundary Roots 2
In. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed .Trench
3 1 o-ro .23-3 s- 1 Pw511 rn0ty s o,S o.~
Ground 3 31 , S V G C- t..1 I J f Q, S o. 6
Q.S/.1'fl. 4 O' r Q~ c uti - 0.7'0.8
7. y
Depth to
limiting
a
Remarks:
Boring r 5 2 D S 0, L
S t -i/0 5 Y2 - 2 Inrbk
`I Z 74~/ _ 2m~1/ I Ivy p.S:o,L
c l,i I f o, s orb
Ground - 9 -L .S 2~& 42d c7, YfC S 1. c~ Des, va u , r /
Depth to
limiting
factor
in.
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots P
in. Munsell Ou. Sz. Cont. Cobr Gr. Sz. Sh, Bed .Trench
Boring # ( O-)z ' Y2 - si_I 2 m ~r v c Z F S 0.
Jr y , 2 rK~l ( - Sr 1. _ . s t of _S o. G
73
Ground 4 50 . IN
Depth to
factor
hmiting L `n. Remarks:
Boring #
J o-, 7,SY2~ 2-sbly m y5 _ O,S'.G,:_
F3 n~~ L-~~ d t 5 ~vf o.s o,
3 5 _5 X23 n ~1 m h.. 5 L~f S '0,
Ground 98- d a -5Y-Oz
Depth to - - - -
Hinting
Remarks:
SBDW-8330 IR. 08/95;
I '~~w~ Svcrso.J P~o~ `Jjah ~9 301 3
Lo~tc j
Fox UOA~y "A
i
G
Wocc~tl r..<;
S1rcPr~ Sl~p<
4s
d A,
0
b
~1.,.~Tac 84
Ei. 99 9 8
7 h, i Q.u a{. I ¢ 5°, .61 I SQ•6< In g.i°1 i~<•
1°"•..7..,,,.i %d al l4sS+..r fl.l pp.e•
U.4 • I
Se lt, Q,.v..~~ l:w< o{ l.N 27 X54 33 / M-
Or.+~°'1 uuwtl 'pY S<..t O..n lv
a
AA P~ ,
14
S ~ti 11 y IL- _ !
- j
f
IL
a [ ,i
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ly
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r:H-GR 3CO: AS AC^LI e\p.C ::HCCK a0k i.5 APPI CAe _t
❑ SOIL EVALUATION Scale. r• = 60 Z SYSTEM
SITE MAP ° 6o sr. 20
PLOT PLAN
PROJECT NAME. DESron = a,r aso c-PD
KoetS Septic Tank Replacement ~ 5' Attach design flow calculations for commercial plans.
?ROJECI ADDRrsS. 832 2 Kit L C, RudSO rI. WI Pipe Material: ASTM Standard (Tables 384.30-3& 384.30-5j
el. 6Ymto + BPo, E evauor r-T \ Saniay Seller 4" PVC / .rSTM D2665
1~~•(J(j
BM Delp color. latiO Force Main' O00" Sill
_ i
rnr;.;u rorinw IM?ORTANT~
S cape Grac H': ('::I ;n,Ell S'maa' jIf aaDICdDW_ 0 Show ground elevat*n GOAfgJIS at suitable Iutentals.
n`TeSlotl YEa R Y is J1awin_
ar._irrt BPnu.aviv
im nc
Y~
Ex s! Ia V 'A. e. -rte
1 C-~ie•xa~~ _ - 1 ~',Y
C. s;lrc
Gcrccc
0'v Z:j (mil°e:
rea aged t'. t . ;;cl'' '
em'
p ,rti, -OrIK - Sc ec'~ '`;,rc
1
8vt
S/✓
It.'- "16J
Gallon -,~pt;c II
I
/ -c-ik,
1 _
1 w;'~.aylc~ S%5 '1
1
1 I
1~ 1
1 ~ ,1
1
' r
_ire r' 11 Prore mot.
/ Line
1 i
1
1
1
1 1
1
1 '
1 1
1
1
1
=rGl,f.rtY
1 ,E -b xE,? 1
8: DO- 11
\ 1
1
1
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1
Page 2
CHECK BOX AS APPUC-3LE. C HECK BOX AS A"P.ICAHI 6
SOIL EVALUATION Scale ,"=60' SYSTEM
SITE MAP 0 60 90 120
PLOT PLAN
PROJECT NAME. nrSiGN FLO'A. 450 GPD
15'
Kol Septic Tank Replacement Attach design flow calculations for commercial plans
PROJFCTADDRESS 832 Kit Lane. Hudson.Wi- Pipe Material iASTM Standard (Tables 384.30-38384.30-5)
6M Sy:^Dm. -1l BM eleeano,. 100 00 rr Sal Sene., 4" PVC ASTM D2665
DMDewriton Potio Door Sill Force Main _ / i
~nmcate Crt o. IMPORTANT
of Slope Teste4 Area e^t :`roj well Symbol(1laDoli;abie) O a-awinv nn, 4,-* Show ground elevation
/pAtcl at sutable intervals
_ o^ me rs:P,cPnm tiro !
~i
i
II Freccst ;_G.: Lang
gcllon tank -4 1 L.~~ Fr o:iriy
e,r
moved tc meet s
code or wit' ar,
replaced o:'th a • ;v=u1
I•lr'Itrct^r I)-v-"~.),!i Huur~
~::1 ti- ] ;711 iC i'•.adiafi9
1
11~
II ~_'i ui Sep1iC
Id
iFob; ^i! 57:j
,I 1
i `
11
i 1
1
i 1
it Pr~,pcr'y ~1
ii Lre I P f°'ly
1 Lnv
11
li 1
li
i I
i 1
1
i
11
Lrt,O -~'~Xf II
I
FieCk ~I(i° I
- ^ 1
rc~~rY,es 1
1
1
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Page 2