HomeMy WebLinkAbout038-1190-40-000 (2)
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
(ATTACH TO PERMIT) SAN-2018-049
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:
June Richter TOWN OF STAR PRAIRIE 038-1190-40-000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
13.31.18.975
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
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR
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 7ed/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: 1353 214TH AVE
1.) Alt BM Description =
2.) Bldg sewer length =
- amount of cover =
Plan revision Required? ❑ Yes ❑ No
Use other side for additional information.
Date Insepctor's Signature Cert. No.
SBD-6710 (R.3/97)
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: '/4, 1/4, Section , Town N, Range W,
Town of , 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
Did flow back occur from absorption system? Yes No
(if no, skip next line.)
Approximate volume or length of time: gallons minutes
Tank Capacity:
Construction: Prefab Concrete Steel Other
Manufacturer (if known):
Age of Tank (if known):
Permit number (if known)
(Licensed Plumber Signature) (Print Name)
I(Title) (License Number) MP/MPRS
(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
IV G C
County Sanitary Permit Application ST. CROIX COUNTY WISCONSIN
CIO,~ in accord with Chapert 12 St. Croix County Sanitary Ordinance PLANNING ZONING DEPARTMENT
y' Personal information you provide may be used for secondary purposes ST. CROIX COUNTY GOVERNMENT CENTER
+<i [Privacy Law. S. 15 04(1)(m)] 1101 Carmichael Road
Hudson, WI 54016-7710
I (715)386-4680 Fax(715)386-4686
6 Attach complete plans for the system on paper not less than 8-1/2 x 11 inches in size.
County Sanitary Permit # 7evisio to previous application
5WA-MK-649 l
1. Application Information - Please Print a rmation Location:
Property Owner Name
PUJ 1/4 1/4, Sec
1
T - N, R E (or
Property Owner's Mailing Address Lot Nu Block Number
City, St to Zip Code Phone Numer e or CSM Number
II Type of Building: (check one) amity ❑ Village Town of
S 1 or 2 Family Dwelling - No. of Bedrooms:
❑ Public/Commercial (describe use):
❑ State-owned Nearest Road/ "
It. Type of Permit: (Check only one box on line A. Check box online B if applicable) ,
Parcel Tax Njnber s)
A) 1.❑ Repair 2Reconnection 13. 0 Non-piumbing 4. ❑ Rejuvenation
- 1 I
Sanitation C`t
B) Permit Number Date Iss ed
40
Z
S
tate Sanitary Permit was previously issued
IV. Type of POWT System: (Check all that apply)
Non-pressurized In-ground ❑ Mound ? 24 in. suitable soil ❑ Mounds 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 Are Information:
1. Design Flow (gpd) 25. 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 Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic
New Existing Gallons Tanks Concrete structed glass
Tanks Tanks
-C; ❑ ❑ ❑ ❑
❑ ❑ ❑ ❑ ❑
Vll. Responsibility Statement
I, the undersigned, assume responsibility for repair/reconnencti ' /rejuvenation/installation of non-plumbing for the POWTS shown on the attached plans. A
iicense is not required for terralift repair or the ins Ilation o n-pl 4ing s ion system.
Plum e ' N e ~n Plumber' Si (no am~)!/ - MP/MPRS No. Business Phone Number
Plumber's Address (Street, City, S e, Zip'Co
< J r
c
Vlll. County Use Only
Disa proved Sanitary Permit Fee Date I ued Issuin ent Signat (No amps)
<Approved Owner Giv~ dverse I Z7_G Od ,I a
ation J v
IX. Conditions of Approval/Reasons for Disapproval:
Coy\ \ 't Q Q I 4//JA'%
Rev: 8/05
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ST. CROTX COUNTY
SEPTIC TAX AR17 CB.A.GREM&"+ " .
AND
OWNTMPUP CERTIRCAYTON FORM
Uv;rernBaye r Ju L
-Maih L-ess
pen. Ads
(NierM=on required frost Ply & 7 mdug Ds muneat far nVw won.)
Cit~7/.S a Parcel Tdentafication Number 6 J' g' 11g~ - yd _ Wb
Proper [ c:az 1/4 , V4, Sec. ? R , ' 0VM of
Subdivision Plat: *f IN, eA Lot 4
Certified Survey Map' Volume , Page
Warmaty Deed 4 ?j (p 2 (a amore 2007)Vdl e PeRe jp
loo s ao 'Lot tbm idettifiabie 17 yes 0-to
SyS' M l!~ApayNANCE AND OWNER CER _`L~C~I~T
improper use and maiutmmoe of your septic systeun could result fa its premature failure to handle wastes. Froper
mamtmmce coa,dsm of pumping out the wpdc tank every three years or sooner, if ueeded, by a licensed pumper. ghaty(m put into
the system cart affm the won of the septic taak as a treatment stage in the- waste diwml aysWM Owaar mah#enaaee
responsi es are specMed fa ASPS. MM(l) and is Chapter 12 - St Caozx Comity Sanitary Ordhan=
7be proparqt owner agrees to submitta St aoix County Plamkg & Zatmg Depmtment a certocaifan
form, sipedby the
owner and. by a master plumber journeyman plumber, restricted phmiber or a licensed pumper verifying that (I) the on-site
wastewater disposal system is in proper opcratin 6g condition ax &orr (2) aibr iitspertion and pumping (ifnecessmy), € a septic tack is
less titan I13 fu3.l of stud ;e.
Ywe, t ie tmdermmed have read the above requn-a ments and agree to mamiam the private sewage disposal system with the
s~nt3ards nt he rak. as set by the i ' a of Saf e. I .Se om and ft DVintmew of Nowai Itmourres,
smote of W* C~ std z Yew s is .sys*m h2s bemmokbimd trust be completed and rem to the St:. Croix
Cow p Z g Vie= witMw 30 'the &me year cqmzdon dom.
Ywe certify that all statements on tints fbim are true to the best off my/our kaowle4ge, Uwe am/= i$e owner(s) of the
property described above, by Artue of a deed recorded is RetWer of Deeds Office.
Number of b oms
STaWATTUM OF A PPLICAN `(S), DAM"
zt:**,Azy information that is misvpreserftd stay result in ; he sanitarypinch being revo}m by tote Pl=Mg & Department:.*.
include with dds application a recorded warranty decd from the Register of Deeds Office and a copy oftbe coed survey map if
reference is made in the warr=y dew
CW.)
Asconsid Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and Buildings Division County:
INSPECTION REPORT St. Croix
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
363990
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: ❑ City ❑ Village ❑ T n o : State Plan ID No.:
LeQue Construction, Star Prairie Township
CST BM Elev.:- ' Insp. BM Elev.: BM Description: Parcel Tax No.:
038-1190-40-000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION #SH I FS ELEV.
Septic Benchmark .2o C9 , O `
Dosing Alt. BM , p 02 .3160
f
Aeration Bldg. Sewer RS 0D. ZS'
Holding St/Ht Inlet (o•$-~ gg;(o(of
TA K SETBACK INFORMATION St/ Ht Outlet (o- RS. 2s r
TANK TO P/ L WELL BLDG. Ve stake ROAD Dt Inlet
Septic )50 ' 30 r r-- NA Dt Bottom
Dosing NA Header/ Man. 7-80 9:7, lo
Aeration NA Dist. Pipe S : 80 9j,IfDr
'
Holding Bat. System S 9- 3,10
%'10
qq.
PUMP/ SIPHON INFORMATION Final Grade
p r
Man r p d St cover
Model Number GPM
TDH Lift Iction TDH Ft
For ain Length Dia. Dist.TO en
~ SOIL ABSORPTION SYSTEM ~ S
Width Leng / No f renches ~DITM INo. Of Pits Inside Dia. Liquid Depth
loolusfico
DIMENSIONS 3/ 68- I
SETBACK SYSTEM TO P/ BLDG WELL LAKE/ STREAM LEACHING Manua ctur r: f
INFORMATION Type n , CHAMBER M e Number-
System 7 • 3D OR UNIT [ .
DISTRIBUTION SYSTEM
Header /M ni old Distribution Pipe(s) x Hole Size Hoe cing Vent To Air intake
i
Lengt Dia Spacing 7
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 discrepancies, persons present, etc.) X 3
Inspection #1:fAV231 4TInspection #2: `f-t -
Location: 1353 214th Avenue, Star Pr irie, W1 54026 (NW A SE 114 13 T31N R18w) - 133118975 Northgate -Lot 26
1.) Alt BM Description
2.) Bldg sewer length=
30' U,-amount of cover = y t B .
k I OD .9 C~" cam- o- .
Plan revision required? ❑ Yes 10 No
Use other side for additional information. p$ Z3 IODJ ~Ag
SBD-6710 (R.3/97) Date Inspector's Signature Cert. No.
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