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HomeMy WebLinkAbout026-1111-90-000 (2) Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix ~ Safety and Building Division INSPECTION REPORT Sanitary Permit No. 600377 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: Chad Bergmann TOWN OF RICHMOND 026-1111-90-000 CST BM Elev: T~~I BM Description: Section/Town/Range/Map No: 04.30.18.633C.634 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark 113 < Alt. BM L / Jam. ,ti V IkC."4 Aeration Bldg. Sewer Holding St/Ht Inlet 1 C~ ~ . ICJ „ ~ - TANK SETBACK INFORMATION St/Ht Outlet KJ~~ 5 TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt I.n.Ie~ f Septic Dt Bottom f- Dosing Header/Man. ►05~L1 U Aeration Dist. Pipe Bot. System - - PUMP/SIPHON INFORMATION Final Grade (4 70 ICS Manufacturer GP nand St Cover Model Number TDH T ift Friction Loss r m ead TD , Ft n ---r Dist. to well Forcemain rgth jakj 131o QJ 7' 14 SOIL ABSORPTION SYSTEM BED/TRENCH Width Length / No. Of Trenches PIT DIMEN ONS No. Of Pits Inside Dia. T quid Depth DIMENSIONS - / SETBACK SYSTEM TO P/L BLDG WELL LAKES M LEACHING Manufacturer: y INFORMATION CHAMBER OR 3i1. +t r'~'~t° Type Of System: nr ! 60r 1 { UNIT Model Number: ~ i /I1► DISTRIBUTION SYSTEM t I +l Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake t' Pipe(s) _ LengthDia Length Dia Spacing - - SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over 7 Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center "7 1 ' Bed/Trench Edges Topsoil L-1 Yes E] No Yes E] No J. 1 COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 1745 MARGARET ST 1.) Alt BM Description =~~zX C~' CSEc Q $c tel' c°"' J ~ ~ 2.) Bldg sewer length c zre = 0 - amount of cover = jl r/ a P a~ I Plan revision Required? ❑ Yes ❑ No L._ (Lo _ Use other side for additional information. J Date Insepctor's Sign -7 Cert. No. SBD-6710 (R.3/97) ~r. kr 7 County Safety and Buildings Division ( -Lo 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.) 037 SpS (f! l,F 2~~ Madi~~70 71 State Trans ion Number „islar it Applicm!On In accordance with SPS 383.2 1(2)Wis. Adm Code, submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to Project Address (if different than mailing address) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law, s. 15.04( 1)(m), Stars. I. Application Information - Please Print All Inform ' 40~S J4/Q Property Owner's Name / Parcel # -9o-.0 0.00 Property Owner's Mailing Address Property Location; O (C,3 L- J L/5-6 o S r Govt. Lot City, State Zip Code Phone Number /a, Section I'Al`~! r / o At OVt J~ 89, 6lo? - 8 yS-73 78 rcleone Ty"~N; R Eo 1) II. Type of Building (check all that apply) Lot # I or 2 Family Dwelling - Number of Bedroo ?5 / Subdi~ vision Name ~J ~ l~cewte Block# V V ❑ Public/Commercial - Describe Use ❑ City of CSM Number ❑ Village of ❑ State Owned-Describe Use 4 0 CL." XTown of III. Type of Permit: (Check only one box online A. Complete line B if applicable) pAiL A. ❑ New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. ❑ Permit Renewal Permit Revision Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date sued ❑ ❑ Q' Before Expiration Owner Z -7 16I L IV. Type of POWTS System/Component/Device: (Check all that apply) Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) rctrcahncnt Devrcc V. Dispersal/Treat ent Area Information: pZ Design Flow (gpd) Design Soil Application I (gpdso Dispersal Area Required to osed f) Syste Elevation yd0 .7 / 96 /3 o 6-- VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units o to v New Tanks Existing Tanks o y r 1( a U cn v vt J CL Septic or Holding Tank Q00 400 000 X Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumb 's Sign turc MNumber Business Phone Number ,69,60 Y IJ77AA :e 347 7/.S-- 74a Plumber's Address (Street, City, State, Zip Code) po, g i 14r~ . ray mil; s as VII mm /De artment Use Only pproved d Permit Fee Date slued Is;~ature Ow yen Reason for ial IX. Condit asons, fof,pisapproval r. r Ili 3> 6L S Gi*emo C*4 rKilt da kXtWNLw1!1 4L "per,TW,Al;~. plan p!rrdded by pitimbe. 2JN W~+~.^ (2 ~exaG. 5 2. `pA ee l S mA;t W t'8,f t. u:E to PK pf"Oth C'CA- I Mi~nnt;e.~, s ~ v rf, o it Aj 1w;&j J,-, C-riK ~ Attach to complete plans for the system and sub tt to the County only on paper not less than 8 11 inches in size 1UP - ZO l8 - 00 ~,o Ctl~ ; SBD-6398 (R. 11/11) PiaeA- &.4" ~ f ...__...._,v.J t v Z 12, F 1 J t j^ ~ C~ v.. r Mme' Fw~ 1 r f _ I c L t~ - p, gd-o36-7 CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Projec. Name: Owner's Name. Owner's Address: X77 A,' /7YS /ti`-e ST New i•.~.,Z~„ Lega Description: _/V4~ :so s y l 713Q ~ 19 04 Township: county: Subdivision Name: lJ of Number: 3J~ f Y Parcel ID Number: UpZ (p - / ~f D - V O Page 1 Index and title Page 2 Piot Plan Page 3 System Sizing & Cross-Section Page 4 Filter Specs Page 5 Maintenance Information Page 6 Manaaement Pian Page 7 St. Croix Cty Septic Tank Maintenance Form Page 8 Warranty Deed Page 9 CSM or Plat ,,PP Attachments: Soil Test & House Plans ,p Desioner/Plumber: U76~A&P License Numbe-. o~a03s~ Date y- oZ S - / o Phone Numner 7/s- 7Gd - 05►~/(0 Signature d--~l Z~/~ Designed pursuant to the In-Gro 4, Aosorptior Sompone:,* tcia-),;a for POW7S l e s c; 2.G SBD-1070 -P (N.-- ' Paae 1 Aef 0 k J IV) e- /a-oo 1 -7 57 X 13 -1 X a - I gdo36 J 1 / Soil Absorption System Cross Section ft 1 - `Fade 4- Schedule L: PVC Vent P W] th Vent Ca_ _ trench 1 k. Leaching i renc ~'~~i1i}i' IIl~t(41Iii~~tlf~~ l 4" Dia. Trench l Header Vent D- ? Oe ;M Trench---, _Leachina Chamber Speciftcations u i ';Manufacturer And Model .~N 44 rXA to i` 7 -:,SA Rating sq ft per chamber Soil Application Rate • 7 goof sq gpd Design Flow • 7 Soil Application Rate =iSA= -a.oers lyro%^.s of /7 -ambers each 17X y= 6~61~ao = l3Gos~ Page Cf 7 c2 01, /6.07 Jul 22, 10:I4 EDT by: OptioFAX Server (10:29) Page t or a W J > a° Zap z N 11LL Z W V 0- W CO O / z J . Y m ZD w / z O > cn - v W C. N J m F W -c T zr T u "VERT -`r ry, t{ LLJ LLJ 1 5~ c) i 11.1 IL. ~1- w rJ r j W CD Cf) 'N Cf) _J J ::D Lc t - \U!tom , W ~M CD (.6 i (1._ Cl_ POWTS OWNER'S MANUAL & MANAGEMENT PLAN page I of FILE INFORMATION SYSTEM SPECIFICATIONS Owner Septic Tank Capacity 07600 gal ❑ NA Permit # Septic Tank Manufacturer ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model ❑ NA Number of Public Facirity Units ❑ NA Pump Tank Capacity gal k1 NA Estimated flow (average) gal/day Pump Tank Manufacturer NA Design flow (peak), (Estimated x 1.5) QQ al/day Pump Manufacturer NA Soil Application Rate ♦ gal/day/ft2 Pump Model 4CtNA Standard influent/Effluent Quality Monthly average* Pretreatment Unit NA Fats, Oil & Grease (FOG) <_30 img/L ❑ Sand/Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BODS) I <220 mg/Li NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) j 5150 mg/L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BODS)) 530 mg/L IIn-Ground (gravity) ❑ In-Ground (pressurized) Total Suspended Solids (TSS) 530 mg/L xl NA ❑ At-Grade ❑ Mound Fecal Coliform (geometric mean) <10' cfu/100ml ❑ Drip-Line ❑ Other: Maximum Effluent Particle Size Y. in dia. p NA Other: ❑ NA Other: ❑ NA Other. ❑ NA *Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: 0? 71 month(s) (Maximum 3 years) ❑ NA a year(s) Pump out contents of tank(s) When combined sludge and scum equals one-third (Y3) of tank volume ❑ NA Inspect dispersal cell(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA year(s) Clean effluent filter At least once every: month(s) El NA ❑ year(s) Inspect pump, pump controls & alarm At least once every: ❑ month(s) 10 NA ❑ year(s) Flush laterals and pressure test At least once every: ❑ month(s) NA I ❑ year(s) Other: i At least once every: ❑ month(s) ❑ NA 1 ❑ year(s) Other: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector, POWTS Maintainer, Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third (Y3) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. UP AND l:PLfiA ION ~ . ltSY~uVtltJ,e, prr£)r €U t1St oT cllp 'v~L7 t ch ck treatniunt tankiF; for f;)e o; ma in£'•dP iho treatf.lGt): f)ro' S ?,'ilr fa ? i JL E;7c t7f5(}BrShc (..II S , ` ) ° i J Ot )lnflt Cht)Ii1P; a taflkis) removed by a soutage se,vicinq operator ,rior If hfgt r.r;; n,; in us , r.€Tf stdrt 11} ~;iali rlc)t JGf:;) L h Sol' cond"ions are. frozen r. i le JV,'GF u - J Ies P Jr,tp tangs may 17 r; ab ✓ o f'r a lilC r harg U zo t` fr,, dt - c,, Fi `..ciYGr IE.V.IS, trtli~;ra Jt, s.nGfa1 Ulf- i7 Sc^ "1' iQad„? t!`t6 t,E'i,, V!10 Illcryy reS J7Y 7,: t7{ iJc f "i`:t.!) :)1~ A,J'tc3c8 {fl,>CniflifF': Fu c3t-pi1 FY-a SituaCiC)7} have the CU.?ten ts of cIe t' iafn Er to the effl JcanY J) or cnnta t a luc ` rnp an remove t t,I,r or J7"A Lt by u "p age S~rwcJf)c~ Operator n inr to c ,,t,.e n ,f).,af .."TS fe s_< r t'.~c sr;tci ? r I .U "c~. .~t n aIT .F ..•t~lfit tic ,r ~ :I{y tJFJeraf~li at: , t<~ drive .Jr park v21li i£s c tan6 ano Is^ rs rs Jc n t reet do, ri sit~ fu o ari :e n~._ th~ru.~i:re <lisru. d' Di 2 S t??C)'.!u cr aJ 3: ade abs rption area. "K du tlan or eliminati£Jr7 of the fa do , J t<, e astewater stream may improve the performance and prolong y 1 S. anltbiDYl S t)dlJy YVtt)ES cigarette fl u tS' ^ I r+ a C,,LtU S vab 1 the i Of IC, r .3L~j.' aye (7''fltr~; T(QSS; f.11a:)f:rs; ti!SlnfE ari ants; '"ai_ 7 21u Jiiinq! fr i to 8.i° ar 4 S p7, vi E..,oY! l 1F,S, g 0' q, f Else: '~-C)ccides; dmaat scraps`; (''1E 3c.wxy t xok(irs, ..ate, - 'IlgatlU?ISM 0!i aANDONWNT so•f .e.?e t. ,,,ne. >t en the P (JV0'S `pits and`or is F)efrlia i r.[%}f 2 En C i ^a r c ) and Sci{E !y L :fie callat":ing StePs S iaiI t)e taken to insure that the s dC)drJtJUned it compliance with ch .2te; Comm 81 3, t.'.IS: Of'.sii? A item I: /-!I oioin£I _,nKs and si, d a C:tsC G;) .e;t° 1;-d le aia!1:f d`?L£! p17i; F n i. gag{ ,d. `lt (_ont ;nts of alt tnr^ s e iti tits 5t ai: be removed and )'ape.-iy disposed of by a~Se;)call) Servicing Operator. prnnping, all -ranks and tits shaii be excavated and rernovect n their ^n 1, {1!"eve} or another inert so,id material. !W(:!- CY PLAN iilI an(f fcrJ Jai 'e;;,pa r,. ;r)' ~+)t1;'J:"JUlC~ n?EaSUreS na Unable repiacemor : arep has been avaliuated and may be ut'ti zed for the iocat!on of a G he replacement area Sh0 4d be pro'.e„ ted from disturbance and compaction acid s } t t! Pd ~ tr)a.Y° iron; gXtc. r) a, ! p oqa ed St £rcturo jolines an PIIS I~ l !,i ee'i ft-Jr ct?ia En)enY a ea ,.•il~ %lr L'v S„)' 3 51.x' < 3ti; _ IO,t "U es,a )it&h a s!JI.3r118 zap(a^~ finent ate-J ta te~ . r tE r _ F) y ittt the r Il.;s if ;,f.e t a u. ,c2mcr i aystems rrw C llmoo' . (f'~JraC;:Pler)i urfla c^^. cs 'uI)i° due to set_ba .k arts . sc)it lin - nn k : nr)r~{_, ~y , ;)~idinc~ tank rrec ae a i.• s. Barring advances in P V ?S a, e J as 8 a5 resC't to t£aq'n .j ,c_ aijf3rj U(J1^: ~l'f . .a `f 4. s. E~eaH+2" ° a 1 11 T, f iitJ ° ~ 1 f /t 7 o inC ti r, AJ,, 3n&j RUC A pri n,i d and a , ade soil auso i rpt7o tilt f Systems may e - viL,.lilt.S . . Sya'., 2S `T.t, iARNINGx. PTIC, PUMP ANi.) OTHER TREATMENT TANKS MAY CONTAIN LETHAL GA ~ N h J i i !7C< NOT ER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY J, a' A'r ~aEStiL ° r,~ t F RSON FROM THE fNTFRIOR OF A TANK MAY BE DIFFICULT OR IMPOSS18,1 :1 ~t a~d9 BTESCUF OF A ~i.I"~d`t"►ONAL C~JMP~tENTS y INSTAI TALLER M1. POWTS MAINTAINER _ L-r,iJ I VAIclNt~ ~aPEr~A~roR (PUn~PER)cre LOCAL . REGULATORY AUTOOTTV s?. F N all-,- -7 I ~hrJr. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address j/ y6"9 hod 5 A-1 8 Property Addres /7 L1 S . Lug, (Verification required om Planning & Zoning Department for new construction.) City/State NA"r_ Parcel Identification Number l~d4b ///l - X000 LEGAL DESCRIPTION Property Location E Sec. 41 , T 3 ON R / 8W, Town of Subdivision Plat: U Lot # Certified Survey Map Volume , Page # Warranty Deed # (before 2007)Volume , Page # Spec house ❑ yes Kno Lot lines identifiable g yes ❑ no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §SPS. 383.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Safety And Professional Services and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. Uwe certify that all statements on this f rm are true to the best of my/our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a warra deed recorded in Register of Deeds Office. Number of bedrooms SIGNATURE OF APPLICANT(S) DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 04/12) N O ~npl4tts~ land I a, 85~ N890 35'E 456.00' 103, _ 228.00 • N 228.00 3ti o 0303 13/o14oJ~ 500o e~ o CURVE LONI 32 A 6E 70 01 S 000 5 PI ij r / b ,~FsO, 00 , m O B 7C .74 W 5.01 ~w30~ ~ ~f.eA B'->, e ~ ~0Oet, w D 60 177. 33' _ 00. N 30541w E 35, `6410 0dyz t E~ `oi t°'2so3,N89°35,E s9° t .Tangent b( co 0 94039 -2700 N* C~'r 0(\ ~'B 1 O 2 r 6 • a ' M 0. 30' 80 ~47°~' WNT2o OO 270°00' 1400 '00 0 st _ o ..33 W N O° - ?1. 205. / . ~j 62°23'3' . /p ; 4 0 , ca N ~2°~5'W e9 f, a w 72°50I 204. 34" ,~9oJO, 11.58' 70°05 m a, 1070300 west P2 p' ~o a /s 29. 200°12' o .~~o . tis s ~ ° 34 o y 90° 32• e 179.93 12s0 28-. so. ra, 9 ,h ~DL ?7 05s 1\ / S z 73 92 tis2O o P3 ON 0 \ 35 O c J/ 27 900 •~2o~B' 226.42' too, OX, ° o ' hjO. co w O`• 3 W - UnplOtted~lani • 009 ' 0) - 116 N 26009'W los, 9 o2 5, 16009"'03' 247.27', • ' 07 5 3 2. 90' 4 Form- STC - 104 / AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP SEC. T N-RZW ADDRESS _5 ik1,j ST. CROIX COUNTY, WISCONSIN ,l~-~. dmt~ S7im- 3~~-35 SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of l'LHR 83 I SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM -LO ~ r i9 70 lo, Ap ry / = ym sct~~ INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point: Z4Q. e-~'_ Proposed slope at site: SEPTIC TANK: Manufacturer: Liquid Capacity: Number of rings used: r Tank manhole cover elevation`:" Tank Inlet Elevation: Tank Outlet Elevation: ~ Number of feet from nearest Road: Front (A Side ,Q Rear, O f feet From nearest property line .,Front 10 Side,® Rear, O f feet Number of feet from: well / 9-? , building: S2~' (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE c r P CHAMBER Manufacturer: Liquid Capacity: Pump Model:;. Pump/Siphon Manufacturer: Pump Size Elevation of inlet::, Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: 'Alarm Manufacturer:, Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear. © Ft. NimVer of feet from well: feet from building: Number V, (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: l Trench: Width: ' 'engrEh: ~U Number of Lines: 3 Area Built Fill depth to top o p /t_ Number of feet fronearest property line: Front, Q Side. O Rear,O It ~ wl N 'ber of feet from well: Numbs .o feet from building: (Include distanceaon plot plan). SEEPAGE PIT Size: "Niffibar of pits: Diameter: Liquid depth: y. Bottom of seepage pit elevation: pfri`~ Area Built: Has either a drop box O r distribution box O been used on any of the above soil o' absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, Q Rear, 0Ft. i Number of feet from well: Number of feet from building: Number of.feet from nearest road: Alarm Manufacturer: Inspector: Dated: Plumber on job: i.rre,rc~ License Number: ~'l3 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS L#BOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING ,MADISON, WI 53707 pq NE~,SE4-,S4,T30N-R18W MCONVENTIONAL ❑ALTERNATIVE State Planl.D.Number: (lf assigned) Town ob Richmond ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound County Road A NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER INSPECT O DATE. Wa ne Wi,6eman 1505 S. GaA6ietd, Sioux Fad, SD 57105 /a, /2- /.3O BENCH MARK (Permanent reference pomil DESCRIBE IF DIFFERENT FROM PLAN REP. PT. ELEV.: CST REF PT. ELEV Name of Plumber MPIMPRSW Na C-umv samtary Permit Number: Caf,vin Poweekz Jh. 1563 St. CIII 112817 SEPTIC TANK/HOLDING TANK: MANUFACTURER LIQUID CAPACITY TANK INt FT ELEV TANK OUTLET E LEV. WARNING LABEL LOCKING COVER y.. /~~'~J~ P,ROOVIIDED PROVIDED i t `(~JCJ I~ YES ONO DYES NO BEDDING: VENT DIA. VENT MAT( HIGH WATER NUMBER OF ROAD: PROPERTY WELL BUILDING: VENT TO FRESH ALARM LIN AIR INLET FEET FROM F~ - - ❑YES NO I NEAR 15 O v~ DYES ONO EST DOSING CHAMBER: MANUFACTURER BEDDING LIDUIOCAPACITV PIIMP MOUE 1. P MP SIPHON MANLII ACIURLH WARNING LABEL LOCKING COVER PROVIDED PROVIDED DYES ONO OYES ONO DYES ONO GALLONS PER CYCLE: PUMP AND CONT LS OPE TIO NUMBER'OF PH()Pf HTY WELL - BUILDING VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) OY S NO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moistureat the d th of plowing I I IIIAME TEH MATEHIAI ANDMARK IN(, or excavation. (If soil can be rolled into a wire, construction shall cease until EaRCE _ MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: _ _ WIDTH LENGTH NO OF IASTH PIPE SPA(JN(. CnvFH INSIDL DIA -PITS LIQUID BED/TRENCH. THENCIIFS bt EfuAt PIT DEPTH. DIMENSIONS $ 7 G AVFLD H FILL DEPTH UISTH PIPE DISTH PIPE DISTR PIPE MATERIAL NO ISTH NUMBER OF : PROPERTY WELL BUILDING: VENT TO FRESH BE L.OW PIPES ABOVE COVER E I E V INI.I 1 V PIP S LINE AIR INLET. <j, I I FEET FROM ~1 NEAREST MOUND SYSTEM: I Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. DYES ONO I OIL COVER TEXTURE PEIIMANINTMARKERS ORSERVATIONWELLS OYES ONO OYES LINO DEPTH OVER TRENCH BED DEPTH OVER TRENCH HEU UFVTIf OF TOP$DII til )I1 Of I) Sf f UFO MULCHED CENTER EDGES DYES ONO DYES ONO DYES ONO PRESSURIZED DISTRIBUTION SYSTEM: . WIDTH LENGTH NO.OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVEH BED/TRENCH TRENCHES. DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR PIPE MANIFOLD MATERIAI NO UISTH DISTR PIPE DISTRIBUTION PIPE MATERIAL & MARKING 'FLEV. ELEV DIA ELEV. PIPES DIA ELEVATION AND DISTRIBUTION HOLE SIZE HOLE SPACING DRILLED COHRECT L Y COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED LNFORMATIf►N PLANS COMMENTS: n PERMANENT MARKERS. OB OVATION WELLS. FEETBFROMF PRNOOPERTEYS WELL: DBIUIOLDING: III O ~ 2 a D YES ONO D YES NO INEARE$T~ O li ,i .1 G Sketch System on G, Retain in county file for audit. Reverse Side. $E6N.\TU11E n TITLE DILHRSBD6710(R.01/821 `~\\DQ~ l,t Zaning Adminibltaton (~H SANITARY PERMIT APPLICATION CO"~ C,~v o~ In accord with ILHR 83.05, Wis. Adm. Code STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than STATE PLAN 1.0. NUMBER 8% x 11 inches in size. -See reverse side for instructions for completing this application. PET= 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑ YES Q9 NO PROP RTY OWNER PROPERTY LOCATION Se « L114- '/a, S T~ N, R E (or) PROOWNMAILING ADDRESS LOT NBLOCK UMBER SUB VISION NAME /S45 S ~q w fie l~ CITY, STATE ZIP CODE PHONE NUMBER ITY NEAREST ROAD LAKF,013 LANDMARK 5 3,41A14 VILLAGE SifoDr)( 1(4, 6) LW TOWN OF- 114.0,Ak 11. TYPE OF BUILDING OR USE SERVED: /aztt'' ` X77 - go 690 Number of Bedrooms if 1 or 2 Family OR ❑ Public (Specify): Ill. PURPOSE OF APPLICATION: (Check only one in #1. Check # 2,3 or 4, if applicable) 1. a. ❑ New b. [Kil Replacement c. ❑ Replacement of d. ❑ Reconnection of e. ❑ Repair of an System System Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit # Date Issued 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in #1 and only one in #2) 1. a. 7I I,a.l Conventional b. ❑ Alternative C. ❑ Experimental 2. a. ❑ System- b. ❑ Holding c. E1 Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. ® seepage Bed b. ❑ seepage Trench c. ❑ seepage Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 14. ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): Feet ® Private El Joint ❑ Public VI. TANK CAPACITY Site in gallons Total # of Prefab. Fiber- Exper. INFORMATION New Nan Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank Lift Pump Tank/Si hon Chamber VII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installati f the private sewage system shown on the attached plans. Plumber's ama (Print): P mlomer'sSign ure: o Stamps) MP/MPRSW No.: Business Phone Number: AY 1 _ 0) ~J S Pum is Ad ress (Str et. City, S te, Zip Code): Name of igner. VIII. SOIL TES INFORMATION Certi 'ed it Teste ST) Name CST # sr9 CST IS ADDRESS (Str t, City, te, Zip Code) Phone Number: 7i IX. COUNTY/DEPARTMENT USE ONLY Disapproved T ry Permit Fee Groundwater ate uing Agengnature (No mps) N Approved ❑ Owner Given Initial v rcharge Fee e lo.,R 9 '1 ()6 410 Adve a DeteLU X. COMMENTSIREASONS FOR DISAPPROVAL: U SBD-6M (formerly Plb-67) (R. 03/86) DISTRIBUTION: Original to County, One Copy To: Bureau of Plumbing, Owner, Plumber ff11 ~ P,iis I~ePt of Safeb/ :C4 i of c ~ F_^,Oati gage _j o' -~1.- Divi ion of ~n et/ and P_siidings - ~plx tY ,,rri~nre ~til~h ~cde - r~EV00Pm~n~ county C~'~ ~^a , At:ach ccrt~p6~z ~ e ss V is r x include but-ttm-M'T"i~ Fd sO vei I~Cal arc! e ~<ai r ei ~e ~n ~n ! barrel i.C~ percew slope.caic, n, rlimelr,lion,- n r ? n~, o. 3+ r ~rsur .e i.<a e5t roa,~! Q C E Pfea5ef rt Revie".r by Date -reno-ai in ou~2:oc yo i pM :it e ay I ; Lai Propell.,/ Ovvne I"7~r d~a'G)n F Gh i} 2 T"' Q t3o N_ X45 f 114 S y 3p ICI R f F_ (or) W - Propeity uv'l i ~A' r . n ic,c >'a a, ~ubd- lame of t:, i t _11`15-~o'S• Plp•. - of 3-~ - 6J~6~?tocLc R.ver Vallee View: ...4t;1 ~idi6 OC1F InIbFi S;riv OllkggE: Sd-l own (\1C.al'~;SP Road F,\r'° r.~ h:VV (;o nstlnc;ior desiMI N,W rate GPD Replacement I Parent matem' cleva is p if a,r,r icab - _ - p General comments =s~g6 -'Cf&-G3r:S 7, ~e arA A+ ~j~Gl ks Tv and recomman;a''On 1 OY.Y~~ J 3 t f gs~~ Q-T w`~ b~► kk, ~A_ re s144,CC"' . ~ °orin C?o In. Soll A Lncatlun Plate ilorizon Deo"n Ii Doniinant c'r .a Poops GPM i.utlc- r onsistece ounoar _ff 92 m i Vi u7sell -oh; Q Sig. 0 P-34 r. i r ti Barir~u CI (nrmq 7 Q _ -lo-170r Depth ~ 17onun"rat D-~~SCn :,sir ! !Q. wire onsis7 icP oundary POWs i GPn/ft I in nth. n,ell I z on r SI,. fll#I - tff~#2- 7A 7 _J --}a- - - - - I- ~ I I ~ ~ f 6 l E uert 4 FOE, ) moo; ~ ~L ~ f!ti-n, #2 `~C)D 30 mg/L and TSS < 30 mgil_ ~ CST Name ("lease. l~nr'4 CS_' cumber qlress a b0~ may. ~c i .vnhmtion C~~i ducted Telephone i~li.irn!~er - - - 9D °ro~ ~-0~:~ ~il~k.M.ab ~ r. _ _ Page ~i~fy~.- 3 , ~ , ~r .o `Imi~i:~y factG UO in. _ _ Soil Application Rate - - Ho•I~ur nepti~ ~nar_ _ I~-': ~ `~,r~ - ~ nc i:;e E onei4~enge _ oundary I Poots ~ GPD/ft I I j II°~ lliunseii ~ ~ ~ SI°~ fif#i ff#fi2 ~ ~ _ - - -4- I j-- ~ T ~ `f 't R ~ ~ d r '~y ~ _~n_l..__ ~ ~ "cam' ' a ~ - - ~ - 4 a_ ~ - - _ _ - -~----t-- - - Po~~r~, ~oril ~ - ~ ~ c. elr ~ ~ i~u o hi'li#uxl ~actor_ in. So I tion Via` - A ~hc..~.., a - _ - _ I Hon~ol~ ~I ~r IC1 il~a~. I~,I ,~u n~ ~nvls~C-nce ~oundan~ Roots _~f'D~Y ' 3 C # t _j0{ ~ i. .t-_-~ ~ i..______._. t __~1 f s I 1 1 I .____-_.I. _ _ _ - J ~ I ~ ~ d t r I t 1 r. I _ 1.___.__ ' Z i ' 1 i _.._.V__.__._~__.L__.,._.. .._..-_______._,Y-.-_-_ 8onrg ~ I,,~ n , _ c ~i Iti ~c ~-~ri~r---- - in. i. _ E _ _ SGI l~ f~~DllCatl01'1 Raie H~rvrni ~ ! i J'h nor i lan ..MCI r r r- z,-~;, a~u~ ~ r pare ~onsisiance oundary Roots ~~PD/ft ~e ' Nl;1S II i. -Ji`li. If r , ~i- ~ Srr. - - , ~ ~ ~ < i _ i - s _1 - ~ i , i } -4-- ~ 9 - L_~ - {d i ~ I ~ t 111 ~ _ / ~ Q 1 0 u2nt _ ~ - _ , i ~(;I~ ~ . 3~f r 3 mg/L anc TSS ~ ? nag/I_ i}c~,t ~ _ ~emn11 ,c. ! I ~,,C;u n cal ~i,si;tv~ce i~? i _ - I1 1~, l i'I f~[)R-~/i(-., 1 i Ui' I I Y l~l l'~li i,!?~l 12.C~Ov i Prope"Omer . Alux r i' Page -oi - I J ~orin~ e Bnrinc= Flt . o„,, ALA- _es; 0 wMAing favor jag in. - ~ Soil Application Pate }lorizor Deprl", f'Yominan ,olo-I Any s,rio _ .i_r ructum ponshomce ~BoundaN I RMN GPD/ft n.. l0unsell >ior SE sn' "Eff#2 _I ` J r E ! ox, VI - Borinc'= , pit Gmun d s - E elev ep 'l tc limiting ractor_ n. Soi', Application Pate H.U. rDa t urnmais Cab Now .r w .rr- Fonsishance -oundary 1 Roots GPDIft I 3 i#k fi~2 I 70M .Nr.; _;r= Sr: I 1 ~ E I tt k r tS011.'1U - BoNg u _ i G-n.n-. same ejev -e limiti;ic iaoior_ in. - P't SOnlfcation Raie horizon Dept ' Domlran, ~oiori F^o x esc-iptni- xt❑ a M mw P onsEAMe (Boundary Roots GPDt r Munseil Ou Q-- ~ont oinr Sz_ Sh { II ff#1 `$02 i l I ~ len` - ROD 30 _ p rJ TSS 3Q _ l;l,aent #2 = BOD _ 30 mg/L and TSS _ 30 mg/I- Ti c 5c t C,1 r-; ai l'rc, cs_ ~c• ~ - 1i` sc h, o -1c7 end employer. IF~~ou ncccl a,,gi9tancc to access ?..7 1 ces o; . c A 71 W.e': , a n W „ he UCE~3i it "inn a-i 60S,-266- i 151 cw TTY flrrough Relay.