HomeMy WebLinkAbout020-1359-18-000 (2)
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
SAN-2018-076
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:
Heather Hewitt TOWN OF HUDSON 020-1359-18-000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
16.29.19.2114
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 f I
IN Q J~I~ 1
TDH Lift Friction Loss System Head T DH Ft / kw- ih 1J tA~
Forcemain Length Dia. Dist. to Well
O4
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 ID istribution x Hole Size ix 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: 937 MEADOWOOD LN Fp(~~ C~iG 7
1.) Alt BM Description = ~Q Ja S itA.~J ~a(( Weaf I>r~4e, e)
2.) Bldg sewer length = •
° Gad 'n
- amount of cover = ` 464) 5
Plan revision Required? ❑ Yes ❑ No y `
Use other side for additional information. ✓ ,
Date Insepctor' ignatur Cert. No.
SBD-6710 (R.3/97)
gnIR
P County Sanitary Permit3 Application ST. CROIX COUNTY WISCONSIN
C'0 in accord with Chapert 12 St- Croix Cowlty Sanit*.`Z RhCtunty PLANNING & ZONING DEPARTMENT
Personal information you provide may be us La &0 s~~d4dtYPDP mentSj- CROIX COUNTY GOVERNM=NT CENTER
gti~ Gr~~4 (Privacy Law. S. 15.04(1}(r)j 11,01 Carmichael Road
~p Hudson, = 5401&-7710
P
(715)386-4080 Fax (71151386-4586
Attach complete plans for the system on -paper not less than 8--1 /2 x 1 1 inches in size.
County S~itary Permit # E❑ Check if revision to Previous application
l$"- 0710
t. Application Information - Please Print all Information Location:
ProPe-t y Owner Name /
q L+-'~, i %4 i i4, Sec r 4J
l L 1: cy -)V-crL `,W'•`j N, R j f (or)Vv
rty Owner's Mailing Aodress Lot Number ' Block Number
City, State Zip Code Phone Numer SS ,sion Name or CSIV Number
W Cx~ 541 t>r!
tl Type of Building: (check one) E ity ❑ `t'illage 5`Town of
❑ I or 2 Family Dwelling - No. of Bedrooms: _JW) ❑ Pubiic/Commerciai (describe use). A/
❑ State-owned Nearest Road
11. Type of Permit: (Check only one box op line A. Check box on line S if appiicable) r- .9 L7 "
Parcel Tax Number(s).
wig-C<~
1.I & Repair 2. ❑ Recon, ection 1i ]Non-piumbing 4. ❑ Rejuvenation
Sanitation ry 3C_
Permit Number Date Issued
State Sanitan Permit was previously issued C
IV. Type of POWT System: (Check all that apply) O~ A
Non-pressurized in-ground ❑ Mound ? 24 in. suitable soil ❑ Mound 24 in. suitable soil i=i Mound A o
Sand Fitter ❑ Constructed Wetland ❑ Feat Fitter ❑ Drip one
❑ Pressurized In-ground ❑ Holding Tank ❑ Single Pass ❑ Other
❑ Al-grade Aerobic Treatment Unit ❑ Recirculating
V. Dispersal!Treatment -,a information: .w c ,rv - 24 - ;2 c c
1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Pate 5. Percolation Rate c. System Elevaiion Z Final Grade
Required Proposed (Gals./day!sq.tt.'., (Min.linch) Elevation
`7 s -7
VI. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic
New Existing Gallons Tanks Concrete structed glass
Tanks Tanks
1 IUL ® ❑ ❑ ❑ ❑
VII. Responsibility Statement
the undersigned; assume responsibility for repair/reconnenctionirejuvenation/installation pf non-piumbing for the POWTS shown on the at ached plans. A
license is not reouired for teralift repair or the installation of non-Plumbing sanitation system.
Plumber's Name (print; Plumb is Sianature (no camps): MP/MPRS No. Business Phone Number
b3RL'fF_ AIFc14N V-LE e~Z771c7
Plumber's Address (Street, City, State. Lip Code) 7 2Z6- (vbJ 2
VIII. County Use Only 17 X
tDisapproved Sanitary Permit Fee "ate I ued tssui Agent SiOna (No + ps)
Apprpved Owner G n Terse ZZS QQ /
ination ,J
tX. Conditions of Approval/Reasons for Disapproval:
(r fe w J~ ~
C". elAA,
I
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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Safety and Buildings Division
SANITARY PERMIT APPLICATION 201 W. Washington Avenue
Visc®nsin P O Box 7162
Department of Commerce In accord with Comm 83.05, Wis I 2 Madison, WI 53707-7162
• Attach complete plans (to the county copy only) for the sys `papenot sv' ounty
than 8 1/2 x 11 inches in size.
R
~ • See reverse side for instructions for completing this app{4k-atibn ECEIVED Sanitary permit Number
3636`~i
Personal information you provide may be used for secondary purposes F ` ;r ( 200 k it revision to
i lPrivacy Law, s. 15.04 (1) (m)]. prev ous application
ST CADX 1818 Ian Review Transaction Number
1. APPLICATION INFORMATION - PLEASE PRINT Li'Wf
Property Owner Name
A?hX*-d 6 1/4 T , N, R E (or W 1 /10 Property Owner's Mailing Addr L ~ m L Block Number
1108 City, State Zip Code Phone Number Subdivision Name or{SM Number
E .55 2.83 )S
I. TYPE OF BUILDING: (check one) ❑ State Owned ❑ city Nearest Road /
Public 1 or 2 Family Dwelling - No. of bedrooms ❑ Village of
111. BUILDING USE: (if building type is public, check all that apply) Parcel Tax Number(s) 14, ) q 9) 1 y AJAA4J- CV--V-
1 ❑ Apartment/ Condo (I. _113 ~0 9 Q2 O 'go /,357-/6 -W
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ 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. 1A New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of S. ❑ Repair of an
System _System_____ TankOnlyExisting System Exlstii2g5yfstem
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 14-to 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 KLSeepage Trench 22 In-Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit StaW~O~~ 43 ❑ Vault Privy
14 ❑ System-In-Fill - 7 3.2
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) Elevation
7-s'n 76 3, tweet Feet
Ca aat
VII. TANK( In alto s Total # Of Prefab. Site
Fiber- Exper.
INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
New Existin structed
Tank Tanks
Septic Tank or Holding Tank 12-00 pd 1 u - ® ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ; , ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plu is Sign ture: (No tam s) MP/MPRSW No.: Business Phone Number:
IaAL'A ~g&Aku 19, /
Plumber's Address (Street, City, State, Zip C de):
i4 E 112- Ivn
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved itary Permit Fee (Includes Groundwater a e $sue Issuing Agent Signature (No Stamps)
Surcharge Fee)
'Approved ❑ Owner Given Initial
Adverse Determination a~ V~ Z2`
X. CONDITIONS OF APPRO L / REASONS FQR DISAPPR VAL:
44
,I
SBD_6398 (8.12199) DISTRIBUTION; Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County:
/ Safety and Buildings Division
INSPECTION REPORT St. Croix l
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Personal information you provice may be used for secondary purposes [Privacy Law, s. 15.04 (1)(m)j, 363894
Permit Holder's Name: City [3 Village ❑ )jown of: State Plan ID No.:
aCasse. Richard ❑ Hudson Township
CST BM Elev.: Insp. BM Elev.: BM Description: r ' Parcel Tax No.:
,.ZS f m 020-1359-18-000
TANK INFORMATION ELEVATION DATA l6t(. 0 ~rP ~Q. l9 a f14
TYPE MANUFACTURER CAPACITY STATION ,~S o' o F5 r&4v-
Septic Benchmark
Dosing Alt. BM ~.35 $ (oS f
Aeration Bldg. Sewer
Holding St/Ht Inlet ~o.s3 Y/ '
TANK SETBACK INFORMATION St/ Ht Outlet
Verit
TANK TO P/ L WELL BLDG. A
ir Ito ntake ROAD Dt Inlet
Ar
Septic > $p ( Z~ r NA Dt Bottom If 35-
r' .(o r
Dosing t' NA Header/Man. (a t $"U 9~, ~r
.aZ
Aeration NA Dist. Pipe o G •9
Holding Bot. System -7, G, gam.
PUMP / SI HON INFORMATION Final Grade
Manufacturer Q [2 d St cover ,3-0
q. r
ry Model Number p c f ~PM
` I
p DH Lift$S Friction's 31' Mesa emr TDH Forcemain Length 95"1 Dia. 2 " Dist. To Well
SOIL ABSORPTION SYSTEM Z~
RENCH Width , Length _ No. Of renches PIT No. Of Pits Inside Dia Liquid Depth
DIME 3 ~y DIMENSIONS
LEACHING Manufac er:
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM
INFORMATION TypeO CHAMBER Model Number:
System: xA), 'S # 8 OR UNIT
DISTRIBUTION SYSTEM
Header/manifold u Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia gth Dia. paling 7 9 6 '
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 C] No C] Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1:64/0Inspection #2: ---f--
Location: 937 Meadow Lane, Hudson, WI 54016 (NW 1/4 SW 1/4 16 T29N R19W) - 16.29.19.2114 Parkwood Meadov s -
Lot
18
1.) ) Alt BM Description
2.) Bldg sewer length=
-4 -amount of cover p,JS /
S 5 J..1L0
Plan revision required? ❑ Yes No
Use other side for additional information.
SBD-6710(R.3/97) Date Inspector's Signature Cert No.
SEPTIC TAI~TK ST. CROIX IMALNTENAN CE AGREED-', T L n IE C[E N IE D
3
AND
OWNERSHIP CERTIFICATION FORM MAY 0 2 2018
I St. Croix County
dwIler/BuVer ic CSR 'f~?~ i c Communit Development
Mailing Address C17)-i f'1'~ Xce c ~ c =c ~ ~l ~ ~ cl ~ 4 ~ i ~Z/rte/
Property Address
f dd (Vezrincation required from Planning & Zoning Department for new, cons a on.)
City/State Parcel Identification Number
LEGAL DESCRIPTION
Prope_rlty Location V4 . 1/4 , Sec. T N R W, Tovvn of
Subdivision Plat: , Lot
Certified Sun ey Map ,Volume , Page #
NN, arranty Deed r (before 2007)Volume , Page #
Spec house D yes D no Lot lines identifiiable D yes D no
SYSTEM NLALNTTE-NT_AINTCE AND OYVNTER 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 ctrfication 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 RT 2sconsm- Certification stating that your septic system has been maintained must be completed and retuned to the St. Croix
County Planning & Zoning Department within 30 days of the three year expiration date.
liwe certify that all statements on ' form are true. to the best of my/our lmowledge. I/we am/ar. the owner(s) of the
proptrry described above, by virtue of a w ty deed recorded in Register of Deeds Of15ce.
Number of bedrooms
SIGNATURE OF APP~ICANTT(S) DATE
Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoring Department
Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certined survey map if
reference is made in the w=ty deed
(REV. 04/12)