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HomeMy WebLinkAbout020-1334-10-000 (2) Wisconsin Department of Commerce County: Croix St. PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 605030 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: Ronald & Cynthia Smith TOWN OF HUDSON 020-1334-10-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: f 3 r 27.29.19.1761 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. 4rtvr l Septic Benchmark IOvsang Alt. BM,-..- Aeration Bldg. Sewer St/Ht Inlet \ }ioldifg . St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Ot Inlet t ry j. ptic E~s~su _ Header/Man. Li Ll i A, Aeration Dist. Pipe Holding _ Bot. System; PUMP/SIPHON INFORMATION Final Grade Manufacturer Demand St Cover ~c 1 r ~0 r GPM 1 f Model Num r L~ TDH Lift oss System Head T H Ft Forcemain Length Dia. te,Wefl SOIL ABSORPTION SYSTEM BED/TRENCH Widtl;„_ s Length No. Of Trenches PIT QIME)FfiIONS No. Of Pits Inside Dia. Liquid Depth_ DIMENSIONS C r - SETBACK SYSTEM TO P/L BLDG WELL LAKt !STREAM LEACHING Manufacturer; I INFORMATION CHAMBER OR i yam' 1 + i t ° Type Of System. t r UNIT Model Number. DISTRIBUTION SYSTEM r 't~ 1 Header/Manifold Distribution x Hole Size x Hole Spacing Vent Air Intake ti Pipe(s) - , Length Dia ` Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth over T Depth of Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges psoil - - E] Yes No Yes— [ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 665 RED MAPLE LN 1.) Alt BM Description 2.) Bldg sewer length = - amount of cover Plan revision Required? ❑ Yes ❑ No f` Use other side for additional information. Date Insepctor' S' na re Cert. No. SBD-6710 (R.3/97) L-_1 U County 2~1 Safety and Buildings Division 1 r^ I y r K N 4 2018 + 201 W. Washington Ave,, P.O. Box 7162 Sanitary Permit umber (to be filled in by Co.) Madison, W1 53707-7162 sir n OO x (J'~1ll~y * , 05 030 elopment n2 - . S=Transactio Number ation 1f: anitary Permit Appli In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate gov ental unit is required prior to obtaining a sanitary permit Note: Application forms for state-owned POWTS are submitted to Project Ad s (if different than ing s) the Department of Safety and Professional Servies. Personal information you provide be used for secondary purposes in accordance with the Priv Law, s. 15.04(1 m), Stats. C--. 1. Application Information - Please Prin All orma ' J Property Owner's Name Parcel ~~111- ~77r, Property Owner's Mailing Address Property Location a1 ' a 1-7 I / / ' CZ L ^ c.r 111 Govt Lot City State / Zi e Phone Number / 1/'='/,, Section F t 1 sclc ,o~ Ype of uilding (check all that apply) Lot T L-_ ! N' R E ~ J Family Dwelling-Number of Bedroo Subdivision Nove AGE. Bloc t ~C ❑ Public/Commercial - Describe Use ❑ City of ❑ Statee~Owned - Describe Use t CSM Number ❑ Village of LA.) /10 ~lo -own of v III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. Q New System lacement 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 Issued Before Expiration Owner 3 Zb 7 / ~Q~ P-T. e ofPOW TS System/Component/Device: Check all that a 1 l G• O Press urized In-Ground El Pressurized In-Ground ❑ At-Grade 11 Mound > 24 in. of suitable soil [I Mound < 24 in. of suitable soil 11 1-Iolg Tank Other Dispersal Component (explain) Pretreatment Device (explain) 7- V. Dis ersal/Treat ent Area Information: Design Flow (gpd) Design Soil Application Rat dsf) Dispersal ea Required (s Dispersal Area opo d (sf) System Elevatio VL Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units New Tanks 7Existing Tanta ram v U l c d ar i 1'C V c J4Q U° y cn P ca ~L Septic or Holding Tank n r I Dosing Chamber VII. Iiesponsibifity Sta ent- 1, the undersigned, a e responsibility for installation of the POVM shown on the attached plans. Plumber's Name (Print) PlluurPb ignature MP/MPRS Number Business Phone Ntun~w Plumber's Address (Street, City, State, Zip Cod { Countv/De artmen Use Only Approved 11 ,sapprove Permit Fee Date lssu Issuing rnt gnahn e Q, Owner 435en Reason for a_ L IX. Condi ' asonsoir ~iVpproval ! . ,S tank, bm. ! r P uisper:•s,i cell must all _bS_Sq as ! tm l itW' tt as per mar.agement plan ptoikieti by pluwnber. 1 i 2. AU Reft * ri,c,.t~wflerats min;t«I+e r.:a;rt:.ir:E U per 1b1:! 0461 I:. (EM31091. f~ t cW1bl# 0461 I ~.ttlilta;tcaR f Attach to compie2e plans for the system and submit to the County only on paper not less than 8 in x 11 inches in size SBD-6398 (R. 11/11) System PLOT PLAN PROJECT Ron Smith ADDRESS 665 Red Maole Lane Hudson Wi 54016 SW 1/4 NE 1/4S 27 /T 29 N/R 19 W TOWN Hudson COUNTY ST. CROIX SYSTEM ELEVATION 94.0/93.9 5' below grade DATE 5/31/18 BEDROOM 3 CONVENTIONAL XXX CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 651 # of chambers 32 BENCHMARK V.R.P. Top of foundation ASSUME ELEVATION 100' Filter Lifetime Filter ❑ BOREHOLE t~ WELL *H.R.P. same as benchmark Red Maple Lane 22 Property Line Vent >6" Quick4 Standard of Cover Leaching Chamber 3 Bedroom with 20.0 ft2 of Area House 5.6ft^2/pair of end caps B.M.* 4' Long 12" Grade at System Elevation 34' ` All piping shall be ASTM SDR 30/34, within 41' 0' of tank, giping shall be ASTM F891 34' T Valve o B-1 Filter Tank 15' ILA 20' 3 B-4 Vents 25 15' B-2 100' Existing system draining slowly 2-3' X 66' cells with >3'spacing There are currently 2 soils tests on this property in the same location, further testing should not be required j C 0 P Cover Page Shaun Bird Bird Plumbing Inc. 1432 120th St. New Richmond Wi 54017 715-246-4516 Date: 6/1/18 Owner:Ron Smith Location: SW 1/4 NE 1/4 S 27 T29N,R19W 665 Red Maple Lane Hudson Manuals Used: In-ground absorbtion system (version 2.0) Page# 1. Cover Page 2. Plot Plan 3. Chamber Cross Section 4.6. Maintance and ntigency Plan 7. Filter Cross Se4i i 6r i 8. Existing Septic ink Form Signature Licenseiu er #226900 System PLOT PLAN PROJECT Ron Smith ADDRESS 665 Red Manle Lane Hudson Wi 54016 SW 1/4 NE 1/4S 27 /T 29 N/R 19 W TOWN Hudson COUNTY ST. CROIX SYSTEM ELEVATION 94.0/93.9 5' below grade 5/31/18 BEDROOM 3 DATE CONVENTIONAL XXX CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 651 # of chambers 32 BENCHMARK V.R.P. Top of foundation ASSUME ELEVATION 100' Filter Lifetime Filter ❑ BOREHOLE O WELL *H.R.P. same as benchmark I Red Maple Lane Scale = 1/4" = 10' Property Line Vent >6" Qu1ck4 Standard of Cover Leaching Chamber 3 Bedroom with 20.0 ft2 of Area House 5.6ft^2/pair of end caps 12 B.M.* 4' Long Grade at System Elevation 34" All piping shall be ASTM SDR 30/34, within 41' 34' 10' of tank, piping shall be ASTM F891 B-5 55' T Valve B-1 Filter Tank 0 , Ar" 15' 5' 0' 20' B-3 B-4 15' Vents 25' B-2 100' Existing system draining slowly 2-3' X 66' cells with >3'spacing There are currently 2 soils tests on this property in the same location, further testing should not be required Cross Section of Infiltrator Quick 4 Leaching Chamber Typical cross section for 2 of 2 cells Quick 4 Standard Leaching Chamber with 20.0 ft2 of Area per Chamber 5.6ft^2 pair of end plates To be >1' above grade / Finish grade elevation Typical Installation 99.2' Vent A CI Vent 3' 4„ 3' A~~30/34 Septic Tank " 5' Long 1 5' 5' Long 1 Grade at System Elevation 36" Grade at System Elevation Spacing 5' 2-3' X 66' Cells Same on other end Observation tubeNent At end of cell A B 16 chambers per cell System elevations: A-94.0' B-93.9' POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION Owner SYSTEM SPECIFICATIONS Septic Tank Capacity al ❑ NA Permit # Septic Tank Manufacturer ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer \ Number of Bedrooms ~h ❑ NA Effluent Filter Model Number of Public Facility Units DNA ]NA Pump Tank Capacity j Estimated flow (average) al ~ ! 'S L Pump Ta nk Manufacturer NA i Design flow (peak), (Estimated x 1.5) gal/day Pump Manufacturer NA Soil Application Rate ai/da /flz Pump Model Standard Influent/Effluent Quality MonthlY average* Pretreatment Unit NA Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter 0 Peat Filter Biochemical Oxygen Demand (BODS) 420 mg/L ❑ NA D Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 m g/L ❑ Disinfection ❑ Other. !Pretreated Effluent Quality Monthly average ~Znn--Ground rsal Cell(s) Biochemical Oxygen Demand (BOOS) 530 m ❑ NA g/ (gravity) ❑ In-Ground (pressurized) Total Suspended Solids (TSS) 530 mg/L ❑ NA ❑ At-Grade Fecal Colifonn (geometric mean) 5104 cfu/100m1 ❑ Mound ❑ Drip-Line ❑ Other: Maximum Effluent Particle Size ❑ NA other. l!3 in dia. Other. ❑ NA ❑ NA Other: D NA *Values typical for domestic wastewater and septic tank effluent Other. ❑ NA IAINTENANCE SCHEDULE ~ Service Event Service Frequency Ilnspect condition of tank(s) At least once every: ❑ month(s) _ears (Maximum 3 years) ❑ NA (Pump out contents of tank(s) When combined sludge and scum equals one-third {'!3} of tank volume ❑ NA (Inspect dispersal cell(s) At least once every: Q month(s) rY' ' ear( s) (Maximum 3 years) ❑ NA Olean effluent filter At least once every : earth(s) ❑ NA Inspect pump, pump controls & alarm At least once every: 0 month(s) NA -lush laterals and pressure test At least once every: ❑ month(s) tither. ❑ year{s) NA At least once every: ❑ month(s) ether: ❑ year(s) NA NA MAINTENANCE INSTRUCTIONS !Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: aster !Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspectio s must linclude a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of c;ombined 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 Iegulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third or more of the tank volume, the entire contents of !:he tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. 1411 other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, land any servicing at intervals of <12 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory autho6ty within 10 days of completion of any service event. Page of START UP AND OPERATION For new constriction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other c~m~rmicais th~}t may impede the treatment process and/or damage the _dispersal cell(s). If high concentrations are detected have the contents of thO tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will ble discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of efttuenL To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump contols to restore normal levels within the pump tank. Do not drive or park Vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWT$' antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; diswdbctwts; fat; foundation drain (sump pump) water, fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting produc0s; pesticides; sanitary napkins; tampons; and water softener brume. ABANDONMENT When the POWTS falls and/or is permanently taken out of service the following steps shall be taken to insure that the system is propetiy and safety abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code:. • Ail piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN ' If the POWTS falls and cannot be repaired the following measures have been, or must be taken, to provide a code comp6mrrt replacement system: O A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption systel m. The replacement area should be protected from disturbance and compaction and should not be infringed upon by requhled setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the neled for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rute$ in effect at that time. O A suitable replac mnent area is not available due to setback and/or soil limitations. Barring advances in POWTS technologN a holding tank may be installed as a last resort to replace the failed POwrs. ---The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a sort and site evaluatjion must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed) as a last resort to replace the failed POWTS. C1 Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. «1NARNiNG>> SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES ANDIOR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TAN UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE O1 A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL C ENTS i U rJ4 S' U > POWTS INSTALLER POWTS MAINTAINER Name, Name ! } 1 cz , Phone Phone r ~'f SEPTAGE SERVICING OPERATO PUMPER LOCAL REGULATORY AUTHORITY Name _77 Name s , Phone , ? c c t6 Phone This do u mentwas drafted in compliance with chapter SPS 383.22(2)(b)(%d)&(f) and 383..54(1), (2) & (3), Wisconsin Administrative Code. N O. ~ Il~fl~ttl{i', _ Imo- -1 f1 . rl I ! ( I ~ I fF iit~il} ft ~ rt I I I, -----J i ~ P E O ~ I I P S J I- ~ 10 i/ LA- I - S , C CID Cr f~ i _ , ST, CROYX COUMTy CERTIPICATZon ZOMZNG OPPICP OR UTILIZATION STATEMENT OP AN tXISTTNG SEpI,I-e TAN 1.'Yzis x K to certify that erving the I h e N 2 5 n / inspected the septic tank Sectio " - res . Preserztl.y the tank Upon~ ~ T N, R ee n z'r located rst:; and baffles to be innSPeCtion - W' 1 Owri 0f- functioWi r certi fy that I have ng properly good condition, and it rottnct appears to he r..,ast time serviced: rvy~ t low back occur from Yes a bs o rption s _ - APProxi No (Tf no, vo ~ Skip next 1 ine}, !.:~Ipacity; or length o f time: gallons "o - m-1rlut.c~;; nstruct.ian: Prefab Concrete !'dIt"faC _ Steel turer: (If known): (e ~7 other ank (If known) c, nature) ' c (I'itl (Name) pl ase print'`'--- - e) r; - - umber) Po '7" to be Statutes) or completed by lice Code) Licensed Disposer ( s NR Plumber (s.245.06 113 Wisco wiscorzSin _ _ - nsin Administrative !'lumber (applying for sanit _ ~ - _ - :Cri acceptjn ary Permit) Certification; Candition g the above statement re conform to theertify that the tank to gardirz axis inspect; n requir meets of ILHR the st of my ing septic tank opening r outlet 83, . Adm. knowledge t tan Name baffle Code (except foz signater _ MP/MPRS ~ ~ ST. CROIX COIUNI- SEPTIC TANK MAINTENANCE -1'iGREEMENT AND OWNERSHIP CERTIFICATION FORM: Owner/Buyer Mailing Address > - - Property Address {Verification required from Planning & Zoning Department for new construction.) City/State - - Parcel Identification Nui zber ~a o ~5 ce` ) LEGAL DESCRTpTION G/ Property Location/ '/4 , Sec. n T N R~r' - W, Town of' Subdivision Cr Certified Survey Map # _ Volume , Page # Warranty Deed # { Vo lulne , Page # Spec house ye no Lot lines identifiable yes \nI SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance maintenance consists of your septic system could result in its pre sept maore failure to handle wastes. Proper of pumping out the ic tank every three years or sooner, ii needed, by a licensed u ou put into the system can affect the function of the septic tank as a treatment stage in the was [e disposal system owner ~maintenance responsibilities are specified in §Comm. 83,52(]) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification fo owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site signed by the wastewater disposal system is in proper operating condition and/or (2) after inspecdion and pumping (if necessary), the septic tank is less than 1 /3 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal systern with the standards set forth, herein, as set by the Department of Certification stating that your septic system has been maintained must be complete and returned to the Stec Croix Coun Wisconsin. Zoning Department within 30 days of the three year expiration date- tY niiiug & I/we certify that all statements on s form are true to the best of my/our h nowiedge. I/we arri/are the owner(s) of the property described above, by vjzr~q of a rranty deed recorded in Register of Deeds Office. Number of bedrooms - - S ~'NTURE OF APPLICANT(S) DATE **Any information that is misrepresented may result in the Sanitary permit being r.-;voked 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. 08/05) ` i v <J L 2.07 ACRES 83.82' 89,965 SQ. FT. 23 _ • i / • • 2.20 ACRES 67, w 95,702 SQ. FT. Q/ cy -9 )01CA~ i . / 2 O• c D ~ H.W.L. 936.0 ti so Ln s4. i ° 3149 Fes: w 22 1 20 a' 21 0 3.90 ACRES 170,077 SQ. FT. 2.00 2.06 ACRES 87, 127 SQ.EFT. 89,597 SQ. FT. 316.80' 194.35' 122.45' 299.63' 22f 3267.18 TTATnr Arrrrwn ST. CROIX COUNTY ZONING DEPARTMEN AS BUILT SANITARY REPORT RF~'ED , to DEC 1 C Owner 5,4 /M f'j Z (L L Fr'L 1998 Address !o &Ey rp 1 H )OL F L A K E s sr coax City/State E { ytl <,,3A ~_k} ( f o ! ~2_ ZOIWNGOFFICF Legal Description: Z Lot I Block - Subdivision/CSM #241) L,4 Nb &4 k 1 %4 mow'/e Sec. 27 , TAN-RAW, Town of Hu'c). C+ N PIN # 62-0 -01q - 10 -SST C T DOSE CHAMBER HOLDING TANK INFORMATION: Tank manufacturer W 15 ( JF k- Size ST/PC I WO / Setback from: House Well P/L-~ S Pump manufacturer Model Alarm location (HOLDING TANKS ONLY) f Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM: Type of system:U F ( (T le PDAMidth 3 / Length S, Z S Number of Trenches - ,7-Setback from: House '14 ' Well lir, C• P/L A."7 Vent to fresh air intake ELEVATIONS: Description of benchmark T-6 P a F l aC ,t fcwN 7 0 1,(,?, Elevation to d, 0 / Description of alternate benchmark -1-0 P g,.r 144)1 1464.E Elevation 2_ Building Sewer ST/HT Inlet ,3 ~S S Outlet PC Inlet PC Bottom Header/Manifold Top of ST/PC Manhole Cover i Distribution Lines $ 8 = y~() , g 2- = q`~' ) I Bottom of System( W.5.5-Z4 3107 O /d = 3, 7 ( ) Final Grade =q~ Z/ ( ) Z r % aL ( ) Date of installation 10/ I S/ IkPermit number 52,O 2S6 State plan number Plumber's si nature jLd_L, License numberfdee iPT -d 3.fVO Date /0 /11 /7 ? Inspector Complete plot plan R NOTICE: Please provide the following: • A plan view sketch showing everything within 100 feet of the system. • Two horizontal reference points to center of septic tank manhole cover. • Show alternate benchmark, if applicable. PLAN VIEW S c ~4 LE 'if 0 y57 z-LF~,-~: H wirAlc Al D ?NF~~7~2~47a a. 9-E.4eA i ~f-7ot4/ A046 L t_ II Narsf 3q, 4~ SS i t A ~ NOTr : C vT To Q E 0i NDt, o AITFP 1(#Tf t+XfA INDICATE NORTH ARROW i I i Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM 'Safety uAd Buildings Division County INSPECTION REPORT ST. CROIX ' GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Persairial information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)). 320256 Ile Permit Holder's Name: ❑FjDSO Uy ❑ Village Town of: State Plan ID No.: MILLER, SAM N CST BM Elev.: Insp. BM E ev.: BM Descriptio Parcel Tax No.: le6 r / 020-1334-10-000 TANK INFORMATION ELEVATION DATA A9800445 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Bench ar4 Dosing _ 4 74 7- Aeration Bldg. Sewer Holding tt/P t Inlet °f Z2 TANK SETBACK INFORMATION JW)~ft Outlet 3--72 TANK TO P/ L WELL BLDG- Ventto ROAD Dt Inlet Air Intake Septic '_S J3'' NA Dt Bottom Dosing NA Header/Man. f9 -A, Aeration NA Dist. Pipe Holding Bot. System 07 PUMP/ SIPHON INFORMATION Final Grade 4 ~j Z•_ Manufacturer Demand 72- Model Number GPM TDH I ti Loss i7e"a"d... H Ft I Forcemain Len Dist.Towe SOIL ABSORPTION SYSTEM BED / TR NC Width / Length No. Of Trenches PIT No. Of Pits I ep 112M ' Z 2 DIMENSIONS SETBACK SYSTEM TO P/ L BLDG WELL LAKE / STREAM E CHING anu act rer: INFORMATION Type o I / CHAMBER model unj er: ! L LZ- L► System 3q so DISTRIBUTION SYSTEM Header / Manifold ~r Distribution Pipes x Hole Size x Hoe Spacing Vent To Air Intake Length _ Dia. Lengthy Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over _De~th•Qyei - xx Depth OfV xx Seeded/Sodded xx mulched Bed /Trench Center _ Bed / Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON 27.29.19,SW,NE 665 RED MAPLE LN-BADLANDS PR LOT 21 Alf. ~►'+n - ton Cfb W-01-" (,OVrfA- 4 Plan revision required? ❑ Yes R1 No Use other side for additional information. I I L l f SBD-6710 (R.3197) Date Inspector's Signature i Safety and Buildings Division SANITARY PERMIT APPLICATION 201 W. Washington Avenue 1*"nsin P O Box 7302 Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707-7302 • Attach complete plans (to the county copy only) for the system, on paper not less County c,q than 8 u2 x 11 inches in size. Dt • See reverse side for instructions for completing this application StateSanitaryyPerrmitt Number Personal information you provide may be used for secondary purposes check if reviwn oopr90F.Prarion [Privacy Law, s. 15.04 (1) (m)). &45 aoe Lahti tmm Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Pr e y caner a ropert Location 51/4 j 114, S Z7 T Z41 , N, R it? E ( W In T P rty Ow~r er's Mailing Address N Nuu mber Block Number Lt FLI'tZ C iState Zip C1,soe7ako Phone Number Subdivision Name or CSM Number SON w (x)-v > P Ill. : (check one) ❑ State Owned 0 !tl Nearest Road Public 1 or 2 Family Dwelling - No_ of bedrooms I Town OF 14k)j) 0 4al- FAE/U 111. BUILDIN SE: (If building type is public, check all that apply) Parcel Tax Number(s) ^n• ~b• / 1 ❑ Apartment/ Condo ©2 O - /33 d - /0 GCY 7 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 ❑ Mobiie 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 on line B, if applicable) A) 1 New 2, Replacement 3. [3 Replacement of 4. E] Reconnection of 5. ❑Repair of an . - SZ/stem ___-SL/stem __------System----------- Tank Only Existinc~System Exist B) A Sanitary Permit was previously issued. Permit Number Date Issued Z V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 410 Holding Tank 1236Seepage Trench :S /QLr 11A11 MIDAt 22 ❑ In-Ground Pressure ~ j 42 ❑ Pit Privy 11[] Seepage Pit 5!! INFILTkA'1oQ„ 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate S. Perc. Rate 6_ System Elev. 7. Final Grade s~ Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation Sto.3 S 7 t - 13 O Feeti 99, 1,0 Feet 1% 1 VII. TANK Ca in ga lions Total # Of Prefab. Site Fiber- Plastic Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass App. New Existin structed Septic Tank or Holding Tank Tanks Tanks ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber {M ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signaturre,Wo Stam s) MP/MPRS W No.: Business Phone Number: 1 CE c- . 49i 4 !h-r% 5.03Soo 4~►' Plumber's Address (Street, City, State, 2i Code): 0.70 10COR Pu"0214 Will IX- COUNTY / DEPARTMENT USE ONLY --N f C] Disapproved Sanitary Per it Fee (includes Groundwa er a e sue Iss ng A t Si n ure (No Stamps) A roved Surcharge Feel pp ❑ Owner Given Initial 16. Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: wsTtztstmon: SBD- 6396 (R.1119T) Original to County. One COPY To: Safety & tuNdings Division, owner. PlurnW - - - Wisconsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page of Bureau'of Integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and S ~G v~ percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # eV o- /o ?Y- YO APPLICANT INFORMATION - Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location Govt. Lot W 114 ,tv-1/4,Sv?-f T a N,R 'IQ E (ore Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# 13_1.-,? u-Ae a Yoe r' / a t ,c rL ✓ a,,'- City State Zip Code Phone Number ❑ City El Village a Town Nearest Road lJ~` h0 G G'~1i avh~ New Construction Use: Residential / Number of bedrooms Addition to existing building Replacement ❑ Public or commercial - Describe: Code derived daily flow G d 9!4., Recommended design loading rate _17 bed, gpd/ft2 • ~6- trench, gpd/ft2 Absorption area required,715 tljW d, ft2 Arench, ft 2 Maximum design loading rate , 7 bed, gpd/ft2_ -trench, gpd/ft2 Recommended infiltration surface elevation(s) 9-L a ft (as referred to site plan benchmark) Additional design/site considerations Parent material Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank U = Unsuitable for system ® S ❑ U 9s ❑ U Os ❑ U 5d S❑ U ❑ S JI U ❑ S XU SOIL DESCRIPTION REPORT Boring # Horizon jDeth Dominant Color Mottles Structure GPD/ft2 Texture Consistence Boundary Roots Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 3 6 93 3- Ground h? 3- X /ri C elev. g20ft- Depth to limiting , factor (a? O in. Remarks: Boring # j a i~ 6 3 S;' F GS bI 3 57 Ground 'elev. ~1 L 7 - -Y _ Depth to limiting ,rr7fvt+yt; , ti/ factor in. Remarks: CST Name (Please Print) c Signature Telephone No. Address / / Date CST Number SOIL DESCRIPTION REPORT PROPERTY OWNER Page a of . PARCEL I.D"!f Boris # Horizon Depth Dominant Color Mottles Structure 2 9 Texture Consistence Boundary Roots in. Munsell Cu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench P 0 VA #7d Aye Ground elev. 9~n• Depth to limiting , factor in. Remarks: Boring # ~s Ground elev. ft. Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench i Boring # 1 , Ground elev. ft Depth to limiting factor III in. Remarks: Boring # Lee Ground elev. ft. ' Depth to limiting factor in. Remarks: SBD-8330 (R. 07/96) jv 4 ~ ~ tda7~h E~~v C5 ,am,.~ 7eQof faa a da ~ a .v Aesr,'N eaAv5 77-w ~ 7io,d ,0 i 133,,4. eed -V To laO i Ta veY.' Fy so.'/ Q T e p 3 s'~stC m ~ ~ df 3,3D 100, DID V ~ J l~y~c O C o ° Nd i Wisconsin Department of Industry, SOIL AND SITE EVALUATION tLa*ir ahd Human Relations Page I of _ Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Adm. Code I i Attach complete site plan on paper not less than 8 112 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and St. Croix percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. N oav-/o APPLICANT INFORMATION - Please print all information. Reviewed by Date Personal information you provide may be used for seco ' cy Law, s. 15.04 (1) Im)) 9 js i Property Owner Property Location Richard Stout ^ Govt. Lot SW 1/4 NE 1/4,5 27 T29 N,RI9 XX(«)w Property Owner's Mailing Address Lot # Block# Subd. Name or CSM* 1353 Awatukee Tra 21 Badlands Prairie City State Zip m r r•j El City ❑ Village [}t Town Nearest Road Hudson WI 5 0L (7t5q fP9- 7 t Hudson Hill Farm Rd (R New Construction Use: ® R gti~F/ jJumber,Qf s -1-4 Addition to existing building ❑ Replacement ❑ Public cr~i r e: Code derived daily flow 6 0 0 gpd Recommended design loading rate _bed, 9W? .trench, gpd/it2 Absorption area required g $ bed, ft2 75 0 trench, ft 2 Maximum design loading rate ~Zbed. gpd/ftZ-8_trench, gpd/tt2 Recommended infiltration surface elevation(s) N (as referred to site plan benchmark) 68.4 Additional design/site considerations Parent material _r_] aC i a 1 -cl a pas i t Flood plain elevation, if applicable it S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank U = Unsuitable for system CRS ❑ U Eks ❑ U Ws ❑ U Us ❑ U ❑ S U u ❑ S U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft2 in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh Consistence Boundary Roots Bed , Trench . 1 1 0-1 10 r3/4 none sil 2mabk mfr cs 2m .5 '.6 2 12-52 10yr4/ none fs 1fgr ml cs if .5 '.6 Ground 3 52-98 10yr4/ none ms osg ml cs 1.7 .8 elev. 9 2 .0-_--ft. Depth to limiting factor - - - - - 9 8 in. Remarks: Boring # 1 q43- 10 r3.4 none sil 2mabk mfr cs 9M -5 -6 2 3 10yr4/ none fs lfgr ml cs if .5 :.6 3 1 10yr4/6 none s osg ml cs .7 '.8 Ground elev. 94 .3_ft. Depth to limiting factor in. Remarks: CST Name (Please Print) Signature Telephone No. lir/~fs/lr`a.s, Salitt~.• !~'--3PC-~~2! Address Date CST Number a 99 2 ?99 .~PRORERTY OWNER Richard Stout SOIL DESCRIPTION REPORT Page 2 of 3 PARCEL I.D.A 30nng # Horizon Depth Dominant Color Mottles Structure D/ft2 in. Munsell Qu. Sz. Cont, Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed .Trench 1 -11 10yr3/4 none sil 2mabk fr s m .5 .6 2 11-4 10yr4/3 none fs lfgr 1 s if .5-.6 ;round 3 9-9 10yr4/6 none ms osg 1 s - .7 '.8 9 5 .9.0_ n. 3epth to imiting actor Remarks: - 6 (ap p, r 3onng # 1 0-1 10yr3/4 none sil 2mabk mfr Cs 2m .5'.6 2 16-45 10yr4/3 none fs lfgr ml Cs if .5..6 3 45-96 10yr4/ non ms os Wl cs .7-.8 around Oev. 97 .0 .depth to imiting actor oLr in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Boring # 1 0-1 10 r3/4 none sil 2mabk mfr Cs 2m .5 $ 2 14-43 10yr4/ none fs lfgr ml Cs If .5 '.6 3 43-91 10yr4/ none ms osg 1 cs .7 ..8 Ground 9 3e!eA' ft. Depth to limiting r-r factor 91 in. Remarks: Boring # ' Ground elev. ft. I Depth to limiting factor in. Remarks: SBDW-8330 (R. 08195) c s a ~9 ~ ~ ~ f~(a~`h E~•v D ~ $ a . ` II b 1 ~ ~ ' ~ ~ ~ d~ l n ~