HomeMy WebLinkAbout020-1485-13-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
(ATTACH TO PERMIT) 605080
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:
Kernon Bast TOWN OF HUDSON 020-1485-13-000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
21.29.19.3088
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing Alt. BM
Aeration Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/Ht Outlet
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 T DH 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 x 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 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: 559 WILDBERRY DR
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)
_ M
CA~ ' Cj - 9
a`'~- '-Qrp CJl V ; County
li Safety and Buildings Division ,
201 VU. Mfashington Ave-, P.O. Box 7162
J U L 1 1 2018 Madison. W 537c7 lira knit Numb [to isesited in by co.)
b 6508
AppllC~ State Transaction Number
In accordance with SPS 383.2I(?), Wis. Adm. Code, submission of dos font to a appro go 1 unit /
is required r
prior to obtaining a sanitary permit Note: Application forms for state-owned POWTS are submitted to
the Depacament of Safrty and Professional Ser"es_ Personal ia$amati[ar Projetx Address {if diffetrttt than mailing address)
purposes [m you provide may be used for secondary /
in ac dance with die PrivacV Law, s. 15.04(1
L Application lafortaafion - Please Putt All inf ata 55 W/rl 1~
Property Owner's Name
Y Y s Tom.
J(` ~l Parcel
Property Owners Marling Address V ~ ~yV
Property Location . d . T q . 3 C)YO
city, to GmR. Lot zip CAde Phone iwanbersection
tj~~: \
(circle one)
Building {cheek all that apply} T N; R E or W
][I Type of Rix
I or 2 Family Dwelling - Number of Bedrooms Subdivision Name
dkt!r~ Block/ Q-C IDP Y, ~ d
A
❑Pubbc/Commercial-Desglberise
❑ City of
❑ State Owned-Describe Use CSM ivrtrmber ❑ lrliatre of
w Z / d'ZZ IA'Towu of U Y7S , rv
HL Type of Perwit: (Cheek only o e box on litre A. Complete line B if applicable)
ew System I C Replacement System Treatment/Holding Tank Replacement Only ❑ Other- Mori"ification to Fisting System (exTlain)
$ ❑ Permit Rene%%] Permit Revision L Change of Plumber ❑ Peratit Transfer to New List Previous Permit Number and Date trailed
Before Expiration Owner
IV. TYPe ofPOWTS v:
Cara ttettt/vzevice: -((-heck all that apply)
LINIon-Pnxsurized [n-Ground Q PrMurized In-Ground D At-Grade ❑ Mound > 24 in. of subte soil Q Mound < 24 m. of soitahle soil G ~
❑ Holding Tank Other Dispersal Component (ta plain) Pretreatment Device (eaplairt}
V_ I3is rsaUTreatm Area IafotIllation:
Design Flow {t soil Application Ra
(gP A Dispersal Area Required (st} Dispersal Area Proposed S
Ls r ystem Elevation
Tank Info Capacity in Total of Manufacturer
Gallons Gallons Units B
New Tanks Existing Tanks
ca v ~ r;, c7
S w/'e lo~.SZs i° i
eptic or FIatding Tani;
Dosing Chamber
urher' Nz si llty &atement'- I, the uadersigted, assume respQ$gbiility for hWallatios of the POWTS shown on the attached plans
) ] P€ s sip MP/WRS Number Business Phone Number
Plum s ti CS City- State Zip C9dc)
VIfL Coun the artment Us Ott
proved Permit Fee Date ed i' lss " Signature
Reason for Denial i/g5 • o~ 18 {
A. Cond-
Disapproval I
1. . eestetts.fot ir~j 3)
f ssparaai cell rust all be s~i fc?s !tor nt~ D ti
8s per maracement plan pro naed by plumber. • Mai
2. All tstrk regUw~r?en;s mint l,e t •a;r t, tree : h a~'''~• 1.tJ t a
t
j 88 per sppifcnW- c;ade* I Mincer,,: y, ►'A
Atb,ch to eampide places for the system aad snbmk to &e •d7/1
Csnn{} oal3 an
Ice rot tiSau 8 r2 z l l inches - sae
SBD-6398 (11- I l/11)
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CONVENT )ONAL '0AA-PO'NENT DESIGN
Residerit arl A'rn'Grafinn
'roiect Name. INDEX AND TITLE PAGE
xN~N
Z b S
C=wnflr's Name: ;
Owner's Address:
Mega(
Township-
County:r►
Subdivision Name: -C k
Lot Nurrtber.
Parwl lD )iu:'t"lsar: Q - j T Z) 3 f I - CS C~ 0
e 3 ItT(i 5 eri(3 age
Page 2 Plo[ ?tan
Page 3 S`1 S7~nj Si<iwr Cross-LsaG n
Pace Filar Secs
P29e 5 }airrlernce 1:,3orrr- xl
Paxie fi fOr. mar". Plan
Page SL. Cr tsl_x C 5i flpuG Tama !Vontenamce Form
Page & I-AJarrsanty Deei
Paqe CSP 0-T Pl2i
J1 trm9-fnbs_ Soil Tast 8-, Nrijse 1p1~rfs
Date: fit}€1-€1 f' t~ter- Lio~se h~wmar.
Phone r4un ber
Sian2tur2
LieSigrer ,ursua~t :a .he to-3rour Saf; Abso af'an Co
mpc,-:rnfivfa a!'n; POWTSversion?.0SOD- 1
+5ii ia'(td.t)f7DT).
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T Technical Specifications
PL-525-EFFLUENT FILTER ( OMM'F IAL)
r- e UT BALL C; ECK --i
EXCEPTS 6SH010 I II CC~
FOR W! ET EXTENTION tt'57 \ 1' I435
! f' OUP ET BUSHWG EXCEPTS 3,J I
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PL-525 FILTER HOUSING 1634 ! -
PART NO.-30142-525 f'
MATERIAL
HOUSING-POLYPROPYLENE ll.~-~{ = L-~
OUTLET BUSHING-PVC
6.5BALL -HOPE
~__Z V P V
r-`00(ETEXCEPTS FLOAT SWTCN
10.271
' E%:WTSt•Sot 40 7091
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( SaaGF7rs SLOTS ai I ! t I j
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SWCETEXCEPTS B04 956
BILL RUSH RW OPENWG . o
1 - j to Ic~ 1 ~ril
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F ~ GPE~91G I I j ~ ' ! jj
79i 2 i 2Z44
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POLYLOK PL-525 FILTER CARTRtOGE i j I I '
PART NO, - 34141-525
. I
MATERIAL-POLYPROPYLENE
AND
OWNTRSRE? CERTIFICATION FORM
M alma Adds q# a t OU
Pm Andress 55R wc -y - Utir
:Venfacau ~ from Pkmmg & Zo=ag D tar
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Csyts zteaS64 Number
LEGAL DE SC ec.
T
-Operty Location
C~ Iotf t3
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Volume gage
certified survey Map # _
Warranty Deed volume ' ~age, #
S= ham -ves- Tot jh= kka6flabk
t IFPI ~~CE oWNMR ~
s s MAP AND
Doper use and nwuwnance of } our septic std cozdd resuR VS w- ew2n_re ;aAm %o What you put inm
flit yew or set , :f tt by a lic msed PwnPer-
Cardsts of $ a3s-t !be segt teak everg Ownm maw
&e systm can mat the n:nct:on of the septc tank as a fm~ ~ .m ~ San system-
responstbilites m spec~i in §Comm 83.52(21 ana in ~ 12 - i -x Coitittp aaital~► -
< P 8s rmamt a ~catioo *nr=. signed by the
?"ac V operry o~ agrees to submit ..ouai3` fr-, (1) the on-site
own= and by a r Plumb ,.i y~ ph~•r1~, res<sicYed p7maim or s tip ~ r ` esswry~ the set'iic t=rk is
QasteR dispos sysm is in prover opcwu' m1ditm ~vr (2) ift= i
less thm 113 fall of sludge-
*ead foe alcove ~ to ~ F~afe sev~a° ~sac~d system ~sth tiM
have
} ,the i Mr-pi t OE i~T8 i3Ld~ Of ~'~ISSa~1-
sbmdards set forth. hMvn], as set by the ~t c&Comm= 83C to tl t~oiac Cozm*g Pja~Q
c~ smfwg that your septic system b2s been a ~ be camdeted and remmed Zom.g Depar- - w, 3 days
of the dupe 3'~r expiration -
for3t ere r f 1C £~e 5 £}fnx jc~c amjav- the oK~er<s: of the
we ce a y ttt a1 state~nts an
Il
property d bed a1~c . e of a &ed;eco=_ded in - .
Number of o?,.05:: It
DA TIE
u_ _ r v OF AI'FLIC NAS)
ss ply 1f4t7I13t2Oc tae is misrePles ted z1 restlit i1t 6112 samiaT}r Bert IevtT£4 by de pIlrtg - , Depat~teu=-
of Deais Crice ana a copy of $ tQ i m3P
l --.hzdeWEth $31s appL'carion a c orded cvarrawxy ceec fi,, t Register
deed-
of is made in the -rrentY
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