HomeMy WebLinkAbout040-1190-60-000
Wisconsin Departmei of Commerce PRIVATE SEWAGE SYSTEM County. St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
453100 0
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 X Township Parcel Tax No:
Myers, Cynthia Troy Township 040-1190-60-000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
L.~`.. " 04.28.19.844
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic 1 J Ben hmark0__
Dosing Alt. BM
Aeration f1 Bldg. Sewer,,
( 11,33
Holding St/Ht Inlet
r~ tGG 5 , .5
St/Ht Outlet
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic , Dt Bottom 3 . /
} i 7
Dosing n i Yt c L<, Header/ an f 3 ~j
Aeration
Dist. Pipe j
•CIO U•
Holding Bot. System a c
Final_Gra_de
PUMP/SIPHON INFORMATION K-".C,- u U <-a S
Manufacturer Demand St Cgver
GPM Ytr 1J. 1 11v~1:; ' _ ~7 a".a ✓ .J / D D . "Z
Model Number
TDH Lift riction Loss System Had TDH Ft
Force n- Len thy, Dia.Z _1 Distf-InUµetl-
!f~`lodr~ r~ .
SOIL ABSORPTION SYSTEM i _
B DIMENSIONS DIMENSIONS Width Length t No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
ED/TRENCH SYSTEM TO P/L BLDG WELL LAKE/STRE . /LEACHING a aoturer:
INFORMATION CHAMBER OR
T e f System:
7n % UNIT Model Number
L V 1 / .~(1 ~4 r / - p
DISTR! JTION SYSTEM
%
Header Manifolds; Distribution , x Hole Size x Hole Spacing Vent to Air Intak
Pipe(s) `~.r"v
Length Dia Length ( l Dia Spacing v - S
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over 'p,1,) Depth Over xx Depth of xx Seeded/Sodded jxx Mulched
Bed/Trench Center ] Bed/Trench Edges Topsoil
u"~:-y~ Yes No Yes No
3
~ 1
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:/ 2fGl Inspection #2: /
Location: 537 Frances Ave. Hudson, WI 54016 (NE 1/4 SE 1/4 4 T28N R1 9W) Valley_View.Heights-Lot5_Parcel No: 04.28.19.844
1.) Alt BM Description =(",2.) Bldg sewer length = 3O+ccvV.' ~x-el
^ w~^ j
- amount of cover = w
I/
Plan revision Required? Yes v'~Na
oY
Use other side for additional information.
SBD-6710 (R.3/97) Date Insepctor's Sig ature Cert No
~J_Cvl V"
` _-7 Z <(cl-7 6
Safety and Buildings Division County
d
81 K l
W 201 W. WSshln A Rte-- . 57• (i /C
Madison, 15 IV E S t Permit Number t
p sconsin ~ E ~ (o be filled in by CoJ
Department Of Commerce (60 ) 261.65"
State PIanLD.Number
Sanitary Permit Applica *on PR t 9 20N
In accord with Comm 83.2 1. Wis. Adm. Code, personal inform ion you provide
maybe used for secondary purposes privacy Law, s15. {l xr{t)- t r ect Address (if different than mailing address)
1. Application Information - Please Print All Information
Property Owner's Name
e uo 11/t//(/ /-1 yETs Parcel # Lot # Block #
Property Owner's Mailing Address
57 7 j/i /7ld/e`/ ( A //1 /1 ~J^ AK-Property Location
/ v~ s~A. Section
City, StatteJ 7 ZCipCJod/~ Phone Number
~U~SO~ [N/ s ~~lCQ 3Y3-5 GO (c
ircleone)
II. Type of Buildin T N; R ~Rlr W
g (check all that apply)
X-I or 2 Family Dwelling - Number of Bedrooms Subdivision Name / CSM Number
❑ Public/Commercial - Describe Use UII (Ji~~ /T T5 °
. v
El State Owned - Describe Use S ❑City ❑Village ATownship of T 12!~y
III. Type of Permit: (Check only one box on line A. Complete line B if applicable) _
A. ❑ New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System
B- El Permit Renewal ❑ Permit Revision El Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued
Before Expiration Plumber Owner
IV. ryp, of POWTS S stem: Check all
that a 1
X Non -Pressurized In-Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter ❑
Constructed Wetland ❑ Pressurized In-Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑
Recirculating Synthetic Media Filter ❑ Leaching Chamber Dri p L'ne ❑ Gravel-less Pipe Other exp ) o1q
V. Dispersal/Treatment Area information:
Djesign Flow (gpd) Design Soil Application Rate(gpdsf) ispersal Area Required (sf) Dispersal Area Proposem Flo.vaq
10-0
? ; 9S•Sa
VI. Tank Info Capacity in Total Number Manufacturer Prefab Jtml Fiber PI tc
Gallons Gallons of Units Concrete G1as
New Exi sting % - -
Tanks Tanks
Septic or Holding Tank C~O-V(,t it
Aerobic Treatment Unit
Dosing Chamber
VII. Responsibility Statement- 1, the undersigned, assume responsibili or installation of the POWTS shown on the attached plans.
Plumber's Name (Printl Plumber's Si ature MP/MPRS Number Business Phone Number
R.-U LQ2 z-Z ~3~lS 7/S•77.2•34i~
Plumber's Address (Street, City, State, Zip Cod
z. ~ ! Z- /4 tom, ~v~e • 5~~~~U(,- ~~l~ • s~7~ 7
VIII. Coun tDe artment Use Only
Approved ❑ Disapproved Sanitary Permit Fee dudes Groundwater Date Issued Issuing Ag6nt Signature (No tamps)
Surcharge Fee) q
❑ Owner Given Reason for Denial I
IX. Conditions of Approval/Reasons for Disapproval
~ ~
SYSTEM OWNER:
1 Septic tank, effluent filter and
dispersal cell must all be serviced / maintained J ) , rI
as per management plan provided by plumber. CJ~ i ~'~0 0 t~ 2 s
2. All setback requirements must be maintained
as per applicable code/ordinances
Attach complete plans (to the County only) for the system on paper mot less than 8112 x I1 Inches In size
l
q) C29) ' I t12 "
SBD-6398 (R. 08/02)
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2812 10th Ave. • Spring Valley, WI 54767 _
715-772-3442 _
PROJECT INDEX
PLAN ID # /u,IA- DATE !T 00 y~P
OWNER C/ND y 14 . M SIG ^S PHONE ?IS' 396, 3 19135
ADDRESS Y-73 r WANde_5 4W. 110D.jO,0 LIJ~• SyD/gyp
LEGAL DESCRIPTION Lb f 71/- U~~.Qy bie4v STS. P/N
/v~~yi S % Ste. g, T 0y0• 1150 •oa •
TOWN OF 7T)e0V COUNTY 5T ~I y-
CSTM R• Whl?1(jG 7
LOCAL AUTHORITY/ SUPERVISION ST• 44-0/'7( Z~,U/iUG-
PROJECT DESCRIPTION:
Rep 1-4a AAt~/ 5 VS?4x4,L_
i
4v I'll, A- pies/f*44, 04&y lvel-le F41<) 6F 600 Des .
co vs1S 71-5 f- 407, • ee-xe (V6,0 - 66~k 4JAI li&,,~ A-1A -5 ~ /-W lAt lid ,v i ~u C ,x~ l U r bL~4'f i' 0 H A4 2. S
o
S f
~t3~2T" ZtLR I~I'c~?~~
NON-CONFORMING Ulbricht & Associates
Private Sewage Consultants
ALL
TREATMENT TANKS SHALL 2812 1 O'th Ave
BE ABANDONED PROPERLY Spring 'Vail(,-y, Wl 54767
PER COMM. 83.33. PA_7~IL A fU~~
2Z(,3-7S
P9•1 INFILTRATOR SIZING WORKSHEETt
P9.2 SYSTEM PLOT PLAN
P9.3 CROSS SECTION OF SYSTEM, WITH ELEVATIONS. /
Pg.4 it It 11 it 11
P9.5 OWNER MANAGEMENT PLANS & ZABEL FILTER SPECS
P9•6 (OPTIONAL) CROSS SECTION AND SPECS FOR DOSING TANK.
PG•7 (OPTIONAL) PUMP PERFORMANCE SPECS.
The attached plans and specifications are based on "In-Ground
Absorption Component Manual For Private Onsite Wastewater
Treatment Systems.,, (Version 2.0) SBD-1075-P(NO1/Ol.
ZIP
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vy
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can to
w ~ !o; poi
A
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rp _
41
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04
"fp
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^Z._ ~/iN/ S QED
sc~. go yi~,4~~_ 100-4
t X
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F9,
7-,r&V4,e e- Ye TAM
Cho SS 5EC Tie-9,0 01 Thy-IU64 ~
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TiP~"~tJ c~
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5-D
OVER: See Reverse Side for Vent/ Observation Pipe Details.
744 7-0,e,5
`iSiI~ELV~,va=X /gD,ZZ'L 3 rX 6 o svv~
• l 547 /~jd~•~Df,~'z ~ c~ SSG Tj'a ~.1
Iff
E T~6/U ~1/4
Eli
ZE VZL
OVER: See Reverse Side for Vent/ Observation Pipe Details.
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Leaching chamber tops are at or below the original grade. Leaching chambers are placed directly
on the bottom of the distribution cell. The locations of leaching chambers are in accordance with
Table 3 of this manual.
Observation pipes are installed in the distribution cells and are provided with a means of
anchoring to prevent them from being lifted up. Observation pipes extend from the infiltrative
surface for stone aggregate systems or from the inside of leaching chambers to a point at or above
finish grade. The portion of the observation pipe below the distribution pipe for stone aggregate
systems is slotted while the portion above the distribution pipe is solid wall. Observation pipes for
leaching chamber systems are attached to the chambers in accordance with the chamber
manufacturer's printed instructions, extend from a distance > 4inches above the infiltrative surface
through the top of the leaching chamber up to or above finish grade and terminate with a
removable watertight cap. All observation piping has a nominal pipe size of 4
inches
5. . See Figure
Water tight cap
1 Top of
'min_ dia.
leaching +ng
/Repa+r couplings
chamber
SlotG" mim
min.
tive surface.. ruin.
Water Closet Collar 8ar(318" mint. dia.)
Figure S - Observation pipes
Vent pipes, if installed, connect to the upper half of the gravity flow distribution laterals and
extend up to at least 12 inches above finish grade. Vent pipes terminate with the vent opening
facing downward by the means of a vent cap or fittings. Vent caps must allow a free flow of air
between the distribution lateral and the atmosphere. All vent pipes has a nominal pipe size of 4
inches.
' SEPTIC TANK & PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS
4" CI VENT PIPE 12" MIN. ABOVE GRADE & Z-
? LO ' FROM DOOR, WINDOW OR ?rWATHER PROOF
JUNCTION BOX APPROVED
FRESH AIR INTAKE WITH CONDUIT MANHOLE
W1 PAD LO
4Gi
WARNING
1 4r~us/sE er osv 4 °f M I
3 c
t
INLET !
9
GAS-
"~L ! i
TIGHT
f9 BABEL.-~ A I SEAL
i t APPROVED
SC.D.40 Fa LTA 4 ~ ALM JOINTS W
UC Pt f' ' B PIPE 3'
31-11o SOLID NOD EL zw A ' 4 -3 75 + ON SOLID SO
SOTL
PUMP OFF ELEV. S6'1~ FT • I 4 OFF RISER
D `v PERMITTEi
AN
% ~ IF TANK
h- MANUFACT?
irk
3" APPROVED BEDDING UNDER 'T'ANK HAS APPR!
CONCRETE PAD
SPECIFICATIONS
>EPTIC / DOSE
TANK MANUFACTURER: -0A)&z2
NUMBER MOSES PER BAY: ~
ANK SIZES: SEPTIC l,~.bD GAL. DOSE VOLUME INCLUDING
DOSE GAL. FLOWBACK: GAL.
ALARM MANUFACTURER: L,Q1/z~ CAPACITIES: A = I?17 INCHES = yC
MODEL NUMBER: aU
SWITCH TYPE: 2 B = 2 INCHES = Tf
SIP NANUFACTURER : C = 1/011
INCHES = 1 4~
HIODEL NUMBER :
SWITCH TYPE: = r -~i ' D = P,!7 INCHES =
REQUIRED DISCHARGE RATE 15 GPM PUMP & ALARM WIRING AS PER ILHR 16.2:
VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE FEET
MINIMUM NETWORK SUPPLY PRESSURE FEET
+ __VZ FEET FORCE~~AIN Y r z/--FT/100 .FT. eFRICTION FACTOR • . 1 1 FEE'T'
I It
TOTAL DYNAMIC HEAD = FEET
tt
.N'?'T~`RPdAL DIMENSIONS OF PUMP `LANK: LENGTH WIDTH DIAMETER!,,
70 h j s !,~lST LIQUID DEPTH
I ' ,jED: L'TCENSE NUMBER: DATE:
S 'YSTEMt P/C
INCORPORATE PER COMM- V OF
833.44(2)c A PROPER ZABEL
ILTER MODEL # 4-100 = C
SE'P 2IC TANK Per Cojnn°n r _
outlet attached approved filter device (Zabel
flitter). Tank shall have an approved above
ground locking manhole cover for regular (every
12 months or less) inspection & servicing by a
I = c€ nsdd Service oumner.
ZOELLER EFFLUENT PUMP MODEL.'98
11EAD CAPACI?Y cunvE
MODEL "of)-, t5- ;
s s/e
ta- ` O +
4 t/re
Io- e
e- i 1/2-il 1/2 NPi
u.l. Mt.IONS
WAS J !o _5o so ~0 so
80 e 160 too '
FLOW PER MINUTE
MAI 111-pp "t-otOW fed,, : .
IMUrnr AND
dWArthNA .
bOAMAtty
Mrja it
►[tf M[t[R[ IA lrrtt "
a►~
to it
Sol 11I Pit
tto 41 170
~ es
LockV&%j
CONSULT FACTORY FOR SPECIAL APPLICATIONS
Elsctrk al allerrteiors, for duplex syslemS, are av.lllable and
euppfled with on alarm. • three Mercury float switches are avanable for controlling single and
Mschsrgcd alternators, idr duplex evelems, are available with or • phase systems.
WORKA SINM switches. Double piggyback mercury float Switches are available for
Variable level long cycle controls.
8landerd rill models- Weloht 39 1be - r SELECTION GUIDE
SSSerba i lf.p• t. 1nlegrylloNopente"Polt 1-hgrkAtrwhch,no external Model ph _ Control 3elac single Piggyback mercury Noy switch or double r control
tpuired.
fig h- Mode A. to awhch. n.ler to FMO471. P igytuek mercury, Noy
Moe elm Ian
1 _ auto "06
P DU ten Mechanical ahernator to m79 •n
OWNER 's #AI111 AINCE OF SEPTIC SYSTEM
PQWTS (landowner)
maintenance of thiss srpemsi Regular proper operation and
servicin ys periodic inspections and
g is necessary for the safe healthy operation of.this
systelp. The owner is required by code to submit all necessary
maintenance/inspection reports to the controlling,authorities.
SPECIFIC CONTACT AGENTS ;,e;e" (i O1
* Governmental authority/ inspectors:
2 0~1~;U(r
0 (0
Licensed installer, responsible for providing an opera
maintenance "Users" manual;
/ 77, & tAl-
Licensed service
/ / inspection agent other than installer:
67`/.
3 C>
Electrician `
for pump, electric controls, wiring units:
IMPORTANT OWNER MAINTENANCE RE UIREMENTS
1. Winter traffic (sledding
area shat.] not , shove*Ing, etc.) across the
the permitted, or frost can/will penetrate into
cell, freezing up the system. Discontinuos use in the
winter.(a vacaction trip, resulting.in no water use) can also
lead to freeze ups.
2. Water conservation needs to be exercised! Or system can be
hydrolically overloaded and destroyed. designed for a maximum wastewater flow o'fls svsem was
gals. daily.
3. POWT5 are not designed to accomodate wastes from a garbage
disposal unit, or any other unnatural sources of waste.
Any introduction of such waste materials will ov
destroy this system. erload and
4. If a power outage occurs, or a
in a temporary overload of Pump fails, it may result
cell, which ma effluent being pumped into the
recommended y adversely impact the cell (leakkge). It is
ecomme that a licensed pumper empty the dosing tank,
allng the pump to return to dosing the correct amounts.
Consult your installer immediately for advice.
5. Neglect of the vegetative cover
erosion preventive (the cells insulation &
traffir~ aio~. n~n can lead to failure.
%
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page I of
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
County s'r'• G RD X-
Attach complete site plan on paper not less than 8 112 x 11 inches in size. Plan must
include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. Nye
percent slope, scale or dimensions, north arrow, andJp~ttatl;~istance to nearest road. p 2 y
1-1 , ` 1r
I
Please print all " fq►~Wlion. ' RevieGved by Date
Personal information you provide may be used f/resq(idary urpos(Privacy Law, `S. 15.04 (1) (m)).
Property Owner
Property Location
~ rn Goit.Lot N6 1/4 s9 1/4 S T2-8 N R 0 r(or)W
Property Owner's Mailin Address
L'-o't # Block #
Sub d. Name or CSM#
f,
S37 ~A A /tJ GQ S x
YASy NT•s. sv/~
City State Zip Code 'Pho FI City ❑ Village own Nearest Road
Yy M3
Y Ve-e s
T ~
❑ New Construction Use: residential / Number o 3 Code derived design flow rate ills O GPD
111 eplacement ❑ Public or commercial - Describe:
Parent material
OSS Oyt.,-- SIf.t.0 -0 uTWA Sy~ Flood Plain elevation if applicable N ft.
General comments
and recommendations:
r Boring # ❑ Boring
Pit Ground surface elev. G ' `0 ft. Depth to limiting factor 132- in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftl
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
l a•t-L 100313 g~M&zP fi// SL 2,4, ti z f
2 /,t /o Yle m& SL f S ie ~ C
/0 V.0 s S. d • s ~P,e Z
132,
D s s T
rle S 14-r 9S. o /30 'A-) C~ 6
If,l SOr'G
❑ Boring
Boring #
2' Pit Ground surface elev. ' ~G► ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
013 100 L12- /1M file d5 -2-
2 1 ' zL 10e3 S/ L shy W6 4L) /74-- z
3 •3(olo R(t <SIL ~i as Z 3
/D 5 15 /4,,,
`/!o 901
' Effluent #1 = BODS > 30 < 2r26 mg/L and TSS >30 150 mg/L ' Effluent #2 = BODE < 30 mg/L and TSS < 30 mg/L
CST Name (Please Print) Signature CST Number
Ro136-/? T- ?~112,f1 CG, 7- i` - ' 4 3 -7s
Address Date Evaluation Conducted Telephone Number
(D s'S D NA "t /4~f) . /f l9pSD.~ /9 3 •200 / 7/S' •3~G - S
Syoi~
SEA ~~caMp~tiy.;vG-
Non-F-
S
Property Owner , `E Parcel ID # TD ~O "V v Page y of 3
Boring # ❑ Boring
3 pit Ground surface elev. os (t. Depth to limiting factor ( in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color
Gr. Sz. Sh• •Eff#1 'Eff#2
l o'~ io yie 31SQL / sl~~ ~sG w . . 3
2 3 o S iG sfi~ a~S 4S Z.
1o S.
. 98 Q (,C) .9
[-q]Boring # ❑ Boring
Pit Ground surface elev. / f/ Zft. Depth to limiting factor ~T
in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fiz
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1
Eff#2
1 0
~o
S s
dSti w z ~ . Z .3
Z
9-33 is 1 SQL /
ash ~ Qs
3? - 4T ~
-7 •S L.S /4" -
,2 cs Z,
o s n~ S. p , s
34 Y
❑ Borin Sc-$l,, H i.Z p
Boring #
Ground surface elev. ft. a th to limiting m.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz
In. Munsell Qu. Sz. Cont. Color
Gr. Sz. Sh.
'Eff#1 Eff#2
i
I
Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L
The Department of Commerce is an equal opportunity service provider qnd employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777.
sno-8330 (R.6/00)
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S'T CROIX COUNTY
SE,11TIC -TANK MAINTENANCE AGREEMENT
AND
OWNERS111P CERTIFICATION FORM
1
(-7witerflitryer ~ .-t : .
Mailing Address
Property Address ?
(Verification required front Planning Department for new construction)
Parcel Identification Nu nber
LEGAL DESCRIF ION g~~)
Property Location i/, Sec. , T N-R' W, Town of
Subdivision
Lot #
Certified Survey Map # , Volutne , Page #
Warranty Deed # , Volmne page
#
Spec ltcxtse H yes 0 tto Lot lines identifiable t i yes 0 no
SYS'I'El}11AINTENANCE
Improper use and ►naintenance of your septic system could result in its premature failure to handle wastes. Proper maintena
consists of pumping out tine septic tank every three years or sooner, if needed by a licensed pumper. What you put into the sysl
can affect the function of the septic tank as a treatment stage in the waste disposal system.
'the property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and b
master plumber, journeyman phmrbet, tesiticted plumber or a licensed pumper verifying that (1) (he on-site wastewaterdisposal syst
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 113 full of stud!
II-me, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the stands
set forth, herein, as set by the Departrent of Commerce and the Department of Natural Resources, State of Wisconsin. Certificat
elafIng that your septic system has been maintained must be completed and retumed to the St. Croix County Zoning Office within
days of fire three year expiration date.
Y
sT(
;Nn ruR OF AI'r CAN 1
DATE
ow NEIi CEIt'I'ITICA•I'ION_
i (we) certify that Fill statements on this form are true to the best of my (our) knowledge. I (we) Ain (are) lire owner )
the property desctibed above, by virtue of a warranty deed recorded in Register of Deeds Office.
t
S_
ANA ruRE or• 1,1CANT
DATE
Any information that is iris-reptesented may result in die sanitary permit being revoked by the Zoning Department.""
include with this appifeaffon- a stangred warranty deed from the Register of Deeds office
a copy of the certified survey map if reference is made in (lie warranty deed
For issuance of permits and designing
Contact: Ulbricht & Associates
Registered private wastewater consultant and plumbers
2812 10th Ave.
Spring Valley, WI 54767
715-772-3442
~L 1
81'. CROIX COUNTY ZONING DEPARTMENT
AS QUILT SANITARY REPORT
Owner ANN M y CRS
"•.dd:~_,s 5a-7 PRArJLt AVE
City State _ H V D Sam, W 1 54 O 1 b
Legal Description:
Lot 5 Block Subdivision/CSM # VA L L C-'y V 1 F W H IF 14 1-t-r S
1V E'/, 2E, Sec_ , T ZgN-R 19 W, Town of -T Roy PIN # 040. 119 O.OZ - y
SEPTIC TANK - DOSE CHAMBER HOLDING TANK INFORMATION:
Tank manufacturer W 1 t-`Str 2 t2OO
Size ST/PC ! 2co Setback from: House 19 Well (03 P/L q
Pump manufacturer zo IFUL U R Model 9 Fr
Alarm location
(HOLDING 'T'ANKS ONLY)
Setbacks: Service road Vent to fresh ait intake Water Line
Meter location
Alarm location
SOIL ABSORI-TION SYSTEM.
I Q F I I- -T-RA-rD
Type of avicK FOuR , CtLL5
system: Width Length (00 Dumber of Tiendies 3
Setback from: House :T2-Well 1 pIL 1 to Vent to fresh air intake
ELEVATIONS:
i o r- of c onc.ret-e- S la b 'n front o f
Description of benchmark base 1»e nt W a 1 K c u-r Elevation 100 •c
Description of alternate benclunark To P of Sep-h c- - -F-i iter - man hole Elevation 100
Cove r
Building Sewer 9 -7-:?3 S•T/IIT Inlet 9 5'.5D S`I' Outlet PC Inlet
PC Bottom 9 1 • Sea licader/Manifold Top of ST/PC Manhole Cover 1 b0 3 5_
Distribution Lines { } { }
Bottom of System l O O. (o 0 q q. 45 9 q 3
Final Grade I O 3 (n O O 2• g S /01-73
Date of installation 4 121104 Permit number '453 m o State plan number N / A
C- t5 %
Plumber's slgnntcere ~~/l,t4A, License number ~5~1 `7.3
Date-g C~ y-
Inspector
Complete plot pier
HIL..E I(\J 5-TALL 67
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