HomeMy WebLinkAbout042-1051-30-000 (2)
Yuis'.onsin Ceparmcn: or Cc mmcrco PRIVATE SEWAGE SYSTEM .:.r,rny St. Croix
Sa!ety antl buck ',p C r sic-
INSPECTION REPORT s"" e°'' Pem"` vc
(ATTACII TO PERh11T'' State=~oo In No SAN-2018-279
GENERAL INFORMATION
-oc or .A "lon"abOn y u r-.ty he used ln, iF..tf,^dary purpa52s lPnva:y La'n', S.'-.C4 ':1li rn ll
('?rru heltl?r's Namr Cu,. Jlzac Tow 11-11 Pe•Cel rax Nc
Jeff & Joan Demuth TOWN OF WARREN 042-1051-30-000
;I Iil•1 ! e, Insp. bbt Elea EM Je scripticn a:::ron; Imvr„F.a-pcB.l:q~ No
19.29.18.2906
TANK INFORMATION ELEVATION DATA
TYPE Ivl. W;FACTURFR CANACI IY SrAI ON BS I!I r5 FI FV.
Seplic W S P•en-t4nalk
r r
r~
Dosing AI; RM
Aeration , - Hld'I Sewel
Holoing - SNHI Inlet
SOHI Outlet
TANK SETBACK INFORMATION S •7 9Z' B
TANK TC P:I :4'F. _ 311 iG c't to.4ir lot, s ROAC DI Inlet
WeS~- 5 6deM
Sep:'.C I ' 9~, 1 _ of Bottom
Dosing / HeadelY6lan
?erasion - - - Dist Plpc
Ho~ding - - _ Bol. System
La•al iiratlc
PUMP/SIPHON INFORMATION Y•61 9(o.L`I
Maniac:-.lrer Demand S; Co•: •r ~r
i;Pr,t 'rn~e,1- COOf.(r W, llt..1 (o
Model Numt.er n
_ ot~1 r `'3.75 Z . / $
TDH Lilt Fujiou Loss System Hea*-' TCtli H
I orcemam I PFglt. Dim Dist, to IN' - - - - - _ _ _ -
SOIL ABSORPTION SYSTEM
RED!TRENCH Nid:h Le-!;e rl +t mw:hrs PIT DIMENSIONS Nc OI is nsrde La Liq.. :f Ileolh
DIMENSIONS ~
SETBACK SYSTEM TC WI Ht UG :'CLL I AWSI REAM LEACHING ` , 1, 1'.
INFORMATION CHAMBER OR
TycrGjyalen . LA UNIT IJCCCI N.,riter
r /ufY
DISTRIBUTION SYSTEM
Ileadrra.l:nnla:l Ds!nb-tee xHale Slto xH~ cSputum an: IC A,'ntaM?
I'rp?',
I r~aIM1 pia Lon;m _ e;pacinc
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
- ~;:4r O..r- "scan r;mr . Jecth e: xx :re a?dr~ec:cA ax NNchcd
e:l:'r?ooti ater ~r:lrLnue'~ :11e': Top::eJ
Flc Yes Nc
COMMENTS: {Inci,;ju cede discroponoes. persons present e1e Inspocl or #I /Inspe::non a2.
Location: a:', H,.Y 12 ✓ (~~¢cQ GaS~'. reLNpJer~ r~Q'a. t/ r,✓/~~ '(1J
I. ii It 6t.1 Descipki?r= I I I Cpd
2.1 Bloc sewer IerglL = ! ,t,, 1 i_.~ 6 n IAle - GO jC.~_.
drrtennl JI ::UYt'r = h /'e•~C
flan levision Required? Yes ND L~ I $ 0.7
U5c ut-ter $.;Ie rcr acnhional in'Ouval )1?
;p.ne ur.e"Ilfs ,ram, Cer.. No
j1W' fii' a IH 3!W:
County Sanitary PerrtftYAppltCation STCROIXCOUNTYWISCONSIN
`.p I :m~: vi f i..p~ t .tai, n t a i r? 'd name PLANNING & ZONING DEPARTMENT
to %*,6Z t, t:J iv a I,n V::., pt 1 it y1, a t".c ,['a'y pL.rpr. :-:I f-.1.)' ..,U ',Tv '?JEf' t1PvT °N-cri
[pri'•a ~I e::.1 i1 i,l 1~!r tat rlael Ft rl
Hurl e t^ 1 401C 1 i
P ~ : 1~ 336- a4 r Fav, '?1 199 4~,EG
AIIn:F.:.rm^L:IC plartc'or ll`.e •i sl.=.'n on pae:r net less than 3-1* 'I in::hcs m site.
Cram BanlWra Perm 1 t ;:`(err: it wvisinrt to previous appli aalion
IS 2- 7
I. Application Information - Please Print all Information Location:
FUIPH:-ly U\Vri H: 1•:;nn
7 y
J C" ~ j u /d J E M~ T N l'i ~ t;4 NE v4. Svc
1' N. R le L(O
Property' O'•ener's Iddilinr Adnrass LO: NJmher 810-k Number
~YS 1{u~a oLcATS -
Citv'Sta1a Zip +Jxle Phom~ tdtr-e' Su`-idiv %ion Name or OSM Number
If
c> 7, L> L.:f 15 140 ;t II Type of Building: (check ono) F-Li:y LJ Village !tlTOwn of
e
1K c or : Fwrhy -rmHtl n;; - N::. of Cc9rco,^is: r I W .4 A
C Publ.r!Gon'n'erC'51!cesrnbe Jsei:
C Slate+-:.vner. Nearest Read
11. Type of Permit: ICher.a on!y ona hex ua f ne .v. Ch' r.F ::a>: un line U Y appl uaul c'. r7 k: - h O E IZ
r areel -av Numvr:.) I u~ 7. 1 .
1.(~(iiyad' l_I Rnronneelinn 3.L~'Jrn-al6mhinr 4. ❑Rep.venatitr, o~ o
c7V 2_I~s/ - 3
Saanatian
B) Fern I Nu'nbcr Date Is.=.ued
I slat, San let, P;:•mit vras pith OJSty issued -4 - 12 9
IV. Type of POWT System: (Check all that apply) 20vt~ K'
W Nur prasanc::d a g-.j id Cl ML ur9 24 in su labb scl C ' 1rum:l ?1 a .t labl_• soil C M.aL rI A.0
Said Lill::' n 0O15inJded we11anC ❑ Peal :-filler FJ DI I; L re
.7 P-erd.ri7e.. jr grrn.r.r: C Huding l ank ❑ ng:c Fn-n ❑ Clh_r
pt-grade O .Aerob e l reanrenl Unit U r,+-i-jlaling
V. Dispersal Treatment Ara Information:
1. g1 Frlt' tr_1pni 'h „ rnl Ara 3. Ditl,~r-.?I Area 4. v:ril A.pF;u:aa!.n Nile o. r'or:o151ion (lain 5. Sys em I'.;all::n Fi wl 3ta-e
r U La.qulrod Froprl.r-;I :'31 di,-441 :.1 I4d 1%inuhi q (.S lev. hni
VI. Tank Information Oapa.'ly in Gallons !olal v it IVI u-tautt.nr 71rnhab 'Site Con- SIea1 Fiber Nlasl
Nen• existing Gal~cns Tian'-. C;urv::n:::e sI'uclM glass
Tanks Tanks
I 6G C v v v. of 2...-yyy- F?' H_ U C
J --J' L C
VII. Responsibility Statement
I• the under-.igned, a55Jme respansibility for rencaiJreccnnema::n'rej.r venatia:N n51a'11hb't of noir r t,mb rg for lie POWLS shown im the allauhed plans_ H
icunGC iS 0a; re=red ter IO'raH1 Wpair or the nslallition O/ nee-pk.mhinn_ s.init9'ion s✓stetn.
Ptt.ntbei s Name ;prink ?IJmibcr'S Signalure i,no stamps). '4'n%1PHS No. Cusinoss phone 'JLMc-r
0X31, T E ~ Al i N u T u (~J ak-t:,, Y7 -Z c
Plt.nrei s Olass rulrael. uly. SIaw' Zip'o
AU _
1 L H. p /Z. c-tN L-1 • S c d 3
VIII. County Use Only
cd Sa:ntary Pcm•h: Foe Datc Rst.ed Is;:w H:c S gnalw No si
Approved ;JVmer f3-..t Adt•er.e
s•oo 9Sl$
ua:i n
IX. Conditions of Approvals Reasons for Disapproval:
Fum - ST C - 104
AS BUILT SANITARY SYSTEM REPORT
N /J
W
OWNER';., TOWNSHIP SRC. /
,',r,•~. - T.j -R
ADDRESS / / a./ ST. CROIX COUNTY, WISCONSIN
SUBDIVISION - - LOT LOT SIZE
PLAN VIEW
Distances and dinensions to meet requirements of I1.HR 83
SHOW BVeRYTHING WITHIN a00 FEET OF SYSTE
?c
Iti/~ 4
c•
~ i
c
In In
NM /r ; p INDICATE NORTH ARROW
BENCI MARK: Describe the vec'tlcal retarenre point ase<1
Elevation of vertical reference point: Proposed slope at site:
I
SEPTIC TANK: Manufacturer: _ __1AquLd Cnpncity:
Nnmbnr of rings used: K, Tank manhole cover elevation:
Tank Inlet Elevation: yy{ Tank Outlet Elevation:
{
Number of feet from nearest Road: Front 10 Side 0 Rear, O ? feet
From nearest property line -runt 10 Side 0Rear, O 1 <1 feet
Number of feet from: well hu1L11 ng:
(Include this information of the above plot plan)( Z reference dimensions to septic rank)
SRC REVERSE SIDE.
ST. CROIX COL N FY ZONING OFFICE
CERTI11CATI0N STAfENILM'
FOR UTILIZATION OF EXISTING SEPTIC T_\.- K(S)
Lba: 1 hav':
:.I.: N
T tincf w JgA kE Al t_ pon in:p•_,,-.-inn i c•,'_ir; T};a? i it vc fou2d the i s 1, t:? the best of v
l n• 3 c «c .i'L. GJn OI:n TO L7c -c"tlirc_TlentS L-L)=. X4.2 - 'xd i, I hey';
ap;-,ear i u; b~ func:ic;nin_prc~ar'., .
V si r:.cent ca- _,f --spec ion or 3e ,-i: c t Y l 8
Dij bi _?L~CLir;ro:11 ab ?rpii0n ,:c"rl 1 C ~0~
1 no, ;i,::7 nt-xt 1 a, }
volun. c or CC t nI . :a Ion.S mi-IuI5
ani: L~a^8C1^v: 0 0 O
Cons le'_or_: Prefab ~:on_- to ✓ c: Other
`1a?:uf:~crv_e. 17f lno,~-I: w_~~Laa - -
T_ir11; f - f 1:aaI"vrl : i 4& S -
Per-=I :;saber (i
LJ (z Lz ;5~ L.-~ Ac 7- E k N IC C- N V 'Cl- c_ 46
1.icer. °u Y;-, r;a r `i_n urel ?_`_n: Nam- i
Dated
-OT71 :o be
and s. ) f.'i5 1~ i CJ Sta-=cs or -i3nsed dlsr over ! NR i ? '+~'1S on5:n
laT st:-a i-vt L-Oriel
Rev. y,"_pQ$
S I. t_'ROIX COI N'FN
SF.NICTAN ~tA[\'TE\:'\ CE:~GhE1:~415~'1
ADD
OWNERSHIP CCRTIFICATION FORM
Ou-:per Fiuv~r ..:~-ri t-- ~5 r-~ Gw,, V\\A--~
A9ailing Address t- l-` \ 3
Property Address
tVerification required from PlannalL Zoning. Departn na for nv%k construction.)
CHv Slatc_ ~-_~-'-f•~`~ l.~il- Parce!IdentificationNumber I.EGA1. DESCRIPTION
Propert} Lo:aaot: N --N' ; . N S.x. / 9 . 1 2 2 K 1(3 \l'. Town of 1 F1 S e ✓l
Suhdiyision Pleat: Lot
Certified Surf ec Map 9 Volume Pate T
M arranth Deed 4' t S b 3 (before 2007)Vohnne Page
Spec house yes Kilo Lot fines identifiable )w no
SI STEM MAINTENANCE AND OWNER CERTIFICATION
Ir,Fpro}er use and maintenancc o~*t\,a" septic s:aem could result in its premature failure to handle .%astes- Proper
nawanownce consists of pumping out the septic tank e%cn three yeas or sooner. if needed, by a licensed pumper. AA'hat you pu: into
ti,r„stztr. am a.,I"l the [unction of the septic tank a> a trca mot. sage in the ,,:,sa J:, posal system. owner maintenance
rr.,p +t ~ibi:!ties are s•.ccTed in :SPi 383011 i and in Chapfcr I ` - A. Croix Counts Sanimr; t_)rdisance.
The pmperto owner aereec to submit to St Clots Counn• Planning & Zoning Department a eeni"ication form, signed by the
n~+ner ;md he a master ;?lumber. iourncyman alumbzr, restricted phanher or a licensed pamper verayrne that is I ) the on-site
a CWwor Oposal system is in proper operating condition and or 21 after inspection and pumping (if necessary), the septic tank is
t1om I. i iul! ofsludge.
ve, he undersigned havz rear: the <^.bovc rquirements and agree to maintain the privzte sew<^.^e dispasal sestcm „i 1: the
.ia 1: sc[ form, here h': a. .et by the C)zpanment of Safe, And Profesnowl Sen ices and rrz Department of Wm& R wu w,
srii, of Akiscrn a:n. Certif,cauon statin , that your septic g clam has hmn mairimMed woo he "on. iced and : en:-red - C,e Q Ww,
C(unq Planning L Zoning Department within ;o days of :he three near expiration d:_:c.
I ve cwh\ that all statements on 55 imm are tru._ w ifc hot rn mo hr v:ir-u. I xr ar n <:,,"q i r,l,_
PnYe is dun:ibce shove be virtue A! a•{writy dctd rc or ,d in Rctis r,.i Tie; d; )ftie_.
~1~1111)er of hedf-opins - J
~I
r A r1: Rk-: OF APPt.lc.aNTl,si ll Art=.
"'And information that Is misrepri•sont::1 mss resnl: in the sar.itan permit being revolted by the Plann9ne R Zoning Depa;uncnt.
Ineiudz with this apulication a recorded warranty deed from tae Kc_ istc: of Deeds 01:1cr and a u,pv o the c -f tee nn'c°zs map iC
referenec i. made in the warramv deer.
MY 0412)