HomeMy WebLinkAbout020-1260-90-000 (2)
S.Je.+ety :Jnsi ano D Builcing ilcmgenl D v s s -jr or- coerce PRIVATE SEWAGE SYSTEM cc.,ny
. St. Croix
INSPECTION REPORT SanitaryPanrilNc
GENERAL INFORMATION (ATTACH TO PERMIT) 606915
Slate, Plan IU Vo.
Personal In`c•mannr Yp~ prov de rnayy to i5?C IQ, Secortla'y purooses )1'r racy _aw, siG (iY (l;im?]
Permit i cur s Name. City Village Townsrip Pa•cel la. NO,
Gloria Hanson TOWN OF HUDSON 020-1260-90-000
CSI HfdE?:. Insp HM Elev. BM Desciiotan Sect OwTevrr., Range ',faF Nu
4 3 it - O S 21.29.19.1262
TANK INFORMATION ELEVATION DATA
ESep: PF 61ANUFACTURER CAPACITY STATION BS HI IS ELEV.
c B enchmark
Tn(-41~f Alt erg
392-
/G r 7~S
Ae•atidr Bldg. Sewer
G.qw
Holding
SUHt Inlet
~-i _ F; t 97
TANK SETBACK INFORMATION SUHt Outlet 47
TANK TO P'L vVELL LD Ve^1 t her I-Irre ROAD DNNUt.-
Sect + Dl Bullom
1`f s7' 15 _L - a
Des, ng I
~•t dg ! 2 x Header--man
AeraCon D rOJ -r 9 7 '
r Dist Pipe
Hold nc
Bo:. System
io-7 9~ 9
PUMP/SIPHON INFORMATION Final Grade
Manufazt,tre, Demand St Cove, GPIA Till /0/,
Model Number
"tt7H C Ficli on Loss S•• Head DH Ft
Forcemain Lenylh Dla. Dist BYde~
SOIL ABSORPTION SYSTEM
BEDJRENCII i':J:h _U'13 Nc Of 1w,ches PIT DIMENSIONS No .n P4, Mice Ina Ligca IM,
DIMENSIONS I Z
SETBACK SYSIEN1 TO 1, P+L BLDG WELL LAIdFiSIREAM LEACHING r'anulacture•'rlr` ~
f7
°vAe O` Syat^e ° `j,,O (•r CHAMBER OR
~wV"INFORMATION K (~(/1 j'7 /t/l1-Y-•
UNIT D,IO:Ie' umbe V~
~`I ~ ~I ~ l• . V N. - Iis.
DISTRIBUTION SYSTEM X111 = c3Z
-ie.aneNrovirurl I if L'al•ihl.t'Jn x Fplp Size x Ho@ SDarirg vent D/i.r Inta/ke.
lerplh 15 Pip?Isi ~ Dia_~ : nqm Jia \ S m_
pac q
LS ~G r
SOIL COVER x Pressure systems only xx Mound Or At-Grade Systems Only ~d
Deph O.er Capth O:er nx Deom m xx Seedec;sccded .x hL icheC
SeClTrench pcn:er r Bec'frcncr Edges Tupsul _
COMMENTS: ;Include code d screpencies pe'sens present. etc.] Inspection at Inspection #2.
Location: 5,52 STACECOi Oi~TRL .
G r Ill CBJ~^ / J_
t)Alt Btd Description =
2.) Bldg sewer length = EYt Ili
aQ
. amount of cove, = 11 J1 6 "J Ae f od
Plan revision Reclined? Yes o C Q _ /Sq'/ Usr. other sda fo forr atlditional rformaoon. A} J
~_-l o R 6e„ Dare Insep•
,e4 Nc
N° F "99N -do i
t; = OCi 09 2018 4.o. Bo~n6x Serdry Permit Number(Io be OW In by Co)
it Applicatio alr Ta.vtw~awm Nwda
In acmNree with SIPS 383 21(2). Wm Adm Code, stbamm of ft form b the approprime AJA
n rpmmd prior to obwrg a maaay, pmt Now Appluabon form for atdaowoed POWTS are su6nwssod b hood Address (if IS tlun me&%addmn)
the Depamnea of Safety and Profawd Swig. Pktaed idotmer on you pmedc may be 1ud IN moooyry
In atxardaloe wihdc lava 15. 1 a Sun ~ME~f7 ~2 ✓ "
I. holormatW - than Pdr AN P
rmpefy Owm s Nam PUtal IF
- IW\ A LL. -H ~ bzo-tz&d-qo. OCb
Prapaey Owner's MmIvV Addmw Property Location I . -
5~G `~7 CJf(Yf "(~ifl I L t:mR La1 -
city. Same Zip Cade Pbm. Nunnbv -tJj) !k section 2
N u 0)v --*-0162 I.-
IL Typo of Bdfa6(ebo& all Wf apply) 2 Pd/ T Z~ N. R~_F.a/
a2 Family Dwelling-Number of _ -J L3 lkas~
❑ PubliaACaoaad- f]erima Ilse _ O City of
Statc (hacaf Dec Us CSbI Nmber O Vitlaae of
Z t W ~•I - - Toren oP__{{ U. -C cw .
tn. Type of Perms (C►at only a# bas ow Rae A. Crplem, Mae B if appileabie)
A. O Now Syaea Syssm 0 7Yes0-Maldig Tank Re Ia-iont Only O Od- b
Funlo6 Sysaaa (eaplaia)
B- OPa., Ranwwl fC3Pama Ra OChoweofPwrbor OPlesit Tnowarm Naw• tat Noanom Pound Number ud Dan hoed
Pe6e Fspistian o.ne t'7'S IvyZ_s-r7-`IL'cserr
eauauwi iwliaaol P.a.wid ire-Caa.ad ❑ AeGak ❑ kiwsi 2i a afaoYhie aodl ❑ bloaad <2A n. dsoaablc soil r
re d Ca~m(n~lao) De.ia(aglan) i~
V. Are.. f.w..u..:
DasW PI.- (md) sm3 APd Degmad Anee Raq®ad (d) Dopaal Mn. g syae®
1 1 017 (,92,SG sC~•.'[ ~f~ 5~D'~ tIS
VL Task bail Capofty in Told # Of
Cullom Callum Use, 7et~ =
Noe Tssks Brio Tats
sq~ anaa
FVIL Regp=WbBky Sbamm mt- L m, asaau raqaa"W am laasWasa at me lOeYlS aarwa r ate aasaea lha
P c'a Nam (Prma) 'a Signmre Mmba &dts Phone N abo
~t.lhss zzaa s7 _715-
P!, v-2ss~
's Address (samr. City. SYtq Zap Cade)
s H1 E S7 WT -S-(47
C-sustyaqLartmew VQI. Use Ody j
Itrmit Pro file -i
a.ed Rmm fo tied s t~! dSgpWe - i
UL Caned' far uiapy...d
t. ' W m a•t n,na
~IW , r. c dt dll hit IL
as W.. manplanp.•xltwpftnbe..
2 N ae!A~rI' piir:..-.?ns mast w a c rt. Ift i ,
i_ MpMRiBICIW4uY5:/:M'.:oT;*.~. .-.J
Armars~eat®ew as.ysrs r.w~uaroce'omtrawr ere a.per ass aa.~'a .r.In err. b.fe S PD-6398 (R. (18/14)
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PAGE 1 OF 4
In-Ground Gravity Plan
Index $ Cover Sheet
CmWoned Mina/ DssW Rerbrencec
version 2.0, SaD-1070&P (N.OM, R. 10/12)
Pg 1 of 4 Index & Cover Sheet
Pg 2 of 4 Plot Plan
Pg 3 of 4 Dispersal Area Cross-Section & Plan View
Pg 4 of 4 Management Plan
Attachments: Encknures:
TNFtk-TOTOR SPECS POWTS Application for Review
Soil Evaluation Report & Site Ma
SGP71C TAROK AaA9P- laeJT
iii
Project Name / Description
owrw name(s): -GL ico L, NA sc PhMe.
Owner Address: 5'S2 2~_ cook," TA, +k [ w., UIF zip:
Project Address.
GOVL LOL- x_1/4 of SF 1/4. Section z( . T-,tL2N-R./qEDor WM
Township: H bl bSIYU~ County: 5T. C Rax
Project Parcel J DA - DZC _ (2Jot)-- 9rJ - CCO
Designer Infiormation
Designs Name: AlA&v I -44"efc-RT PhOM: 7i5 _41~* !7
Das1WwrAdrlress: ZB49'1 KIA16ARTHN e4 r QAggL&CV/. Uyr ap- 9:50
E-nai: llbi( Sf+CrdeS(dn r DJA+1ooK ear This
License Nurnbsr. _1Xsg-o07 ~-.,f
Remarks: aoCr f 6&t-e tin s Y J0
>i[
DR g88~9~ ~
skpmt ire: hln a~
Date:
1 ,AG & Zo `y
N..f i.71 i..~ ccs
W r;
i
i
i
r w _
` R LAD,
-TER u Nast
c t Y.
r ' 1
. ~U1 ADD FiL BA sAEf f FK7E/G'
U ~ r
c O I
A
I r
p I ~
- ~':yo
an¢-
; o
1
1
`r
i >71 u Tar(e) u.. -
IN-GROUND GRAVITY DISPERSAL AREA
Uniform Elevation Trenches with Quick4 Standard-W Chambers a.sao TwaUlvdomo*
34R Trerch (down saing cred8) 145 ad _-pn - o+ -+a
AMID A#'- ' EMrrl.UWM&~
uF~rr •xe
r en..a caw wd e
SOa. COVEN
tS
uwe TYPICAL TRENCH
CROSS SECTION VIEW
i----._ Y (NO Scale)
' P.wYm mt m 3 fl
sysmn a¢albn but w n truitlax.
9~; I
esralon
"Ocal)
antke Stwviwd.w
EM cap 'a' TYPICAL TRENCH
(Snow location d 61W I Wald ppa maermn w pan Mar.) a~ PLAN MEIN
Prv~+l1 (NO Scale)
T = A=3DI D
a~- ~r------- G)
B = - /r a m
mpM SWKWAd-W Churbw w
O
NSTALL. PER TRENCK INees a+wta.aN~~^''
~.tslrrwrnr~rss.r.ar.t+~ A
~I piWs16 ozo1CEmAkhnbw-
+ 1_PaYSdand caps@6!'EISAhti►w ~I'
Propo" RSA qr bvMt ~ 311 or rLagyad Jr,li.d. A~ - ~4 DIetrhMlnl Metlw&
Dandles = PrOpoud Trial EISA L W ANB& IF LD
q-50" 0, 7 LK = OZ-&-Q-2-41wI/KWA F~Equl2-Lp
t,'iZ.le - 201E15A JAMT = 32 ~`f UNITS
law
In-ground Gravity Management Plan PAGE 4 OF 4
ll~oRTAr~rr-
T
r9Wff0TW* 1* WS he Ow w of 8his 0-ground Wavily 0yown shall be resporwNe for ds perpetual operation and rsihlensnae pureuent w
a hsa ~lU . ~ V riot rtwkftbinaooowe uM nft a~ ~ ored ppr reamgerms plan
Rrdhernme, al iaPecdon and raai bmrllla WWAH s shad be performed by a roghwwed POWTS 1111aino6low in
a=M%nos WO SIPS 30M (31 Wiisc. Admit. Code.
Osslgn Flow ° - y S 0 OFF WIN S rm t1VO; T88 5190 nV ; FOGS 30 nQ0
o type of use INSPECT EVERY S YEARS
o age of system
o nsrdaemce factors (ke_ odors, user opmpisints, afa.)
° medsrrcW mdkir cb m (Le.. Pumps, vaNea, swkdmm 8oeir, eda)
o materiel fatigue (is, leaks, breaks. corrosion, eta)
solids volmne in a ewuW iresigr"" tank(s) and arty did d illon eppuienasm(s) (Le.. dwfti lam I drop boxes)
o megleat or inpropw use (La., =Weeding design copeciies, prW* ted acYVNes, elm;.)
o mint Of P°*rdng to der ftAlon Cad Prior to dosing
o closing kmgWwidBar~' m - if spigicabb (ie-. Pram "s<-ycritg. host wAlc n seWrgs. alc.)
J di~rtion Www or s - N 8 (is, wiig. aornecWM mftdm. controls. llrners, aim., 4W)
rert orvice
or pkggmg (maesrae haeral distal press" - compere to deaign mecNfrallon)
V "face discharge or hftrai
sewage bads-up inb stnrdus served
idY1W AON EVERY 3 YEARS (or when nscmmi y)
IMMc and done fansfat shall be pnped by a CwWbed WP 6W SavkkV o wMw licensed under s. 281.48 Wis.
Bloch win ft vohatts of sodds In Its fwdqu) aroasds erhoflmlyd (1/S) Ws Ugtdd vehdms Of fba tynir(y OF
as 1 "W by local ordnanoa Disposal of coltwte sited be pursuant b NR 113. Wnsc Adtnir Code.
Sshell be itepeclad w4wy 3 years and shad be loaned Men nea.aowy a meow any
masses 8000rdOg to mrhaMdaCf Aces apecillicaliorm A aavk ft p VON eted i always be greater them 12
S w
311111141 Wimr- n ma AdnWr Shad be subwithd b go prgW joCaf OovwrmwW we in atf art dim r aft Code Repwt stay compass isiwe or wadYwcess *x
Name d indvddtwl or company;
i ' - l I ~J/'r' phone:
LocelgovarsmertUnit __ST.CF2Vt) COMA416)JJZY D OELDP.MENT Phase: -716-.3go-14W
Local gwerunat unit eddress ld DSOM zl Awof/ 7
Any defediw pat of this systsn Sh W be spared, replaced, or rantowd pta RWO to WS 38351 (1~ Wisc. Admin.
Code- Repair err'Pbcament of failed or maknc iorlirtp Cdepothada slat aanMty %a SPS 383 Wbc AdrNrL Cade
No product for dhantcat or physical mWoradon of Ste POWTS may be used uvily approved by YAW- Adn department in
L
20ONdahre hsldt SPS 384, Wisc AdmifL Code.
IhhgRMY Phur in the
"On a Plea sulx t 00 any d treebratt cornponert of this POWTg carrot be mPwired, it shad be mplecnd prastdart to
appopats Q9wxY for review and epProrraL A fared'
abandoned and replaced by a code-oomplyig dspasai oomporsmt in a prsda W mrse of WA~abde~soacjnay be
%mil"n 6w - wA
11 use Of I* POW M Is d19o0nliared, d abed be abandoned In aooontsnce with SPS 389.33, Wiry Admin. Code.
0vie*4
The Quick4' Plus
N F IL r BATOR" Standard Chamber
Gu
6;;,;~ Quick4 Plus' Series
The Quick4 Plus Standard Chamber r
offers maximum strength through ,
its two center structural columns. I * c;
This chamber can be installed in Al a : $
a 36-inch-wide trench. Like the s's<, t
original line of Quick4 chambers, rte.
N. ;,X
it offers advanced contouring y<
capability with its Contour Swivel I a..:.
Connection- which permits turns
up to 15-degrees, right or left. It is
also available in four-foot lengths to
provide optimal installation flexibility. I Quick4 Plus Standard Chamber Benefits:
The Quick4 Plus All-in-One 12
Endcap, and the Quick4 Periscope Two center structural columns offer increased stability and superior strength
are available with this chamber, Advanced contouring connections
providing increased flexibility in . Latching mechanism allows for quick Installation
system configurations.
Four-foot chamber lengths are easy to handle and nstall
Supports wheel loads of 16,000 Ihs/nxle.with '2' of cover
I
Maximum Strength
40&
Size Quick4 Plus All-in-One 12 Endcap Quick4 Plus All-in-Onl
34"W x 53"L x 12"H Benefits: Benefits:
(884 mm x 1346 mm x 305 mm)
- - May be used at the end of chamber Allows for raised invert installations
EffeeBtre Length row for an inletfoutlet or can be 180° directional inletting
48" (1219 mm) installed mid-trench
12" raised invert is ideal for serial
Mid-trench connection feature allows
applications
louver Height construction of chamber rows with
8" (203 mm) center feed, as an alternative to
inletting at the ends of chamber rows
Storage CapacHlf Center-feed connection allows for
47 gal (178 U easy installation of serial distribution
systems j
Invert Heigh Cart,iied by ':,e lrae~nnnu„i
0.6" (15 mm), 5.3" (135 mm). I ' Pipe connection options include
8.0" (203 ni 12.7" (323 mm) l sides, ends or top and Mechanical
- - - - - - Officials (FAPMO) l R~~'
APPROVEnin
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CffEC11VE LEni; P1
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1rOINIS LOCAIIW,
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ro WATER TECHNOLOGIES, LLC('INFILTRATOR
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u``O 19 WftW.. W.., T.in 1.111 C N.,M mxanee T IMn 115A DLUS'..:':
DIVISION OF INDUSTRY SERVICES
PO BOX 7162
®MAD69ON WI 53707.7162
ip (!eVsd Through Relay
l i ' ~ hap>/dys.af.pogerppntim6NakAk,.sarrs
~i
- Soots Walker, (ioeertwr
Dow Rose, SeeraWy
.1~y08, 2U 12UIS
CAST ID No. 1316956
;:•AVID I I•NI'7
GOVT AFFAIRS DN7'T INFILTRATOR SYTI'NMS We
4 BUSINESS FW) K RD FO Rol( wR
0fJ)%AYHRt)0K -7 (Ny1?5
Ide lifica lk;; Numhers
Trsasrelfoe ID No. 253M224
IT ID Na
Hr'. !)tvscriNlion' I FA(:HIIVG CHAMRFR I'Ieaacreter In both idcotifVwation numbers,
Manufacturer: INFILTRATOR SYSTFMS ING, aborc, in till
corn-Y I~Mencc wirh rhr, ale
Product Names QUICK4 PLUS STANDARD, QUICK4 PLUS STANDARD LOW PROFILE (LP)
L CACHING CHAMBLHS AND END CAPS (trans. id 2534224)
Model Nunlbcrisj (_'UICK4 PLUS STANDARD (INCLUDING QUICK4 PLUS ALL-IN-ONE 12 ENDCAP
VV!TH TOP, END, OR SIDE PIPE INLET CONNECTIONS USED SINGLY OR IN
PATHS AT ENDS OF CHAMBER LINE, OR AS A M106CHAMBER LINE
CONNECTOR) AND QUICK4 PLUS STANDARD LOW PROFILE (LP), (INCLUDING
('UICK4 PL US 8 ENDCAP WITH END PIPE INLET CONNECTION USED SINGLY
OR IN PAIRS AT ENDS OF LINE: AND QUICK4 PLUS ALL IN-ONE 8 ENDCAP
WITH TOP, END, OR SIDE PIPE INLET CONNECTIONS USED SINGLY On IN
PAIRS AT ENDS OF CHAMBER LINE. OR AS MID-CHAMBER LINE
CONNECTOR)
QUICK 4 PLUS STANDARD, DIMLNSIONS: 53.0 IN L. X 34.0 IN. W X 12.0 IN H,
MAX. DEPTH OF BURY- 8 fl.
l_ ISA for chambers with or without fabric . 20.0 sq-1tJchamber, EISA for Quick4
US,%in-One 12 ErxlcW installed at the ends of a chamber row = 2.8 sa f fend
cap, EISA for Quick4 Plus All-m-One 12 Fndcap installed n-line within a chamber
rn,.; 3.6 sq. R./end cap; Laying length of chartlber - 4.0 (l., Laying length of C)ulcK,i
Plus All-in-One 12 Endcap installed at the end of a chamber row 1.5 h., Laying
length of Quick4 Pkis Aft-in-One 12 Erdcap installed in-line within a chamber row -
osi it., QUICK4 Plus Standard Open Boffom area - 9.72 sq. flJchamber, Quick4
Pius Allin-One 12 Endcap installed at the end of a chamber row Open Bottom area
sq. fL/end cap. Quick4 Plus Alll- -Ona 12 Endcao installed in-line within a
chamber row Open Bottom area 22 sq. ftJeW cap; SEE ALSO ATTACHMEN LS).
QUICK 4 PLUS STANDARD LOW PROFILE it P), DIMENSIONS: 52.0 IN L X 34.0
IN. W X 8.0 IN 11; MAX. DEPTH OF BURY. 8 IL
it I;;A let chambers with or wilhoul fabric _ 20.0 sq. flJch amber; EISA for Ouick4
Plus AP-in-One 8 Endcap installed at the end of a chamber row - 23 sq. (vend Cap.
F ISA for Qwck4 Pka AM-ir One 8 Endcap installed In line within a chamber row -
2-0 sq. flJend cap. EISA for Wck4 Plus 8 Endaap installed at the end of a chambe,
row - 0.7 sq. ftJend cap; Laying "th of chambers - 4.0 fl.; Laying length of
Quick4 Plus Alt- n-One 8 Endcap installed at the end of a chamber row - 1.1 ft.;
Laying length of Quick4 Pkls All-in-One 8 Endcap installed In-line within a chamber
row , 0.9 fL; Laying length of Oleck4 Pkss 8 Endcap installed at fie end of a
chamber row = 0.4 ff., Quick4 Plus Standard Low Profile Open BoRom area . 9.7i
sq. fl /chamber Quick4 PNs All-lrl-One 8 Endcap Installed at fie end of a chamber
row Oprrn Bottom area . 1.4 sq. f Vend cap, Quick 4 Plus Alltn-One 8 Endcap
installed In line within a chamber row Open Bodom Area = 1.2 sq. ftJend cap; Gluck
4 Pitts 8 Erdcap installed at the and of a chamber row Open Sotlotm Area = 0.4 sy
fl-lets cap SE L ALSO ATTAOHMFNTS]
product Files No 20150111
7_$:Sg224 Un'.'IU II_N7/. I'uf. 2 zq~ip~The spoc:rtrcatfons andla plans lot this plunU.iryg product have been reviewed and detarmrnad to ha in
cemphanuo with chapters ,51'S 382 through 384, Wisconsin Administrative Code, and Chapters 145 and 180,
VV:~onsin Stalttlas
The Department hereby issues an approval based on the Wisconsin Statutes and the Wisconsin
Adm nishative Code. This approval Is valid until the end of May 1010.
This approval supersedes the approval issuer! on i ill 112014 under product rile number 20120137.
This approval is LwntirWnt upon compliance with the following stipulMlon(s)
• This product must be installed in accordance with the manufacwrer's printed instructions, product
approval, and plan approval. It there Is a conflict between the manufacturer's instructions and the product
approval endror plan approval, the product approval and/or plan approval will take precedence.
• When this product is installed in a dispersal cell that is sized based on the EISA rating slated in the
regarding block of the product apwovai letter, this product must receive wastewater having a BOOS value
less than or equal to 220 mgA, d TSS value less than of equal to I W mglL and a COG value less than or
equal to 30 mgrL on a morift average.
• W hen this predrrt is installed to a dstnbubort con that is sized based on the LISA rating Stated in the
regarding block of the product approval Miter, this product must be installed in andividual excavations that
reate a row of chambers that ate horizontally separated from other rows in other excavations by at least
1 feet The 3-foot measurement is measured between the closest outside edges of the leaching
chambers.
When this product is installed in a distribution call that is sized based on the EISA rating stated in the
r euafding block of the Product approval letter, the distribution call design must slow at (east six Inches of
rxxKhnrg in the chambers without backilow, of wastewater into the drainpipe that efisrharges into ihn
chambers.
When this product is installed in a distribution cep that is sized based on the EISA raring stated to the
regards g block of the product approval letter, this product must be installed in a distribution system,
v4kh has the lop of the distribution cel at or below original grade.
• W hon this product is installed with geotextile fabric on the skies of this product in a distribution roll that is
sized based on the EISA rating stated in the regarding block of the product approval letter, the EISA
rating with fabric must be cored to sae the system.
vV hen this product Is installed next to each other in a distribution col that is NOT sized based on the EISA
:alms stated iii the regarding block of the product approval letter, Me effluent distribution area is equal to
the length ernes the width of that chambered area. The use of geotexhle fabric in this lype of installation
i,: optional
When this product is installed with geotexlile fabric on the sides of this product in a distribution cep that is
sized based on the EISA rating staled in the regarding block of the product awoval letter, the geutextile
rabric must meet all of the tal owing specifications:
. GeotaxtiM shah be ion-woven
. W eight shall be 0.35 oz/sq yd to 1.5 ozlsq yd
Apparent opening sae (AOS) shall be 20-30 U.S. Sieve (ASTM LI-475 i )
• For mound designs, see the manufacturer's pnoprimy mound component manual for this product line.
• For mound designs, see the manufacturer's propriety mound component manual for this product l ne.
25342Z4 DAVMIJiN7-4
ycs? ;r82ots
The department is in rho way endorsing this Product or any advorhsing, and is not responsible for any situation
which may resutt from its use.
Sinceroly,
Glen Jones, M.S.
POWTS Product Reviewer
phone: (608) 267-5265
fax: (608) 267-9723
ernai: gion.iM*s@W.gov
The DSPS Is committed to service excellence. Visit our survey ar
www.surveymonkey.con%Wdspaiscustomersa4efari m
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ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATIOI)l OF EXISTING SEPTIC TANK(S)
C~cLrJ.~ L 1-l~niS~n/
This is to certify that I have inspected the existing septic and/or dose tank
presently serving the following residence:
(Street address) 55Z 5~ cr► TR>41 t - located
at: Nwd ''/4, sF 'h, Section 7_t Town__ 2!L_N, Rangei cl W,
"Town of HuDnnN , St. Croix County Wisconsin.
Upon inspection, I certify that I have found the tank(s), to the best of my
knowledge, will conform to the requirements of SPS. 384.25, and it (they)
appear(s) to be functioning properly.
Most recent date of inspection or service 10-3 ai
,
Did flow back occur from absorption system? Yes__ No
(if no, skip next line.)
Approximate volume or length of time: gallons minutes
Tank Capacity: f Q~ /
Construction: Prefab Concrete X Steel Other
Manufacturer (if known): W ii✓'t~
Age of Tank (if known): _ .jQC;. Z
Permit number (if known) 17!5" Z-
(Lic sed l,lumber Sig ture) (Print Name)
(Title) (License Number) NCWMPRS
/.0J3j/~ -
(Date)
Form to be completed by licensed plumber (Dept of Safety and Professional
Services Chapter' 05 and s. 145.06, Wisconsin Statutes) or licensed disposer
(NR 113 Wisconsin Administrative Cade)
Rev. 2/2012
ST. CkuiX 4CuOUN`r
SEPTIC 'TANK MAINTENANCE AGREEMENT
AND
OWNERSHW CERTIFICATION FORM
Owoedlleyon l r f F-~{{NSO/J
Mailing Address 55Z STAB CO AC M -TR A I L-
Prap«ty Address c M ~ L -
(venbcaboe mqmmd fiom Mms" a toms DVeuomt Ibr 9ewCemhaehOe) -
city/stale { i t~sun , iA Parcel Idea>sficafion Number ~ZC _ ! Z" -90- Oct!
LEGAL DIliR(~IP77Ax -
"rtVer y Lin Y-. ;rte'/• , See- -71 T _Z,7 N R I q W. Town of +i IL L1SCI j
Subdiviam Plat: '171qAI °I E V l 5 rA 7 ill fl QDA/ ' Lot # Z
Certified SarmT Map # vo)ame _ Page # -
Warranty Deed * &5Z4,57 (before 2007)Voltm4e q7Q Page #_j
7FS
Spec home ❑yQ~p 1-114 lie" °lmtina(aia~ycaooo
Y
Improsm we and
mairu®ce consists of O°O1 a ofyov septic ■yst®eoeld cad, in io pretuatum f-iliuc m talc aytcs rcga.:r
peoPata oaa Ibe agatie oft every three yass or sourer, if needed
ale -
syOem cm affect the fmcben of the Pb. aetank eaa tro mev[ Mac is the vea0e disp o! Poaopra wbaf y1u put mto
req~oeobilitiss am Vazfiod in fSPS. 383.52(I) and m o a odju Owner
Chspser 12 - Sc Croix Ca" Sanitary Ordiomw.
The property owear aWma b submit b SL Cma Comfy planm%Fc D'W=tnmti M abmd by the
owner and by a mashy phambw. joemeytam phmWw. mat ricied dtan6er or a 6emeed t ren dot (
wastewater deposd syada is in peeapc vmyieg dot (1) 1110 o.-sita
It= than I/3 fen of sludge, PmPQ~~~ ~0e aodbr (2) -W Mq- 6m and p.Wi g (ifnecewmyl the swdc tank is
standards sea here read Ste above regrireraeanta and agree to reamra e, Sae W ame a %qp dWood s3
fix* herein. h6otiao by the Dtparm®m of Safety And 1'ao6moanal services and Sae Depetaams of Ind ltm wth eat
Statc of wnol.aet the
uccz.
Tommy ~B k INIM ~ septic aysbm has has maiamaiaed rant be olmplemd and rta~md b the S< Croix
7~8>~tmtat tai/se 30 days of the 6a year ataitatiae dah-
of lm gut tree mnm In the best of cry/oar i o vtadge. Uwe 3VwarC the Opene(r) Of the
Inouetly It" Ow d» dma m Aftmeaft
y mmrdod in R4saer of Dads Oflicc.
Number of bedrooms
sI OF APPLICANT(S)
DATF.
•••Aay int-matim that;- -my murk m the
memey Pettit Odo6 revoked by the Ptrrnorg & Zevie6 Dapartemeot
4adade a"& His appiieation a retarded aarraeg. decd from trio lsaffiou of Deeds Ogre
rderex is made is tlm wama tv &,,d and a copy of the ombfiod survey smapif
(Amwni
v lJ l I-H JCUVIVU HUUI 1 1 V IV
THE NW 1/4 OF THE SE 1/4 1 AND THE SW 1/4 OF THE SE 1/4
WN OF HUDSON ST. CROIX COUNTY? WISCONSIN.
N1/4 Corner
Section 21 NORTH LINE OF THE SEI/4
".69.74 209.79 S
79-7
N I
W1/4 Corner
Section 21
- 12-- 2j3-1) 22
= 96115 Square feet = 100129 Square feet
N
(2.207 acres) (2.2 )
99 acres
in 21
e ON Ni0
103859 Sq
a rd Z Y, 6
(2.384
t °
ul
N 89059'45"W
I 73.55' - (4)
ATE ;m); - '
l Wisconsin 4 '3
72.5sTQ~
the best of my NA9°53 46 W 3-A \3
.nding and 0.- 3
e?9 9
•ided and 96Jdam~~A YSk
:dition,
and the NW 1/4 ?09.
R19W, Town 70.60' A.6z^3o' 6' , F
669~59'46'W C6.=N46045'O6"E , -0
iconsin: that L . 105 50'
vision and L.= n5. 20 - PRAIRIE
Verlyn " I I, 6o 00'
ibed as S
6 3-A A.5.06' 50' (2) ~.-6.3.•50' 209
C a =S56-AN.
T.OCItTIOH: HUD~Oji 21.29.19.1PRIVAT~SEI~VAGE SYSTVMLANE, ounty:
Wisconsin Department o in ustr ,
I obor and Human Relations
Sifety and Buildings Division INSPECTION REPORT ST. CROIX
(ATTACH TO PERMIT) sanitary Permit No.:
GENERAL INFORMATION 175642
Perm.t Holder's Name: city Q Village Town o State Plan ID NO.:
I m SAli HUDSON
T BM Elev.: Insp BM C ev SM Description: _ Parcel Tax No.:
ar / > - SF ve~J 020-1260-90-000
TANK INFORMATION ELEVATION DATA A9200301
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic / Benchmark (e 3 /p4,3 /00,0
Dosing
Aeration Bldg. Sewer -
Holding St/Ht inlet 5.96 q y, 3r/
TANK SETBACK INFORMATION St/ Ht Outlet 9 3 q
TANKTO P/L WELL BLDG. Vent to
AirIntake ROAD Dt Inlet
Septic/ I S/ )S NA Dt Bottom
Dosing NA Header/Man. C1, 7a SQf
Aeration NA Dist. Pipe ~js 96, 3.l
Holding Bot. System qs-, S
PUMP/ SIPHON INFORMATION Final Grade y 8
Manufacturer Demand
Model Number GPM
TDH Lift Friction S stem TDH Ft
Loss Forcemain Length Dia. Oist.To Well
SOIL ABSORPTION SYSTEM
BED / TRENCH Width Length NO. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION yDe 7ttu) CHAMBER Model Number:
System. ~6.iA 7,
' OR UNIT
DISTRIBUTION SYSTEM
Header/ Manifold distnbuuon Pipes 4 xHole Sire xHO eSpaang Vent TO Ah Intake
length _ Dia. fr I Length -I-- Ora Spacing b
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over I xx Depth Of xx Seeded/ Sodded xx Mulched
Red/Trench Cenlew" Bed /Trench Edges Topsoil ❑ Yes G No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) ID• S<
UJL.L l^I 3.4 j,, t .LC+ s I C' 9 f
3 St
Plan revision required? ❑ Yes ❑ No G
Use other side for additional information. I O( c t,~ '7 G
SBD.6710(R 0551) is Inspector's Signature Cert No
L
Wisconsin Dapartawnt of Industry. SOIL AND SITE EVALUATION REPORT Page __L cl 3
Labor and Human Relations
Division of Safety a Buildings in accord with ILHR 83.05, WIS. Adm. Code
COUNTY
STCRo~~_
Attach complete site plan on paper not less than B 112 x 11 inches in size. Plan must include, lout PARCEL I.D. I
not limited to vertical and horizontal reference point (BM), direction and %of slope, scale or
dimensioned, north arrow, and location and distance to nearest road.
REVIEWED BY GATE
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION
PROPERTY OWNER: PROPERTY LOCA1 IOV e
SAM MILLEII~ OeyrtoT r!W nro$E nla,SZI T Z9 N,R J9 E(or)W
PROPERTY OW11jF MAILINr~w DRESS LOT r BLOCK N EE SL5ct'K NAME CR CSM t
-Tt' 252mx I ai~r z
STATE ZIP CODE PHONE NUMBER ❑CITY ❑'JIL AGC 05VN N=AR~sT ROAD•
pi 5 N W, -46,6 ( ) r sow, Z`. 1. 1. LAU
New Construction Use Residential I Number of bedrooms 3 ( Addition to existing building
( I Replacement I I Public or commercial describe -
Code derived daily flow 41~0 gpd Recommended design loading rate _bcd, gpdr1120 B trench, gpdrft2
Absorption area required 1 LO bed, fl2 trench, III Maximum design loading rate 0 7 bed. gpdi t2 stench, gpLtm2
Recommended WIVabDn surface elevation(s) 75•SO It (as retened to site plan benchmark)
Additional design t site considerations
Parent material _Flood plain c'vv,.hor, if appl,cabte If
$c Suitable for System CONVENTIONAL uu NO N-GFOUND PRESSURE A- RA3E JeTEM NRLL HOLDN
U= Unsuitable for stem S❑ U N. ❑ U S❑ U Vs nu I S❑ U ❑ S U
SOIL DESCRIPTION REPORT
De th Dominant Color Mottles Struclure Can Roots GPDJfi
Boring N Horizon p Texture sis:enct Earri~y
in. Munsell Ou. Sz. Cant Color Gr. Sz. Sh. Bed rte
17" L 1 >"SbK 7 0,5
1 $ 'r , n" p A~ J 1~ M 5 ~~~?7 I C L .Z.
Grouts 8 19 " J_ - S-+ ~ Irv, C '
/ e~4Zft
Depth to
t tor
>fac
Remarks:
Boring # e / L 1 5 b_K '1 C Z a 4 s
Z 1 V 5, . 5h I. C 2 03 len,
Q I C I O, g
5
46
Ground
CM-9 eev4-7 /
It
Depth to - -
limiting
factor
y9 b7
Remarks:
Prone 1
T Name: e e Print
:r Dated CST Num
Sige V' Mgr