HomeMy WebLinkAbout020-1342-10-180 (2) ,
Camr;
= n Derar-e"' c`cr^°erce PRIVATE SEWAGE SYSTEM St. Croix
Syctx artl n.jio;in , U vem•.
INSPECTION REPORT Samar/Pe,maND
(ATTACH TO PERMIT) 606969
GENERAL INFORMATION state Pan ID No
Pe'soeal w1ontla nn 'frr_ pmy de °ap Be, usetl trr senardary ow=ses IP•Nacy t aw S :b u4
let, t Holdei s Name Cry V.Ill Tawnsrip Pa'GEI Tax No
Jim & Lisa Dardine TOWN OF HUDSON 020-1342-10-180
CST 1310 E ev Insp Rid Elev B`.1 Descript an Season:TOwriRange1.tap No.
32.29.19.1834
TANK INFORMATION ELEVATION DATA
TYPE MANU=ACIURFR CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Ekl,s rI I.X, ? /o
Dosing c-- At. BP/_,`
Aeration Bldg evrer \ Abe 11.1(o
Holding SiHt lrlet
r
SvHt Outle:
TANK SETBACK INFORMATION
TANK TO PrL :HELL BI DG Vert to A r Irtake ROAD Of In el
Sept¢ Dt Bocon•
Dos ng r \ ` HeaderM.1an.
Aeralicr i.. Dist. P.pe
10116 .3~q
Holding Be:. System 1R~
ti
Final Glade
PUMP/SIPHON INFORMATION r
CD r .36 . 4 Q ~
Manl.faclurer Demand St Cover ^
GPaa ~.1QJ 3Cr
Model Ni ~ t 11.4D 6
TDH L A riot on Loss, \ 10ys:em He d TDflt Ft
Forcemar) Lerg:n Dia. %1t c bveu -
SOIL ABSORPTION SYSTEM
I
BED:TRENCH WJi•l / en Stn , No. 01' cr,•.us _ PIT DIMENS S No D'Pi nsice Dia _ ~r+w:-4~F_:i!
DIMENSIONS ~l~ l_!~~
SETBACK SYSTEM TO P:L BI.DG WELL LAKEtSTRCAM LEACHING rotan6facn.rer. p J
INFORMATION CHAMBER OR
I,Il tix&Nm UNIT MoJe.i Nitrite,.
71~r yt ,..,I 1f2...tXCtA.
DISTRIBUTION SYSTEM i 4-2-6
1HeaderMani'rld L sir buton x hole Si>e x Hole Sprang Ve A64s
irLenctn 1 /O D e_ i er:)•n ~ Cia SFdUV _ SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Deptn Over Dept- Ovr x.+. DeF'.h <4 xx Seededr5odce,; xx Mulr an
Bec~Trernc'r Cu-Icr (J I Bedl`rre-ch Edges Ti~Psr' - yvs _ I ND _ Yes r.u
COMMENTS: 'include code ascrepencies, persons presert e:c; Inspecion Rt: Inspection ff2
Location: 508 CARRIAGE LN -
r
1 ; Alt Blvt Description
2; Bldg sewer length = T1
- an•ct.n: cf cover =
p 9 - - I _I O l O JAI) ,
Plan revision Required? ! Yes No Gnn No
Use other r side for for additioral information
Date Irse ctor's Sin ure .
SBD-67101R.3:97;~
ST. CROIX COUNTN ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF EXISTING SEPTIC YANK(S)
I his is to certiA that I have inspected the existing septic and or dose tank
presenth serving the following. residence:
(Street address) located
at: _ Section - To\Nn 1\. Range
To\tn of _ St. CroiN COMM Wisconsin.
4_'pon inspection. I certil\ that I have found the tank(s), to the hest of mw
knowled_~e. \~ill conform to the requirements of SPS. )k=4.25. and it (the))
appear(s) to he functioning Properly.
Most recent date of inspection or scn ice
Did flow back occur CrOill absorption system:' Yes No
(if no, skip neat line. l
Approximate volume or lem,th of time: gallons minutes
lank Capacity: _.S
Construction: Prefab Concrete _'7\ Steel Other
.Manutacturer(ifknown): g
A~,c of] ank (if know))): o
Permit number (if Known) ):.-z 1 1[9 e-
c (Licensed Plumber Signature) (Print \amci
Title) - - f.iccn>c Numberi Nll' MPRS
(Date) - -
Form to be completed by llcenNed piumher (L)cpt of Safety and Profcssionai
Services Chapter 305 and s. 14.00. Wisconsin Statutes) or licensed disposer
(\R 1 13 Wisconsin Administrative Code)
Rew. 2 20 1?
}-r•. R :»lely aild HLlildmgs I )Iwso J r' {
Irf 1 `1 "f'_ 901 W_ Washington Ave F C•. Box 16,1
~Samtarv Ycrnnr Nambrx (n I tulcc
P I Madi!or. WI 53707-7162
;''ns 2ula (ebb gjoq
l it t - 1 -dIC IYA @::11:11 Ilmhlll
~#7lt Permit Applition N
„lll r -
h I _ AJn,. CoJr, submresior, of it.... tor 11, • rh.:q,pnm:iulr. eovrmmcnla: 3.111
I n. plir«! poor tr oM,ir lq• :I : mx 'v 1 L..y,pb I lo, s:nr o N.11, '1 me cubmmce sI FTO)ccl nJJres.. (rf urtlcrem than maihug a,kl¢.a)
! u, )cl mnr. u n nl tv n:d Yr d uunla! Scn crcona oil om:nbx. eoo ,u)v tnv Is:+[I r vc
ary
j
. Application ~ wth't Imaa ePa t nfI MIDI. SL,rs I-_ _ 1 -5a$ Ca ff,G J rt'~-
11 )I I , ua0on~l nlrm Itiou Please
n fnr ti
1. cn
t J<C / l un III
PI vIV )w vNwm f uc~l
t (a ~ I O~C - 1 '3 y',~ - /!t _ ~z/c•
1' "acna roller's Mailing Andurs
~ P:Cpc:'ty l.ncanon -Tq--i 83 y
4-(^
Cm, St:,h: Zip Cexk ohrru: IJwnba
~ ,yet : ,Z,Z~ Soo„I
F~L
II fnIerc P of Nu~ddin{'(check all that apply) I-,r4
Uwdlinl `dumber <r(ik:Jlu:rtnc Subdtvrun: Name
I I nh;le;('om:ncmia Uc..cn:,c 1'~sr - !I l C na of
(Sid Sunober ! . \ dlargot
._SCilcf)wncd-;n•c::rine
( I,K1 fouu r'
`II F 4 pe of Fennit: (Check IJZ-one-hux" 1r A r omplelc iii, B irapplc bl' rl
\
L-
:cwS~cnn h II,-.., ,::I i. YsI-I: I~l 't wano:.wl ddlm, I:mk ,cyrm_r,u,u.I i)o!r I ,.)mrt Yt.dd¢azlnn If, FKlsvng Svsrcm texplabij
I Icu R nanl -cmlil It:vra<^ I v; Previous Nora Numbc and Dw Iss c I_..-_
It. I I F I I Ch:mc_r at I'hmmcr ~ I c mil uu>t; to N::x 2~/6
ly- of P( /
- (".S- 't•1- -stem!( nmpnnent D-evice: - - (Check all that apply) - - J3Tq 175 It - -
IN=
/ - lM nr n ' r « um <I 1 l rzn,tW I r ~.urxd m iuauul I I -r n:I I W,aW . m 0 gat,bic .oil ! I Ylnuud ~ I x. ul nmmbl-sod -
InI< t t u : j I I )Iha Unlx .al a-.nnporno k xplsiu' Pre calmcnt Ikvec t<xplalttlr x'14 Qv ~y
r V. Dispersal [ r eatrtu rn :1rca Iniw mahon
'Jr. I Iluv ticu 4 ;7,31 ,m Rat
'.~P✓ PP pdsQ Ill.: pcrc:u Awn 1« 1c:rc.l (sf r D,ry r :al :\nn i ry,.n~ IX', I Svstem Elo.n um ,~.~as
- - _ 7G
i VL'I':mk Info I ' apau s m- fold 44ertufa:xutcl l d i
Oalk s <; Jloue ~ Unns
11uIJm
! I~ - t - 1 ~/CV ~ r 1 r
1 VII. Responsibility Statement t, it,, uudougued, assume respunslbihp' for r[,stxllhono of the PCI'AIS shown on the anncbrd plane. -
Plumt,•: Vn^x ll'nntl P:umhelvso-mine j,SSP/A11'RS Cuud,c: 6usmess I hone ],aniu
- - i - - -
"r.;m! cr - dt-.-as SIn.9, Co), Stan, i.l. (Adel -
Vf[1 t ountNJ) lrtmvnt lse 6nh _ a0
,I t r a.,,, ~t/~~ `coon Fcc UatC vCncE I
1 ~ ---~----Issuin<- we Sionalurc - -
t „>„a ;•a<), a,- )Cn , X85, 6r7 ~ili~f//~ ~ n I
Ix. ondifiy4T&AFi*WEdVNeacoua for Disapproval -h
i. S,epl tack, ernt.bn ~Iltc , n1 .3) ee.7 (`wti l aS
a•~I-err , er'I "u e all 'e r
s ~r _ l/~ D
is P"r marayerren pl r.
j 2. All alefiack reeuw ens in-, t t. . .
to per spp&nblit c?: ; :0
, , i
Atbcb n < mptrtr rJ.ws for ,bcw re ,n .utu, , rbc C'uuaty holy n,. pxxcr un1 Ivv tool 6 R in > I I inrbo i.
a<c - -
`HR-b ^LU i R. I I! t i l
ZOO-
V7
/t 1 J`
V
\i
^V
1
1
✓ 4
OCC3'C
I
oll
ICI . ~ I
O
Soil Absorption System Cross Section
!
It
a" SchenWe 40 Final Grade
PVC Vent Pipe
VAth Vent Cap i
Leaching 1
4
-__V--_ y-- -'v System Efevatlon
If b _ tt tl
Soil Absorption Svstem Plan View
C ' it
n
tl ~~IIi~II~1.iID.~.~If~I[[~IIII
It Leaching `-Cench 1~
Cha nhenc 71
a" Dia.
1 Trench 2 ~1 Header
Hen: o: Obsewation Pine
I~~~Il~ll l!11'111[[mmom m amm
-Trench S _J
I-eaching Chamber_9pacfficafions.
Manufannirer And Model Gt °3
LISA Rslinq. i t 1 - sq f. per chamber Soil App!iuation Rate - gad/Sq f.
qrd Dasigr: Film b 1' _Soil Appht:ation Rate z- _ z c FISA Chambers
:3 rows of chambers each
Paye w
~hry9 2 . h/ r h r
1,056 ACRES
45.969 SO. FT, 2f P N
III + rv I N 1.076 ACRES I° I U-)
46,R65 SO. FT. ( I I
- f 1 'J It ~ ~ _ - -
1
-J H5'SB'55' F~-w n's ~--N 65'3206••.K O7
- 269.45'
- '1.06.65 . a 100'
j
w
I m 33 133' I Q'+1 i to
I m+' _ I ~ I I I V i
, I4 20 Ld
1 Wj I
I. 1.013 ACRES ' I; I
r \ 44,716 SQ. FT.: 10
I'7 4{ I
27 I v
1.061 ACRES \r - i m p ;7
5,221 SQ. FT.~i / \ JAb vi _
J /l \ `tOAi t' •F O I
.~.yN r/`l3• \ 19 In I
AcRLs S 88'49x43" W
50,102 sQ. FT. m 12.50x
rx/ PUD11 r/~ ! \ = W I I
17"E ' V \ 100 5 I
0' _ 0 a io 0 1
p
-34.97 u f I 1 p
is o° w O ~l I .i I ~I
• aVE,
y lea 0 1 ~+j
t,t cn j I E-
\s 17
1.395 ACKLb 63.4. Fj. ' ` 7i I 1~ I ~ I A,
60,745 SQ. FT. \ J? I rv S I
8449x43" E
ss ACRES (J
1 57.15'
SO SO. FT. -3 I
\ ; n 1 SOUTH LINE HE NW1%4
~ 33.133• I
` \ 87:1.55' I I
I
- - m -S 89'11'05" W a
~-Lty
-
36' M10E EASCNCNT FOR INGRESS AND [CRESS
:ANDS RECORDED IN VOL 766. PG. 200-201 AT THE ` is.
ST. CROIX COUNTY REGISTER OF DEEDS OFFICF. I r -
x '1y_^•
I ~ N
N O 1
N I
N 1
W ~ I
I
NUMUF.R DIRECTION DISTANCE •
12 510'36'10"W 232.44' I
L3 562.57'00"E 70.0!1 0 1
- 14 N40'59.0"F 66.33' ^
p try k 51a nir.
pto, A,:
50$ C rte ~iACf E, lrH E -3tl.-Ittarn Permit APT lltatton .lc.. 'J.
ii 1, - t t
~7 /aoo~aln t~'every3 f v'•: 1 [
trs rt~.?:o r rt ..y ^I ar, ..ri o~~ec:"ct. py`4~.cre~ ,„crleom~~/uo';;(orn' oeou ,
tK I. 'i _ ft t nc
6f t .
DeNryryrr el •n,o•ru IYr ac• / .
~m 41
~'~pi,t, 1'1iPSUfn [ KovltV iJn irs W4~f
t ,111f '.tC 06 dl'4
SNWr~eN 71'rtllte 110"10"1 -.,1...J
Afamsing raw M21 OW
/_a.,uG ubervuion eet►Or Nl,el '
~fo/C 38G
iiGliY~.AlGii pp.~.r 6- V C.cy
~a ( Oflt) ~ 'r.»41r ~{wvs. ¢\rl~af
p 1m1ML17pKtIYy-No o181drootne~;,~ y!){.. ,~T u Sd~ .
0 AubW"Ca~ildMP~uw)'
Ka 1 Nenw:
. IPp•
e hj4k only =A-Mr e 0".1 lot
] Q ~IItNnM10f e C Addtll/r' d Ilp Il p,
020 ' 13'{•?_ - 10 ^ I Ov
A) 1, xwrw iymm 1 C P.w:werlmt T
tlu<
~ 1 umlK 2~ nq lq, 1534
DNm t t (CMda 111 ilt t pPl)'+ ° " - t Tb C fled 011W 0 Conat~etld W'pttnd
0 MxOa q Wnpe hm G JrIP Llne
~e11111WL ~ CKo4ieiTeni OUCWWSIIPI 0Omlr
C) Aerobic TnltMin; knit -
C 31 3 x .s. {~AAJ s^ C
ae >
V is evsoan
tan
"yam ~wiWv t~• 'u>Rnw+t 6/
' luderat(c.b, p,groledl(rb9~,F ,
GO'O tic
iJ3~ :Ind p I
rj a ew r wa con. !'IIC
T j I Ok kill ' lob ' Ow
I Iltltt>•td
h~Of W11011 1
w
t
' . ai ~ d 1 nm Nvn~ '
1 Vepye leo ttroN l/S'-YBG 3/SZ /
fir'/(,,. p~s S~rSCr w<-a.YEV
UM Otity c tAmaae rlrep,
wry Mw l
y~Aypm"d .I o O"W avM ln;del AdvNr 1 tee? S. LR? aA4tk 9 2~ 1 ✓~a
Ce~lgtal r e' pfbvtllt " iu.:-(a GA ulu"j-0.
•lk A+.IQ SeY7a<,j~c w+I.y} N.atw}axr, s DAl 1 .W L.cusp
+bA - .~y~C,~,;f . -
g
ysSylRl t r J e e~?eMS ~o Qt to k v U 3i Ity}< al~rtCy~t S H14s a< oe o.
ilAdlii fA. Mr001
U.) 10.J flroi 1fc rG94.irr5 SOrr~GC ~~4w..cy O~ ~ s
/ r
i, p- Z,9 ytars• ~'~tur-~✓ ~D :r~~r»-- ~rd~perf[~ GtA1a-✓
+tlcrcf VrUr<i,'o.. -!o✓ C in 5y SKh ~iCa bn>
Leu,~a ~ Co~.t~ds~r 1fC~< roetjsr.+ry .Inrr .r -
Private Onsite Wastewater Treatment System Management Plan'
Septic Tank And Gravity In-Ground Soil Absorption Complp nit
Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite astevAV Tfis?tment
System (POWTS) shall include information and procedures for malntalri'aq,0e syrie!w, ftv
the pmetBrs-afiC=in 83 and 84, avid this cow dilionsrA aparsval Dy t a ¢ep
j t
or governmentat-unit. Theapproved-pfansand permits-fof-systemate
zoning or health departmert.
This management plan complies with Comm 83.64, Wis, Adm. Code, ano the In-Ground
Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD-
10567•P (R.6199).
_
Table 1: System besl n S pecIfications
Sanitary Permit Number S~
Number of Bedrooms -
Design Flow_ Peek (gpd)
Estimated Flow Average (9 d)
Septic Tank Capacity (gal)
So l AbSo pt an Component Size (fF) , n
Typo of V)astswater ornos_tic ~ s
Table 2: Soil Absorption Component • Limits of Reliable Operation
~ Septic Tank Componon~_ Sell Abaor lion Com22rt2nr
Design Flow - Paak ( d) 2 6e2 L~1gas ( hS~
Maxlmum Influent Partlcle Size In
Maximum B SS (mglL) rrg/L) _ 22U
Maximum T { - _ 1SU
_ Table 3~: '-M'ainte'nance Schedule
Saptle Tank Inspect and/or servlce once every S- are
Outlet Filter Inspect once ayear and clean at least once every 3 yuars
Soil Abso lion Component inspect once every 3 years
tip clank
The septic tank shall be maintained by an individUa! cartflied to se.'vice septic tanks
under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with
NR 113, Wis. Adm. Code (Servicing Septic or Holding Tanks, Pumping Chambers, Grease
Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Prlvles, or Portable
Restrooms).
The operating condition of the soplx tan nd outlet fiber snail be assessed at least
once every 3 years by inspection. Tht(ouL,; filter -hall be cleaned as necessary to onayr-q
Rroper opergd!on. The filter cartridge snould not be removed unless provisions are made to
retain solids in the tank tnat may slough off the filter when removed from is enclosure. If the
Management Plan for a Septic Tark and Sod Absurption Component
filter is equipped with an alarm, the fitter shell be serviced if the alarm is activated continuousiv.
Interco ttent filter alarms may indicate surge (lows or an impending continuous alarm-
in the
septic tank shall have Its contents removed when the volume of scum and sludge
exceeds 1/3 the liquid volume of the tank. If tho contents of the tank are not removed at the
time of an assessment, maintenance personnel shall advise the owner of when the nerd service
needs to be perforated to maintain less than maximum Scum and sludge acwmuiabon In the -
tank. - - -
Manhole risers, access risers and covers should be inspected for water tightness and
soundness. Access openings used for service and assessment shall be sealed watertight upon
the completion of service. Any opening deemed unsound, detective, or subject to failure must
be replaced. Exposed access openings greater than ti-Inches in diameter shall be secured by
an effective locking device to prevent accidental or unauthorized entry Into the tank.
No one should enter a septic or other treatment or holding tank for
any reason without being In full compliance with OSHA standards for
entering a confined space. rho atmosphere within the septic or other
treatment of holding tank may contain lethal gases, and rescue of a
person from the Interior of the tank may be difficult or Impossible.
Tank abandonment shall be in accordance w;th Comm 83.33, Wis. Adm, Code when the
tank is no longer usud as a POWTS component.
Sol Absornt~4 t
Thu soil absorption component serving this structure is designed to accept domestic
wastewater from a iesldential facility. The timits of operation of this component are shown In
Table 2.
The longevity of a soil absorption component depends greatly on proper and timely
maintenance, and system use within or below the limits of reliable operation. Good wallet
conservation practices by all occupants and the Installation of water conserving plumbing
fncturea are key factors in extending the useful life of this component,
The soil absorption component's operation must be assassed by Inspection at least
once every three years The inspection snail Include recording the levels of pending, rf any, in
the observation pipes, and a visual inspection for any evidence of surface seepage or discharge
from the component. on steeply sloping alias, areas of erosion should be identified and
reported to the owrer for repair. The surface discharge of domestic wastewater or sewage
from the system is prohibited and considered a human health hazard.
1'rafflc around or over the soil absorption component should be avoided particularly
during winter months. The compaction or removal of snow cover over the component may lead
to hydraulic failure by freezing. This type of failure is usually temporary, but is difficult or
Impossible. to repair until weather conditions Improve. In general.
to the sell and d epers soil C01 wh ch may r hit0
component will reduce diffusion of oxygen into more intense, and earlier, organic clogging of the soil
2
ST CROIX COUN'T'Y ~ R a.
SE11I IC" 1•ANK MAINTENANCE A(7REEMF0T zCFNEQ
AND OWNEItSBiP CERTIFICA-110N FORM
CWN7V
r 70INCi
OwnerMllyer -1-'M <~5'a fJr4_y~,- U G T T -
- Caaaiacn6
Ptopetly Address .,~cf
.
(Vedfication required from Planning Department for new construction)
Cilyl$tate ~(i.~ I Parcel Identif rntiun Numbrt
LE-Q1ES(.1dPTt0N
Property Locatitnr e4t) Ye, A)&? `b. Sec, 3r2 , T-29 N R-z! ---W, Town of
Subdivision IV-L-,0 'ry~. Lot !J
Certlfird Survey IUnp IY Volume.. Page # - - -
Warranty Deed H Volume Page N `/fr
Spec house O yesbf no Lot lines identifiabl4 yes 0 no
SYSTEM MA1N'TENAWE
Improper ow and meintenanrruf your septic system could rcsull in its premaoue failure to handle wastes. Proper maintenance
consists of pumping oil the. srptir lank every Three years or sooner, if needed by a licensed pumper. Whet you pill into the system
can affrct the funclinn of the septic tank as a treatment slope in the waste disposal syalem.
Tlrc property owun agrees to submit to St. Croix Zoning Dep ttinent a certification form, aiyned by the owner and by a
mostrr plumb-r, jotnneyman plmmbrr, reslticted plumber of a licensed pump" verifying that (I) (be on site wastewater dispogal system
Is in proper otwinhng condition and/or (2) ■pcr inspection and pimping (if necessary), the septic task is leas than 1/3 full of sludge.
1!we, the undersigned havr lead the shove requirements and agree to maintain the private sewage disposal system with the standards
, in, apt-thy the Department of Cornnrtree and the Department of Natural Resemtues, Slate of Wisconsin. Certification
salfo rth h .
lating lh It scp)lf system has been maintained must be completed and "tuned to the St. Croix County Zoning Office within 30
:1181401c,
days o h 'there y at exldralion dale.
SIC1NA111RN, c* A V Lif A)JT' DATE
(~1V EJ~CEK'1'l 1()~1
(wr) err, y that all statements nn this firm are true to the best of my (out) knowledge. 1 (we) am (are) the owner(g) of
the pt a try destr cd alwve, by vii tae of a wannnty deed rrcorded in Register of Deeds Office.
0/
sio Anlpn Of Arrlll'nNT DATE
Any infmmalion that is mis represcnled may [endl in the sanitary permit being revoked by the Zoning Department.
Inelilde ullb tills arpllesdon, a slanted warranty deed from the Register of Decds office
a copy of lire cerlihcd survey map if re[crence is made in the wannnty dcrd
r
W1WOrWn Deportment or Convnero,
So* tied 8A*v omition PRIVATE SEWAGE SYSTEM o~ih`Croix
i , INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT? P-7i" No
Piinatd Mltermion you p vim nwy bo twAd for ooeorxloy psrp " (Prlvery LS-. 9.16.04(Ixm11 38 17
m H r r me: City vi cage Town at: ute n 1 -
rdine Jim/Lisa Hudso Nownship
CSTBIA~ Insp. BM E e.: It Dcr<n ra l.x No..
qS ?S 9-S~ l/ 020-1342-10-180
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS FI FV.
Septic n ~L O Benchmark T, ff 0
n Alt. SM
La - - 11 fcp
Aeati - Bldg. Sewer /
Holding 1 Ht Inlet S s 9y2
TANK SETBACK INFORMATION Ht Outlet S ~S
TANKTO MwriiBLDG. ROAD Qukg~
Septrc NA '9r
NA Pleader/ManL f.
on Dist. Pipe M .Od so 9/.T-O
f/. f
H6wing Bot System hR ~ ° 'i°al.s'P
PUMP/SIPHON INFORMATION Final G(ade
MaLlufacturer Demand St cover z.
Model Number G
TOH Litt F uroil S tem TDH Ft - -
Forcema9- 'Cength Dia. o r
SOIL ABSORPTION SYSTEM
r Imido Di+. Ipud Uapth
No.Of Trencher No.of Pie
01 EN 0
N S'51 DIMENSIONS
BEbI NCH; LT~
E urer:
BLDG WELL LAKE/STREA L 4CAI
SETBACK INF-0RMATION ~A a uvtr
DISTRIBUTION SYSTEM
Hea,ier /Mnn:~to ni<trib.Xa ,pe s - x H e ¢e + nv n pa<h,9 enl lu Mr Int. ce
n
L9rgth ~ I t nia 4 I nngth (lr` ny ~ Spa<wry S^ 6 ` I / > j'~
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth over baOth Urer xx U¢pm Ol xx Seeded/Sodded xx MUlcheO
tled /Trench Center hrvlrTren<h Fdges Topsoil ❑ Ye, ❑ No ` F3 YK f1 No -
COMMENTS: (include code discrepancies, persons present, et(.)
Inspection #1: /11/ d/ Inspection #2; / 1
Location: 508 Carriage Lane, Hudson, WI 54016 (NW 1/4 NW 1/4 32 T29N R19WI - 3229191834 Windsor
Heights -Lot 18
1.) Alt SM Description _ o 5~,. t A> lFu n.r d
2.) Bldg sewer length= ? 2Z r Est "`r _
-amount of cover = > 17 r
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Plan revision required? Yes (,J No
Use other side for additior6 information. M-1 ail]
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