HomeMy WebLinkAbout032-1066-10-200 (2)
1 of Lc^:merc. PRIVATE SEWAGE SYSTEM St. Croix
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INSPECTION REPORT .....x,P,-,!N„
GENERAL INFORMATION !AI :A::H T;) a-RPAITi ID No 420381
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,,w Ildl:oYV Name ll itr `i tll~~e town-`q. I Famcl -a. NO'.
Jason Kammerud TOWN OF SOMERSET 032-1066-10-200
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24.31.19.328A-20
TANK INFORMATION ELEVATION DATA
Iy~F MANUFACTURER G+\P:u;a 11' STATION B1~ III FS FR FV
Settle Fencirri
Josin9 Al: B1d
Avrallon Bldc sov .T
f biding SI1 it inter
TANK SETBACK INFORMATION SIP it Outte'
: ANK T::' mil :h'LLL BLDC; Rr;AL D• Intel
SCpI1C DI Snttarn
[ri;on - eaoer,-Man
DISl. Plpc
Idg Got. Svslenl
Fina', Grade
PUMP/SIPHON INFORMATION
Manufacturer Demand Shrove'
rrrr
lvi .xlel Numnc' -
l DH t iH Fiction Lots System Head ' Lit I Fl
OrCemare LY Ua!M D:a R'ell
SOIL ABSORPTION SYSTEM
BED/TRENCH •.bm:ri L,-,lV NG CY ':cn::bc: PIT DIME NSIONS ur OI 77 In:atlcC Liqu<Deoin
DIMENSIONS
SETBACK Sys-LM 1!) p!I. BLLT3 'v'ti=11 iW,=~~:T RCfuV LEACHING nr=nuteoLre:
INFORMATION _ CHAMBER OR
:4:r ~Y 5'ismm UNIT
Idcoel Nareuer
DISTRIBUTION SYSTEM
'mvyvorvArnnrtale tic,mt ul .Hole see =Il:,r su:u,nul :em'. r. Ar ntaec
n,pn' - Lzngin _ i:r: Spacm
9-
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
ueF:n Over tic otr <p e. ,r ❑VOn W c:frc r ,ytlcd zr Mulcnec
Fsec'I rz^[li Gen:ei Bctl'l encOl ane:: IaFm1i -
Nc Ye5 N!
COMMENTS: nmlu;te c.nae d!x°epeneies. c-•ewm; plesenl, ail: i Irspor:tur si :rasped,nr 92.
Location: ;27 ;2NG SI
1 ! Alt RPA Descnption -
?.1 Rb b sevver length =
- arnnunl of cover
olar Icvlslon Requued-~ Ye5 No
. se other side for additional mfolnlation
bah Inseprort-S,pnaurc ..rl Nr.
SRrv- adt Goa
G° iq County Sanitary Permit Application ST.::RO,X COUNTY WISCONSIN
..L h acoJrU wtl naoert SC ~roa unt1 .am an Jr;wanPLANNING 8 ZONING DEPARTMENT
_~p.•~, °vrsonal info ratio y,u nr1 may Dt L!s iX ~n ary uurposc•s T C~,JIX 0711N7Y ,DVL~ ZNIAEN7 "ENi=F
j°rrea^1' a11.-S. ^ C1♦{ jmi~
.j 1ussr71an Vdt 54015.771,
rl
tr•l' ' i'.355-4;~9C rax t~i5',386-4585
AY•an. i.ornclelc Plans in' the sysleru :2 x 11 m(ae5 i- sae.
Courny-samtan >ernr. C ] Checi. i` :evisior tc previous aoPiiaa:ur
5 - L6A- ao3
A ilcatior Information - Please Print all Infor tion Location:
'ro;>?rtV lmme* Name
1:4 1+4 Sec
iN p i0^1111''.
~rooeny 31wiwr M.admc r'iodress Lot Nu.n❑e- 91ogk Nu:n~r
Cry Stale 2:Ip Co::e r'hom Numer Subd;msion Na'nc o''CSW Number
r
c.5 vv\, va t l5 yZIF
I' Type of Building: tcheck one; o}C el ~ 12;ny ❑'Village Town of
n amlty O vet clc - N: o' BedroornC'. .3 (1;
❑ Puohv-Diem to".oescribe Usti
❑ StafE o'A'ned Nearest Road
L. Type of Permit: heoi. o.nw one Dos an line 4.. Che:J', box nr line F V aPphablt', 7Z7
Pace. Tax Numbef;si •7 1
Al Reair ^./fS Reoonneciion ]NOr-pi-mbin[ ]Fr?.ruv31aEOc
Sanaabon~
Bi Pernit Numoer / -tart 1 sued
„''Y Sialc Sanaarl ='ermh was Prey gosq tssaed -
IV. Type of PDN'T System: (Check all that apply]
Non-pressu-r_ed In-around ] Wind -4 F. su6abk: sail ] Mound 24 in. sultaole soi, ❑ Mound A
❑ Sant Filter ❑ Cnnsin.aed Voetiang ❑ teat Filter ❑ Drip Line
Pre-ssuauC iv-prnu2d G Holding -aril'. angle Hass D Other
10-uraoc ❑ Aefob4 -reatrlcnl Jrit ❑ Re;'uCU;gbr'y
V. Dispersal7reafineni Area Information.:
i. Despn FU1. PPd - Cii>p.za. %uua :i Dspers,a Are* 4. "Sol, Aochcaflor =ate 5. ?eroota:tor i•lalc n Syslern Gevdhor 'T Fine Graze
/ KequireC Imposed !Gats:daysg t i IIVi r.Jmctj Eiecatior
VI. Tank information -apaicig it 'alms Total p of Uaaufa°.ure' p'e`at !Sae Con- Stee! Fiber' Piasilc
Ne, Exlsung gallops -anus cona-eie Stricte! glass
Tanks Tams < ,
C ❑ D ❑ ❑
VII. Responsibility Statement
L ille underxigoed, ass;ITE fESDO-ISID"I'Y fof rP.palCreoJpo20:ID'lif°_inwenatlo9iC[iaila[ior o, non-plurrlbil; `n' tie PO1h7S abnWn or tie aaached p:ar.s A,
I`.✓•rsc; !S/hot m tared tor terralift repair o' Ine ins;al:anor o` noY-;rfnrurrp sanGailgn s)5tem.
='lunftibrs Name ~pfcltj. Plcmoer jrdnamre ru~e-tamcs:.. MP•T.1PRS Na. 3usumss Phone NJratv_•I
PlJrbe AUJ•ess iS lee Ciy, °l sir CcU7r -
VIII. County Use Only
77M 7
:`allrarr PermH Fee F;aT ISSJeC issuing er S'•gnn-,ue.
>610proveC Jv(.IL "a'-gn~a ~e 41 L5U /:3 /
;X. Conditions of ApprovalfReasons for Disapproval:
SYSTEM. OWNER: ~ 1 T~s~~,~~ ~e~ ~ ~ ° e~ • P 1 kr~
1. ',Sltptk link, ErBa ~Iltc' :n 1 I _ ` n, \ / r I
all ~ c<II ^u:,: all be
is per,tlaragemer• pion p c iue . Ly ~lu.nce~.
2. All Whark fe•ct,ir!• -.en„ frill .t Lt,.- r. nt. r .
aperapFncblicnC.!:rd gnat
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7RE~X-HES WILL HAVE It STA1ll AKA WALT. EWCA
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF EXISTING SEPTICTANK(S)
This is to certiI'v that I have inspected the existing septic and./Or dose tank
presently serving the following residence.-
(Street address) located
at 'A. Section Town N, Range W,
town of St. Croix County Wisconsin.
Upon inspection, I certify that I have Ibund the tank(s), to the best of my
knowledge, will conlorm to the reyuirernents of SPS. 384.25, and it (they)
appear(s) to be functioning properly.
Most recent date of inspection or service Did flow back occur from absorption system? Yes No
(if no, skip next line.)
Approximate volume or length of time: gallons minutes
'l'ank Capacity:
Construction: Prefab Concrete Steel Other
Manufacturer (if known):
Age ol`Cank(ifknown):
Permit number (if known)
(Licensed Plumber Signawre) (Print Name)
(Title) (License Numbcr) 'v1P/MPRS
(Date)
Norm to be completed by licensed plumber (Dept of Safcty and Professional
Services Chapter 305 and s. 145.06, Wisconsin Statutes) or licensed disposer
(NR 113 Wisconsin Administrative Code)
Rev. 2/2012
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Wisconsin Depar(mantof Commerce PRIVATE SEWAGE SYSTEM County. St. Croix
Safety and Budding Omsiors INSPECTION REPORT Sa Itary Permit No 420381 0
GENERAL INFORMATION (ATTACH TO PERMIT) grate Plan ID No:
Posionel information you provide may be used for secondary purposes IPmrau-y Law, s.15.04 (1 xm)I
Permit Holders Name City Village Township Parcel Tax No
Kammerud, Jason Somerset Township 032-1066-10-200
CST RM Elev. Insp B~Mt ~Elev: BM Description
d m0 • /IN. f/ol .B fyl 1`1
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic ^3 X.,~y O>, ' v Benchmark 3 eb
,L~~
Dosing 1- Alt. BM -7 'p g
A : ` 13.5 It
Aeration - Bldg. Sewer
3 0, 9
Holding ` . SUHt Inlet
all /oa.s-7
TANK SETBACK INFORMATION suHt Outlet
, 9 ( Q5. 3
TANK TO P WELL BLDG. Venito Alrlmam ROAD D Inlet
Septic ) f r f Dt Bottom
3
Dosing Header/Man. 510
Aeration Dist. Pipe IZ S t qg 1
Holding Bol. System
Final Grade
PUMP/SIPHON INFORMATION 2 • Z
Manufacturer f mand St Cover
1 •sS ~O•S
Made umber
TDH LiN Fri oss System Head TDH
Forremain Length DISL loWell
SOIL ABSORPTION SYSTEM
BEDlTRENCH Vv'idln Length 1 No Of Trenches PIT DIM NS No. a Pits Inside Die. Ipuid Depth
DIMENSIONS
SETBACK SYSTEM TO P/L BLDG WE L LAKE/STREAM EACHING Manu r 1
INFORMATION
CII
TY f System: AMBER O
UNIT Model Number ` - a-t o
DISTRIBUTION SYSTEM J J d
IHeaderMandod U Distribution vy1 t x Hole Size x Hole S~ V .6j,
LengthO_Dia_ LengohI //5 t kT. r7 ' ~7 , JCY
iPs(s) _ Di0_. _ Spanng / S
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only d l
Depth Over Depth Over xx Depth of xx Seeded/Sodded
Bod/Tronch Center So&Trench Edges Topsoil
i
Vc"V
yy n; Yes No Yes No
COMMENTS: (InGude 961 ~screpencies, persons present, etc.) Inspection #1: /e //d Inspection #2:
!-.2
Location: 727 72nd Street So_mrsrta'et. WI 25 (INrWW 1/4 SW 1,4 24 T31N/R"19W) NA Lot 7 7 - P/arcel No: 24.31.19.32BA20
1.1 Alt BM Description = q l "J o k Aw n ( ~rGYt dlJ [~y7~/ f 2 F~ (~f f yw ~f/1 6(/ ~DyArQfS
2.) Bldg sewer length = 13' -d~~ 6rhig, kUU "-'a s4ko4j, - , _AA;74- J vJ,►' ',_g 5facAML,
- amount of cover = . r-ICLCLt'~- dl t7 evA't2- ~"~~J'T' /Q~,~`~.-.~cpua.e ~f*Ut iQd
Gl.~(.t?f" / S ~c~i I►. II //.tom.,, .
Plan revision Required? a.. Yes _ No
Use other side for additional information.
SBO-e710(R,v97) Date Insepaors igna(ure Cart. No.