HomeMy WebLinkAbout020-1349-05-000 (2)
Voisvnn:.m Comrr.:l:x St. Croix
l;vpartrtwnv of PRIVATE SEWAGE SYSTEM ry
Su'mv w d lintlu^a D v*icn
INSPECTION REPORT Samrar-. Pem::: No
A I TAC' 1 TC PFRM:l 607047
GENERAL INFORMATION ,la,e Pla• IE No
=^c:::oal llo:ratior vc.- proaA:::-uy be urztl IJ'seconeari =,;rP¢:v:. -o ancY 5 11 VA : ,
Perot hl.~ldc. Nnn-c ry .•111dGC -ax--;h is Fa¢1i ;.v No
Richard Stout TOWN OF HUDSON 020-1349-05-000
CST 31.1 ahI UeS. iJLNt $c<:I VU/-<rxnfH.dn4e+Map Nu
~3•.2l oL,~ 4:,.Cr~Q I~ 26.29.19.1881
TANK INFORMATION ELEVATION DATA
-YPE h1AN'„f FtCTURFR CAPACIT' ST''.TION Rs III -S ELEV.
:v_onC 30nglmarF,
6_w, 64 FA LJ / 1 s o 7.6 /06-Z 1 93 21
Uw^Inq i/ ri i. /2.Q7 AIt. BPI! 9 'f53
a.
w S;Mk.~: +cl Ring : E ;s+ 4s s1
Haidlnq `+UHf Irilel
SUHt Oullut
TANK SETBACK 11 FORMAT N a
ANY. T::' "LLL R. DG Verol n'nmke ROAD D11'11_1
5~ 8c~
i>cu,ic ! . 1 !1 Dl Bullnm
>So 7ino IZ 9 - - $Z.3
Liosing 7 Heade:Wan qq.
Sa 7 iaU ZD Za - 7,
A~ra6dn DIM Pipo .
Holdlnq \ Rol System 93 II/
Fina Grade
PUMP/SIPHON INFORMATION 3. 75 9 sf
Manufacture- / Demand St Covet
Zoe( 1, s I Fr $g . ~F
,
PI NIrZ o0 152_ ! O ri (t
"Iln Lit. 0 Fll(alm I oss System Head TD-
j/. J A)w % 3./¢ Ise
oreernaln Lela tr I Dia Z / _)Ist tc'NCU
SOIL ABSORPTION SYSTEM
BCD.7RENCH aidfh Le^pC No Of'en_nec PIT DIMENSIONS No Of ° f:. ms:tln C LIrJUJ :1in
DIMENS
IONS of _ 1 /e SETBACK [G P!L BLD. LL LAKFISIHEAM LEACHING INFORMATION CHAMBER OR C0AJeAX , /o / 17 A4_ UNIT 11
DISTRIBUTION SYSTEM 1 a-2--2 r-Z S
LcnStn _p~Ck~ _cng:h Ga ~ on:"":'
SOIL COVER x Pressure Systems Only xx Mound Or At-Grad* Systoms Only
Lcpt" -^a+r rePr.:'.m xx D1.11 of xr Seedn:: SCatletl xx Mulcnen
Fr:,: 7rencn Center Z L / Badsl cencn L"-=t lopsotl N; °cE No
COMMENTS: (Include code disciepenccles, persons present M:. i 11 Inspection ult Inspects
Location: '19 BLUE JAY LLN'1 4.-
) All RM Description - Jr• C~aJL+I~ 4-o 600"
I
3!dp sewer lengtn
- arn:mn: w ccver - 1
-;ar (.vision Requnef~ Yes >x1c
use :4110' side f0' aciollmna nlonnallor'.
~atc Inse o"Sign ae Con No
z.RC+-G?tic t2 t'5?',
Y
'F, rO- 2D A -oq 3
tIj 1~ _d _ 1400 E Wa*wgtm Avc [•~V~~
rte.. - P.O.
W] s3 53 6z -216
dmon Smmrr~wobaFIDWfi dabyC.)
~ l,t , wl to o7a z{7
a `L Sani Permit Applicatio Same TanootmN.aha
G ecmdmioeMklt SPS 353:21('2)• W4, Ad,
Cock,
m athmiasm dtl~ktm to
>rVOtad PnOr W Obpwini.0aywyy pmna. Note. Apphcabm farm for sbft maw- POWIS are subetaeed b
the owwbnatef ssfoty wfrokmomr tiev;cn Parotmi mfamobnt ym p vmk mry be used aemrdmy Noled Addmr rifdiBmmt thee m.tliog eddwm)
L m_. -ram mot Antafw=Min 719 PLt:Z--: 4Y L-AVC
f4aparyt>wcl Naatc ,
Pend r
Y~ t L' tf~) D ~ ~ / Su LGT ~ n l-YS /f:~ '~K ~/~s LLL 0.20 • ' _30 - U S5 6oo
mWorly ow- Molvtg Aadio Rawly Lacebm
3 4
cdy.si*e T zip co& Prase MAMINN Gw".ol -
1 Type of Byid (NeekJ WeaMl1) lag T-`=_L N• R Eo~V
ar2FrdYDad
its-Ntmberd OOdramo J sabdi.nm l4war
a PObiwrCmurael _ Dmmle the IcYe Me.'~•i ' P1~1~~~~ s ielJ)Y~[
❑ city
❑ Sbk Owned- Dmatle Use CSM lieebv D vow of
-
3 ll w 254-2,54- ZS ~9 TOaa or
ILL 1"Cem mr: (Cbeck(((_ Ifne A. Cespkfe Rme 5i11 applimble)
A. ❑ New S p Repleomtaa Sys TmtlaetMdd'v,8 Tetk RVWmnaa Ody ❑ Odm Math kol m In
8. D Paint Rmcwal O Ramt Ream ❑ chmovdpk-6. O Pwmu Timakr b Nw Lid Paeriota Puma Ma~ Sad D! bmmd ,
setae pipirenm
IV Cbadt snow o.oa W~ 55 ; 7
mply)
~ br mmd 11 Pwirrd
kr•Ona.-Od ❑Aefialy ❑Mam>24 is afnmetMeawl a~
Q ~'wsTao~ 'omen lhspCml caetpame (W~)~9 : V v~ - "I E.cj ❑ d--~- Dm,;Oe (@~)_ .-Tn~-'.'1d'r Q✓.~<•Je- 1
Area Insrmiarba:
Desip Flow,, p,yaB, sad keti n Dape,N Am Regwted (d) Diepnml AM Symko Elevation
Vt. Took Into 5
Q
Oren Callum uwn kramaLmvQ
/ J ybt cT
Sqft New Tads Pa4rTmb w 71HfZC. ~ t+ ~ ~ a ~ ~ ~G~
QNrr,~~ r w
DmeR(ysQ Q: 11L'10 ~G /ESC r D.
va I .c0 lzC~) i er X
Seareas.e- 4 eke awes r.*eaalRky. for fine ffisom or Se POWTS Own w s m, atSOed
Ph.ahm'a Name (Prim) 'a SipiO.e
' a~'Yr(PRS Number Bu= tW Pbme Nmnber
7y~R1~ LZ{. r z7-44a.37 7S-
/
r1 •aAdWas(Sbtt•City.SWezlpcode>
CS H( E sT• CA ~ WT ST17z
vnl rose
al Use
App ad - i Farm Fee Dele SB>m~ _
for Damd ' S 5,60. 3 Z9 /9
nc c
o,pwea1 c~ - .i J, lX A,.d ~j' y~l,e 5 p- o
asperiW316emen pin c. ~.i ,,:..nDe
Z. All aelyp n'c~Jrr-errs must W., -X..t. ii e , {ad(~. '
aOMlfFdpWeGIC•:(:rncsmc •rr.r....n u. JL 8) Z 5 G1G~
Aeetd r.raar ere rtr re .y.. yym.w V m.. a V1: et vtw. r
sBDL3" (R. 08/14)
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER. _
I
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- . - - - - - - Gam- ~ 7
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PAGE 1 OF 5
In-Ground Dosed-Gravity Plan
Index & Cover Sheet
Component Manual Design References'
Version 2.0, SBD-10705-P (N.01/01, R. 10/12)
Pg 1 of 5 Index & Cover Sheet
Pg 2 of 5 Plot Plan
Pg 3 of 5 Dispersal Area Cross-Section & Plan View
Pg 4 of 5 Pump Tank Specifications
Pg 5 of 5 Management Plan
Attachments: Enclosures:
Pump Curve - crj FILL POWTS Application for Review _
Pump Specs - o.U F 1 eE Soil Evaluation Report & Site Map
Filter Specs
rank Specs -C~ BILE 'S'pecs
Project Name 1 Description
Owner Name(s): Fl I Ct6-IE1,D ~:;16u_T Phone:
Owner Address: I 3 AUJATflkLL TgAI! -,FyP`--= ^i Zip:
Project Address: 719 &-t IL 'Ay I-4 ^'L H u 1
Govt. Lot: 1/4 of 1/4, Section 2e , T I N-R l~f E [:]or V1
Township: I t hD` / I County: s efz IC
Project Parcel ID c!.l ! - c=,-
Designer Information
Designer Name: Mary Jo HuPPert Phone: 715 _426 _1775
Designer Address: 28497 King Arthur's Court, Danbury, WI Lp- 54830
E-mail! hollisterdesign@outlook.com
License Number. 1859-007
ILIARYJo
Remarks:
•~.Lj\ ND1859T
'.RIVER FALL1%,J
vel ` c
SIG[J~.F
nn:wamI
Signature Date: --7 c:
On<pna}! ignature requrten oh ca WY bMMLd copy
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
:
1
I 1
"
1 t I
W
i ~ t I I I 1 ~
I I
I ~
47
3 I 1-' j
4-4 c
t i i t 1NJ 7
'Alt
74-
1 1 , ~1bD Dr
i
NOTICE: Please provide the following:
A plan view sketch showing everything within 100 feet of the system.
• Two horizontal reference points to center of septic tank manhole cover.
• Show alternate benchmark, if applicable.
y PLAN VIEW
b h
I ~d ° F
_ I
INDICATE NORTH ARROW
r
)IC>U~ r)I~~~~
= PAGE 3 OF 5
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PUMP CHAMBER CROSS ~ICTIOIJ Akif, SPECIF ICA-I 10hiS r
- .57 1,ti&
VENT CAP .l
'I C.I. VENT PIPE
WEATHERPROOF APPROVED LOCKING
25' FROM DOOR, JUNCTION BOX MANHOLE EOVEF.
WINDOW OR FRESH IZ•MIU.
AIK INTAKE I
GRADE I
Y MIN.
I
IB•MIU.
couDUIT
INLET PROVIDE I
AIRTIGHT SEAL i III
A I III
I III
I I ALARM
6 I 11
I I
c *APPROVED I I Ou
I 1
JOINTS WITH
ELEV. FT APPROVED PIPE
31 ONTO PUMPS OFF
0 SOLID SOIL
CONCRETE BLOCK
X- RISER EXIT PERMIIEED ODLti IF TANK MANUFACTURER HAS SUCH APPROVAL
SEPTIC E SPEC:IFlGATIOAIS
DOSE
TANKS MANUFACTURER:-dW' 77~ AIUMBER OF 003ES:./4"'_PEP, DAy
TANK SIZE: /.2C6i GALLONS DOSE VOLUME
ALARM MANUFACTUKER: __dl_ rn~ INCLUDING BACKFLOW: asF GALLONS
MODEL DUMBER: 24 y CAPACITIES: A= 21.3 RJCHES OR 1401_P GALLONS
SWITCH TYPE: Q ! B= 17 INCHES OR " GALLONS
I PUMP MANUFACTURER:L•
ld S C><_._ L _ RUCHES OR l3g'7GALLOUS
1 MODEL NUMBER: F rs T
D ~ INCHES OR 11.F_ GALLOW
i SWITCH TYPE: ~>e v DOTE: PUMP AND ALARM ARE TO BE
MINIMUM DISCHARGE RATE- y~ CPM INSTALLED ON SEPARATE CIRCUITS
VERTICAL DIFFERENCE BETWECU PUMP OFF ANO DISTRIBUTION PIPE_ Xe ` FEET
+ MINIMUM NETWORK SUPPLY PRESSURE ..fir FEET
+ -a=._FEET OF FORCE MAIN X a,G.ZFYo RFRICTION FACTOR..-7,11'? FEET
TOTAL OyDAMIC. HEAD = 4Z FEET
IUTERDAL DIMEIISIDDS OF TADK: LEAIGTH ;WIDTH ;LIQUID DEPTH
91GNED: / LICFWSE NUMBER:_Zez Q DATE. 9~
PAGE 5pF
In-ground Dosed-Gnn* Management Plan
OMPMMT:
The owner of its illgaatd daaedmgad(y syaban shw be reepMatls tar ib parpaid rperatm and.ndnrwlsrtoe
pustrerl to nageiaaltsla d tips 302-31K Wlae Adds Cods Pharrt to SPS MM (2), Wise Admin. Cads. fit
syslorn shat be mtetdered a have homM heeane' f rot aei I I 'IN eoeadmnca am aft approved toenogpmtwl
ptam Fiatssaac a. at, - and mairferrarm actftiiem shellbe perisnled by a ra§1 I POWM Ualahhw in
amordwrce vdh WS 383 52 (31 Wisc. AMAL Cods
Daman F bw a firs: MM S ZM wept'', M S 150 wQO, FM S 30 mgt''
hmemon2wom Hi8PECT EVERY3 YEARS
o type of ems
o aped system
o nuisance fvdm (Le, odour raver ooapsirle, el;)
° nradrstan n"MW eau' (La. POMWM vaYau. s+i ' &01% I*-)
o wslmfd th"Wm (La, teMm. taeutes cMresiorl ab)
o solids vduwe in astawobie tleamllwt fus(s) MrWS any ddrbeerlm apprrewmrne(s) (La_ dmMMian / dap booms)
0 raa,art orleeprrper use (im, arwse6eg dssipel anPaiss, pr --a, aelNSias„ dr^)
o ea.1 -of pdatrlp in dibfeetut vet illwb doailrp
° -10 tiagumd em -ir t iookel s (Lae, pump w -q r foot safth aelligs, ae--)
° elec. cowomeri a - t applicable (L0., r- - 06 wldtea. oowds. saws. derw^ a/c)
0 dieii kgm kftW a tall Mica pfutf bums hied dsld pnsmeaa-mopes In nadOn $tadtcason)
o safaoe dfedr gm d eOeat ar message badcrp its abuckea served
MAWAM EVERY3 YEARS (or Wait- nfoasem A
o Stela rr110n 1r valt~l0 d all be mad by a carted arpisps asvigep opare- - -versed udar a 281.18 Wfm
as rawAmd by bod ardnarme_ tm&W nb asa.ihind (1A) f10 HgNd vohae0 of 1110 taeige} or
Ofrpwai of
ooraeet0 ells- tee peaarsl b "R 113 YYisc Adsrh Gbds
0 LUMMANIN shat be irepecbed every 3 yaws and shM he dameed wbn recereary b plasma any
I
sOkk aeeoef® b maraiact<m% wec&Mwm A servicing pwiod,ri swap be premier OW 12
dh&
8PS M s0 rrhet be subwdthd W 1110 proper tool govarrswant tad[ Irv MIGGA Mpe wits
fba flat aa7l oowepenak tNnaa ar wmUlaldion fs
AM ddedies ttana d irttiriduel a oonrpaty: A pV.1.t,C6D SLI~AC Plrona: ])5-703- 8'55']
~mallraaw.nante.en.ddr.esc~~-'-~ 2F
~ Begun a ciiep+acameof wed or WA&mdot M apwren to WS 3B3 5t O wiw Adrr~n
"o p1 W W kw d,.raral a Pik redorafon of ft rorrfs C01"~' °R' WS 383 Ws- Adair. Cade_
acmnhrl® UM SPS Sea, Wiw- Admi>_ coda. be limed yrbess approved by Ow depauwmr
Sf Pfan
a ate at"t tat any feted beaineri eawytonmrt of b-& POWTS co riot be repaired i shell be replaced p=mt to
Plat elebatled b lifts appropriele agency for review and approval, A failed hVo nd dispersal o xrVona t may be
abandoned MOWS nnpiloed by a COdB-m~ diapered cMIQMBK in a Me-delanni led area of suilalso a7i5.
n
If use of tae POWTS is decoemrarwi, it shat be abandoned in amMdentca vlttt WS 363.33, Wier. Admit Code.
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i 1 S-F-100 FEATURES
a
1.
• Low maintenance
Easy to install and service
1 Fconomical
' - - Extends life of drain field
d1 1-' Improves effluent quality
_ The last line of defense before the laterals
Vortex scrubbing action helps keep fitter
clean providing maximum maintenance
• & intervals
;'x d Uses a S.S. filter screen with .062
!E - diameter holes
5 ? Provides a 69.52 sq. in. or 41% 7per.
_ area which allows the filter to pass 83.6
f GPM at 1 PSI
_ r! Assures quality effluent with lower TSS
levels, keeping pressurized systems
functioning at 100% efficiency
loft, Low head loss.5002 ft. or.21 PSI
c Flow rate with clean screen 120.6/1' . GI'D
@ 1 PSI
Flow rate with 95% plugged screen.
d 114.912 GPD @ 1.8 PSI
Job ready with 2- schedule 80 LJMnf%
STF-100A2 and tailpiece attached (STF-100)
Field assemble does not include an ian
or tailpiece (S t F-100A2)
Use optional filter socks to filter smaller
Garl:cle;
Ft TER aCNFEN t!5 _
oN1IfRF1®YfTN
a w ar~a4ES5 s1EH TvFF 5« ~5 a
MtR00@FgLF9 25 •F->' i
. _i_x_r. Il ~ Orde•rac P:a SlG-ton
STF1 .0M^
,
-I J 1 , -i r97Fxr<•hlolMOr.
may,
::A: ] daa'il dr'r.~ng a~a,.a:d, m WCF format
_ I
v - I ~rM<O&!1<F NARY
.-RELATED PRODUCTS
~~°f~ - -tea 9 rF-104{OON page 14
STF-104-15019011A page 14
I STF-104TN page 1.
SrF-101 page t.
H3i .0 )t 21675 STF-101A
pag^ •4
~M STF-t07page 14
-J STF-107 page In
_x _Y•.iii....~-_ _r_ STF-FC page 14
FILTER INLET) Fpepeg!LEr S117-150page 14
l rrT U S PaWM Y 5. 985. 452 STF-103epage 14
Canaea Patent 0 2, 237, 751 STr-105 page -4
r ,ii Free e88-99'i n,;o rtN:.73' ,g2-1023 Fax 231582 7324 Er ai;l :.ir:teelQfreew;n. net Web w. gag walerh ~mn P.1ta
2
PUMP PERFORMANCE CURVE
PUMP PERFORMANCE CURVE SUMP: E_
--UENT MODES
ar t.-e x'seu~ ~aesW+:,_~r~~ YE 1.7 S 14' SOLIDS PASSING ^ Ao
_ ACtl
I.
ry mm
1 I
+-~I-t !tl Ml)) al '1 Jtl- .~6 14' W ~ <l1 4
t 1f' '1 G' a Lt
t Id =1! 1 i _ 1u !i Y 3X !"r'fi 8.
nr ..f
rzr_ a _ _ :R lug _ - ti
dGFf Yt 6. u•-
x
rt'rc-. 1'IC ---y<t1: 14 eh. la•<y 'hYldf
I( ~ ~ y 1
)f <Ift i I \r d ~ y. 5~ Y t~ 1 at l ~ ,l
9 f. 9 3 r} 6 3
k . u ~ G D. ~ ti /
I ^T- ter' I ~i tv-~ Y u n n~ W y
c 6 K .ID
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i CAUTION
r" _ r. a r n. n INCT .r - - u - oar. rt.:.unr
Tom' 'I•t^; r
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SEWAGE ,klC_~ -
-E DF'AATEZIhG
PUMP PERFORMANCE CURVE
- - - - - - - SEWAGE MODELS
- - - 2" SOLIDS PASSING CAPAI- T Y
r
'.C 3' arty.-.c. l[1•.=V3r he n:~
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF EXISTING SEPTIC TANK(S)
This is to certify that 1 have inspected the existing septic and/or dose tank
presently serving the following-residence:
(Streetaddress) 7/4 13LuC.jAy L*VL _located
at: 5w' -'+L '/ction ~ro Town . 7 N, Range H W,
"Town of H" bb J) A) , St. Croix County Wisconsin.
I''pon 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 _
Did (low back occur from absorption system? Yes No
(if no, skip next line.)
Approximate volume or length of time: gallons minutes
Tank Capacity:
Construction: Prefab Concrete X Steel Other
Manufacturer (if known):
Age of Tank (if known):
Permit number (if known) 4iySS j _
L/I K ITtl
( ice o sed PI ber Signa (Print Name)
il a E-- Al
(Title) (License Number) ~IP/M PRS
(Date)
Form to be completed by licensed plumber (Dept of Safety and Professional
Services Chapter 305 and s. 145.06, Wisconsin Statutes) or licensed disposer
(NR 113 Wisconsin Administrative Code)
Rev. 2/2012
S 1. CROIX ('01 N FN
SITIIC I':\Vh.1:UV"fl.N;\VCG:\GlZliI:MI?NT
AND
O\\ NFRSIIIP (TR I IPICATION FORM
Uwne1;'I;over ~ L'11_f ~ ~ /C
.Mailing Addlcss - Gl ~t (~FL° ~ ~LIc~.SC N t Ll L J~ C~~p
Propcm AddlcSf If ILA T~- ~rlrA:S` ~~~u l Aj
tber i licatunl Iequn'cd from I tanning c, Zoning Department for new WIWI aelrun 1
UlpState ~~tt~ I <O~~i ' Parcel Identification Number
LEGAL DESCRIPTION
I Ill pelt ' Location ~ ~
,
I Y .Sec. _ IN R ~ W,'Io\am of
Subdivision Plat'__ .Lot It
-3 -
Certified Survey flap H - - Volume . Pace ti
N1 arran(y Deed h - (belbre 2007)Volume Page #
Spec house )rs no Lot line, identifiable ecs no
S1 S FF,\I M,11N FENANCE AND 011'NF.R CLATIPICA1 ION
Improper l1w and ma Ime mince ul*cour septic slslem could Icwll m its prelnaurc tadurc In handle l,,ntes Proper
owmLenanre eonsisls ofpumping out the septic lank elen three scars or sooner, dneeded, ht a licensed pumper. What you put into
the scstclll Callaflect [Ile flllellon ol,lhe Willie lank as a (reamklll stage Ill the waste disposal ms(e•rll. Owner maintenance
n.~ponsvbIllues arc specified in ASPS iXi I ) and in Chapler 12 -tit Clot\ County Sandarv Ordinance.
"I 'lie property owner agrees to s1.Iballt to St Croix County Planning K Zoning Department a certification firm. signed by the
owner and by it master plumhel. Journeyman plumber, testrlcled plumber or a licensed pumper vent'tire thal 1 I I the on-site
llaaelvater Disposal system ism proper operating comfilion an&or ) al)er Inspection and pumping (it necessary), the septic tank Is
less than Iii full ofsludge
I `we. the undersigned 11a%e read the above reytill enlenls and agree to maintain the pmale Sewage disposal system with the
standards set firth. herein. as se( b% the Department ofti:Ilch And Prnfissronnl Services and the Department of Natural Resources.
Scnc .,I "i.consrn. Certification rating that your septic system has been maintained must he completed and returned to the Sl. (lol\
Counh I'Icunling k Zoning Depaninenl wathin is davs ofthe three war expiralion dale
I.\)e cemIN that all stalerncnts on Ih limn are true to the best of nix our knuwiedgc I:,cc till arc the ownru s l of the
pmpcrh dcscl IhcJ above, h)' virtue ofa wa :mty decd recorded Ili Register ()I Deeds Ollic,
Nllu~her of bedrooms
SIC, .'f( RI'.OF APPIJCAN I'(S) I)A 11:
!
"•'Am inti)rnlation that Is misrepresented nlay tcsull In the sannan pernut being revoked he the 1'I:mnulg e~ Zoning Depunmenf
Include 11111111% apphe:droll a Ieeordcd )vamom deed bon the Re;_i:ICr of I peed. 1 )Mice and a cope of the eertihed Sill %Ck neap if
relctenee IN made in the aurr.nh decd
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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM / Safety, and Buildings Division County
INSPECTION REPORT St. Croix
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permtt NO:
Personal Information you provice may De used for secondary purposes (Pnvacy Law, s.15.04 (1)(m)l. 344588
Permit [folder's Name: ❑ City ❑ Village Q Town o State Plan ID No
sird Town of Hudson
~ftli, ev.: Ir;sp BM Elev BM Description: Parcel lax No.
t~ lad -Iota r' PUL " _
TANK INFORMATION_ Cl) ELEVATION DATA_ _
TYPE MANUFACTURER CAPACITY STATION 65 HI FS ELEV.
Septic Y~JR /G Sb Benchmark •Z7 la; z ! tT T~
90 , 0 3
rig A I ~-<J71 AIL BM -100
Aeration Bldg. Sewer 7-.b;~ Sfl•S
Holding Q~NV& inlet r - S S 6
TANK SETBACK INFORMATION Z12 Outlet r p.r,yt b .o'
TANK TO P/L WELL BLDG. Vent eoake
AnInt ROAD Dt Inlet T
Septic 01.r l2~4• NA Dt Bottom 11.16 gf~
Dosing 20r NA Header/Man
Aeration - N Dist Pipe t• If °/4/, / > LM
Holding B System IO.ty7 fir
PUMP / SIPHON INFORMATIO sL! l.- 4r ~ al Grade 6.7$ QG: /
Manufacturer w 1 AS Demand cover 6 6x ! /SY ~T V
Model Number EPps GPM
TDH Lift Friction
11 ,.14 Loss /-I i System- TDHj6, Ft
Forcemain Length4-,Q' Dia. yr Dist. rowee
SOIL ABSORPTION SYSTEM
BED /TRENCH Width Lengths No Of Trenches IT DIMENSIONS No of Ms Inside Dia liquid Depth
DIMEN IONS 75- ) SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER TypeO / - Model
um r:
Syste OR UNIT
DISTRIBUTION SYSTEM
Spacing I Vent TO Air Intake
Header /Manifold rr I DistriuLOnpipe(s 7 , xHole i1 I. Hole
length Dia. t4 Length ~/S Do Spacing -7 /4 $r-!-
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over lkpth Over xx Depth of xx Seeded/Scidded xx Mulched
Bed / Trench Center red r Trench FdgeT 1 Topsoil _ LJ Yes ❑ No p Yes C] No
COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1:10 h~/'"► Inspection #2:
Location: 719 Blue Jay Lane, Hudson, WI (SW I/4, SW 1/4, Section 26 T29N-Rl9w) - 26.29.19.1881
roi (F)
( t4I4. SMA- Tep
~y{t.. t I tJ1~pl ~e t vlwvyr~ dA I I Shrd (whT,i ~S~~rI cw W a 5 , Ys try l lr.a/ ~ ~ Ytie loci q r.a~ ; w~
-"l tic cos V a t avs e~-
Plan revision required. Yes ~ No C
Use other side for additional information. . U- 1 I - 7
SBD-6710 (R.S,'97) Date 'nspector's S: ature `Zrrt N`i
S Safety and Buildings Division
SANITARY PERMIT APPLICATION 201 W. Washington Avenue
iseonsrn in accord with ILI IR 83 05. Wis. Adm Code P O Box 7302
Department of Commerce Madison. WI 53707-7302
• Attach complete plans (to the county copy only) for the system, on paper not less County
than8lrz x 11 inchesinsize. ,9~~► `
• See reverse side for instructions for completing this application State Sanitary Peefrmit NO~umpob>er
Personal informs on you provide may be used for s~ d" purp s ❑ check 11 h T r~e..ws application
(Privacy Laws. 15.04(1)(m)). 1 ql F/l isie~
State Plan I.D. Number
1. APPLICATION NF ATI N- P E E PR I NT A 1INFIRIMMASTI-ON
Property Owner Name Property Lora LOn
v4 tr4, 5 T N, R 9 E (or6-
Property owner's Mailing Address Lot Number Block Number
K S
City, State Zip Code Phone Number Subdivision Name or CSM Number
Ka` C g6 , r -If or, ( /5) _ 71 V S
BUILDINU: (check one) ❑ State Owned ❑ it y Nearest Road
Public 1 or 2 Family Dwelling - No of bedrooms a I Too n OF l u ;L, 4,r,41,9
III. BUILDING USE: (if budding type is pubhe,check allthatapply) Parcel Tax Number(s) 19- )
1 ❑Apartment/Condo 0,7o-13Yy-~~
11-
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church /School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: specify
IV. TYPE OF PERMIT: (Check only one box on IineA. Check box on line B, if applicable)
A) 1. kNew 2. ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5, ❑ Repair of an
---System System Tank Only ExistinSystem Existin0rY em
B) ❑ A Sanitary Permit was previously issued Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non Pressurized Distribution Pressurized Distribution Experimental Other
110 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 410 Holding Tank
12 gSeepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit r h 43 ❑ Vault Privy
14❑System-In-Fill S X /3
w. me
VI. ABSORPTION SYSTEM INF ATION:
1. Gallons Per Day 2. Abzorp Area 3. Absorp. Area 4. Loading Rate S. Perc. Rate J6Sytem EI v. 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. f) (Min./inch) 7537 'd Wxs n /7 ] '
Oct /.3Q a la A fa, _sir Feet OK- Feet
VII. TANK CaPaclty
in allon5 Total # of Prefab. Site
Fiber- - Fxper
INFORMATION New Existin Gallons Tanks Manufacturer's Name Concrete stuned Steel glaze Plastic App
Tnk Tn
Septic Tank or Holding Tank M~y G~ l r~ yT~Y.d ❑ ❑ ❑ ❑ ❑
I ift Pump Tank IS phon Chamber y~ g y C ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite se age system shown on the attached plans.
Plumber'/r's Name: (Print) Plum tier's Signature: N Stamps) PRSWn10.. Business Phone Number:
Plumber's Address (Street, City, State, Zip Coder
10-,76 gcqz&~Z-l S
IX. COUNTY / DEPARTMENT USE ONLY
/ ❑ Disapproved Sanitary Permitfee (1ntli°0'c.a ..u. a e issuing n S, nature (No Stamps)
OApproved ❑OwnerGivenInitial -elij t~
Ad
verse Determination X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL:
SBD• 6398 (R.I11/97) Mnaunoa: o.yw ra cmxar. oa. <oer so: Wins auuav, c a~ o...,, w.ae«
w'scahe'n`8panitentOf cem"'erbe IS.OILAND SITE EVALUATION
Diviskln of Sa''My and Buildings i Page of
Bureau of Integrated Services , in. accordance wAh s. ILHR 83.09, Wis. Adm. Code
w4.
Attach complete site plan on pepper not 1 aW8 12 xR«g sao. Plaonuin County
include, but not limited to: vertical and he on 141 reference print (BM), direclion.nd St. Croix
percent slope, scale or dimensions, north k. I a to nearest road.
Parcel I.D. N z
APPLICANT INFORMATION - PlApa eerint a@da/tDfnation. A. ~ a 0 by Date _ p
Personal nbmwlxm you provide may be fined kx onPdPQNK Y ~aY'. s. (1) lmll. \ 7~
Property Owner Property Location V
Richard Stout l.~ Govt. Lot Sri-/ 1/45~/ 1/4,S T,79? ,N,R IV E((x)W
Property Owners Mailing Address Lot N Rock# Subd. Name or CSMN
1353 Awatukee Trail rs Brown's Ridge
City State Zip Code Phone Number [1 City ❑ Village kj Town Nearest Road
Hudson WI 54016_j(71!'))549-6731 Hudson Meadow Lane
(A New Construction use: ® Residential / Number of bedrooms 3 Addition to existing building
Replacement ❑ Public or commercial - Describe:
Code denwd daily now 4 5 0 gpd Recommended design loading rate 7 bed, Wde --1$- trench. gpdfW
Absorption area required _6 4 3 ...bed, h2 5-6-3_ trench. ft 2 Macwymum design loading rate 7 bed, gpolft2 • 8 trench, gpdr42
Recommended infiltration surface elevation(s) T.1 /a, •Z S- _N (as referred to site plan benchmark)
Additional design/site considerations _ 9S• 00
Parent material Glacial-.-Deposit. Flood plain elevation. if applicable It
S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Flit Holding Tank
U Unsurtable for system M S ❑ U EIS Cl U [As ❑ U Ck s❑ u ❑ S K) u ❑ S U U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPDMt2
in. Munsell Ou. Sy Cont. Color Gr. Sz. Sh. Bed Trench
1 1 --6 10yr3/2 Sil 2mabk mfr Cs IF .5, -6
- -
2 -30 10yr4/4 Sil 2mabk mfr 5_.6
Ground 3 0-9 10yr4/6 MS osg ml .7. .8
elev. - -
J_ft.
Depth to
- - .-q - 5 - .
limiting
9 r
Remarks:
Boring M
1 -6 10yr3/2 Sil 2mabk mfr cs IF .5 .6
2 2 -40 10yr4/4 Ls 2mabk mvfr cs e7.5 .6
3 0-9 10yr4/6 Ms osg ml 7,--.8
Ground
e~llev. - - - -
yS~s'n
-
Depth to
limiting
factor
-gamin. Remarks:
CST Name (Please Print) Slynaknn; Tulephono No.
William Sahramhker (715)386-3121
Address Dato CST Number
1070 Scott Rd Hudson WI 54016 ;q ?~~fv0
SOIL DESCRIPTION REPORT
PROPERTYOWWER Richard Stout Page
PARCEL LDA _
Boring # Horizon Depth Dominant Color Mottles Texture Structure fConqstenoe Boundary Roofs Gppn,2
in. Munseil Gu. Sz Cont. Color Gr. Sz. Sh. Bed Trench
3 1 0-8 10yr3/ Sil 2mabk CS IF .5 .6
, N
2 8-4 10yr4/ Ls 2_mabk r
Ground 3 40- 6 10yr4/ Ms osg .7 .8
Depth to
limiting
factor
!2
9 6 in. L
Remarks:
Boring #
1 -10 10yr3/' sil 2mabk mfr cs 1F .5 .6
4 2 10-4 10yr4/4 Ls 2mabk mvfr v✓}.~5
- 3 44-96 10yr4/ Ms osg M1 .7 .8
Ground
Depth to a-
miting
factor
9 6 in
Remarks:
Homes DepthDominant Color Mottles Texture Structure Consistence Boundary r1F GP
in. Munsell Gu. Sz. Cont. Color Gr. St. Sh. Bed . Trerndn
Boring# 1 0-1 10yr3/ Sil 2mabk mfr Cs _5.6
2 12-_ 4 10yr4/ Sil2mabk mfr Cs .5.6
3 44- 6 10yr4/ Ms 0239 ml 7 .8
Ground
olev. _
Depth to
timting
taC1IX
4_6-tn. Remarks:
Boring #
Ground _
elev. -
It.
- ' - _
Depth to
inviting
factor
-nn. Remarks:
SBD-8330 (R. 07/96)
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