HomeMy WebLinkAbout022-1057-10-200 (2)
PRIVATE SEWAGE SYSTEM St. Croix
S512f(End Hui ding ~wis.On
INSPECTION REPORT ',nn Ia:> 1'eni Nc
(ATTACH TO PERMIT] SAN-2019-220
GENERAL INFORMATION ;Inle - an ID No.
Fer;;c's nlmnttd on you o1uade rr ay tc usce for sc da-y du :gses IPn.acy Law, 5.'CB4 1Vim;Q
✓E11r IJvILerSr,a'Y n1 TOWN OF KINNICKINNIC P T,. 022-1057-10-200
Patrick Traynor
CST Md f r: Ira e`a rlev I RN Description SecCUMTOxnrFnnge:%1''
20.28.18.313C
TANK INFORMATION ELEVATION DATA
TYPE MA.N,.FA.:.:TOR=R CAPACITY SIA110\ BS HI FS LLEV.
Sapl r. Barlanna k
Dosing A I BrI
Aelaton El cg. Sev'e'
Holdlnc R1ilf! Inlet
TANK SETBACK INFORMATION StM:O,IIlel
TANK '0 PI_ bVHI BI WY deii R)A:, DI Inlet
Septic D: Uo::oPt
Dosing I loaderildan.
Aerat,on Dist 'ipe
H::ICI9!t Bcl. System
Final Grade
PUMPISIPHON INFORMATION
Vanu`aet,rer "ielnar':f It cover
f;n AA
Model Number
TDH 11-if! I nchon Loss System l lead TDH r1
Fcuxmafl I Langl'r Die. List lc'tveu
SOIL ABSORPTION SYSTEM
BEDfTRENCH _eng:h Nc OI Tre^c^cs PIT DIMENSIONS tic 1;'1'1:5 I-lice Cla _ quid ecpt
DIMENSIONS
SETBACK SYSTLIA TO °:L ULDG IV-LL LAKE:STRFAral LEACHING Ll:mul:u:L.~ei
INFORMATION T,/po C` Sy s:om. CHAhIBGR OR
UNIT f,!,:.:1n1 P,um Lei
DISTRIBUTION SYSTEM
NOle Spac -2 to 4rsnake
-1t.'ICe:Arsn'eIC. )151ra0hae Y -olcS.c ix
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Dept- ''ecr Usmt^C"c. the •Sae ded Scc Jcd .x rdulcried
Red!T•ench Center Ecd!T-cnch Edge= hprso'I „-5 Ne
COMMENTS: Iln icde cede discrepences perscrs present elC 1 Inspector a:1. trlspeC.hon Ott:
Location: 243 KNI'Y -5
i j AIt RM Description. _
2 ) Bldg sewer length =
- alncunl of cover =
ar revis or Required? Yes No
,.se o:he• side for additional infor'nalicn.
Date hs:.rors Sianalu•e Cerl No.
SL'C-5~ tC - , Il
:ZOE
y County Sanitary Permit Application ST. CROIX COUNTY WISCONSIN
In accnro vith Cn2parl 12 St Croix Co m:'✓ Sat itary Orcrnarn:e PLANNING & ZONING DEPARTMENTA
` Per oral Info•mffion yo l, i e may be Used 'or ^Cwr tr r7 purpasrs ST. CROIX COUNTY COVERM-ILN] ChNf hH
Pnaoy Law S. 1`` 1~i,~Ir iJ ~ 11 a'. Cava cnael Road
Hudson.LYI 54016:;10
_ 15'386.4680 I-ax ;?15'3864686
Atlach com ,rote plans lot :hc sys 11 x t' r..hc„ : , <u-
'Guu•ly Saafarj•Pern t 41 (;tip" i' •e'tsion :o previous auc wahon
-Z6
1. Application Information - Please Print all I Lion Location:
P•opclty O•nnc: \x1re / _
=r I(IC ii- I('Cam kt r- T N, H c:orl '
Hruper:y Owne's W li•,g Acu•ess I of N,.rnber Rlock \umber
n ri? w... _f ~c ~
Cty. State Zip (:::::e ":t IQ Neri Subdi•uis or Name - CSM Ndmoc,
7),- zzz I iLI
II Type of Building: (check one) Of_ CCI C \1 I at 0 ..:vn of
7 I ur 2 FarrP: Uv:ell cg - No. of Bedruams R
F-. Publ cr COmmorcal (eascdbe use?: f 0.✓^ 1 ~dr nV~, , 10,
C S:a:e-uwnerf Nca•csl Ruad
It. Type of Permit: i,Cheok ra y one box on lire ,k Chock bun or line R it applirable7 Ak~
Pa•cc Tax Number(s", . I~ 313,
A) I. F1 Rocar 2.J4 Reconnection 3. NOn-plur-hma ❑Rcuvcralion
Permit Ndmdo- Dane Issued
e) yd State Sammy F'C'Mll vat; prey nosl y Issued bL%7
IV. Type of POWT System: (Check all that apply)
X Nor' pressunxe:: Ir•-ground ❑ Mo.md= 24 in. sui:ab.0 soi. ] Idcu^o 24 r. su4ablcsod ❑ Mound Ar0
F Sand Filic• ❑ Conslruutou Welland L) Peat Fife, ❑ Dtip L re
C essunveo IFground ] Hold rg talk C Single Pass ❑ O:hor
C- A' ,grade ❑ Actubic Tmalmont Unit L Ftooir;ulalnty
V. Dispersal Treatment Ar a Information:
Qcs cr F uv: P CISpC•sa Arca 3. Dispersal A•r-•a 5url Apploalion Rate 5. Percolation Pate 6 S'ysten• Elevation I Final Grade
F Rop.l led Proposed IGa s. dadsq ft ) 0.1irl inch) I- ovation
C C i
VI. Tank Information Capaicty :c Gal ors To:a Cot Manumcluror n• ,Ab Sde Ccn- Sleel Hi::r. Plastic
Nev. Existing Gul'a:ns Tanks Cnc:role rao,,JK: glass
Tanks Talks
WreSe ❑ u ❑ ❑
VII. Responsibility Statement
1. file uroms-i5cea, assume responsibility for repairreconrenetion:rejuvenaunniins:a:laticn of non-plumbing for the POINTS snown or, the alla::hed plans. A
license is not regaled br Ievatill repair or the insta laiicr is m.n-plumb'. rg sanitat on .,vsterr-
Plumbers Name rp•in1; 1`1I.4tr s Sulnaturef me sir IdP+MPRS No. 6u<_iness Phone Nunloe•
P:en•bor Address (Sr•cel. City, Slate Z p Ccd
N -16- t 7 , _
VIII. County Use Only
10 sapid Sanilwy Po,mit roc D to I sued o5 in gent Syr lrnjff o st p
/'t0~ e:ed :5,:,.r. G:.:,• ntnTA,vrr z!p ob S 19
Co. • . r:n
IX. Conditions of Approval Reasons for Disapproval: /n( ! I Q
BYSTEM.OWNER: 3 ~ryi f BOAS rn. LU - ~ q.Jt
1. 'SeptM tack, Uflu•oo-, tlte- un4
unfer:.:,t ceti M US: all be-:IC-.s': ,:':i
es per ,atar3gemer4 plan p . rued by plu.nlx:.
t. AI arri rqtc:Lir em 11 i ue .nt, it e
• psr PfFiloi M& i :M, A1064.
no^.: il: g5
Plot Plot Page -al Of-0
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Site Address:
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I
Lr File No. 521649
LXHIBII A
Lot 2 o` Certified Survey Map recorded in Vol. 10 of Certified Survey Tulips, page 2944 as Document
Number 530654, being located in the NI 1/4 0' the SW 1/4 of Section 20, 1 ownship MN, Range I MV,
Town of Kinnickfinic, St. Crax County; .-Visconsin,
St. Crcix County 10124:43 Page 2 of 2
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St. Croix County 1086029
BETH PABST
Affidavit for a single PO W I S REGISTER OF DEEDS
serv~l/cing Tw`o~~S~tructures via Private Interceptor Main - 5T. CROIX CO., WI
Tr'!<~ /rR C/NC/ RECEIVED FOR RECORD
Name- (Owner) T ed or printed extosfo1/zMP 11:28 AR
. P ravt s:
heitl8 (111IN Sw'OI'D , ,tales. tinder oath, that: REC FEE 30.00
COPY FEE 2.00
I lehu is the Owatereo-owner of file liAlowim! parcel of land located in St. Croix PAGES: I
Counter, Wisconsin, recorded in Volume Page I)ocumcnt Number
Z'N3 SL Croix County Register of Deeds Office: : u,iu~ , : ura
Narne and Return Address
A parcel OI Ixnd located in the NE " r uf'lhc 56J!. of Section ZO . I'Z%N,K/S\N. P~ ~~iQ ~fOY
Town of:nn?c)a:,.a:c~, St. Croix Comity, W'isamsin, being duly dcsaibcd as Zy3 Cil'~9.J~-6s
follows (include lot number and subdivi_`on:CSM or detailed legal description):
Z a~ CeCi:~ a S~lve~t. PV.. nits- ull5 GJ~ S~OZZ
Jol~ to P~'~ 29`f`~ epee 1 53o6ss~ 0zz-Aos-7 ,/o - zcb
14r<:eI Iau;bhc:nvou ]umV.+.; WIN.
As o+v'ner of the above describcll property. I acknowledge that a Private On-rile Wastewater I real ncnt Sy,lan i POW I S) serving the
prinuarn~ residence is aired Im Y bedloum(sl with a design wastewater hoes of 44~gallni day i D\ F is based un 150 gpd ihedroom iris 2
persons per bedroom). A maximum of'Woccupants are permitted: if the number of occupants exceeds the maximum for POWTS
design, the system will be undersized to accommodate increased wastewater flows an&or contaminant loads and may be subject to
premature failure. An accessory structure NUT to be used as a 2" dwelling has been connected to the POW IS via Private Interceptor
Main Sewer (DIMS) in compliance with SPS M2. tor 1'2). I understand that disclosure of this information will be made to any parties
interested in purchasing (fits properly in the future.
a,Qaa111 f 1114/ l /
Dated this !5 _ cfayufp_m5t N,
2C) 1 pct, Off
Ira J- 7-,
AUTHENTU ATION ACBNOWI I-A? 1P:NT~6L IC
Sicnahlre(s) STATF.OFWISCONSIN, I 1 • ,
_ SL Croix County WlSCO
) ly.+unwu+++
authenticated this day of - Personally came before me this day of
(Year) (`rear) the above named
k
TfI LE: MLMBER STA I L B.AR OI' WISCONSIN - - - - to me known to be Lhc
person(s) who executed the foregoing instrument and
acknowledge the same.
Aulhori/ed by 0 06.06. Wis. Stats.)
'I HIS INSI RLMLN'f WAS DrR~nAAF I ED 13Y j i
CLAr?r
(Sit`matates may be authcnti fed or acknowledged. Both are Notary Public, State of Wisconsin
not necessary.) My Conttnissiou is permanent. If not. suite cxpimtion date:
Date:
"THIS PAGE IS PAR 1' OF THIS 1 F.CA I. DOC'I: N1FNT - DO NOl' RF lO% N"
'Phis H(jnrnunion mnsl }e conlpkted fry srhnriaer: daewnenr laid. Horne cti rvhwl address, and i1 v glrcganrrU t)/Air iq:wanalior: a'ur%r as ri;r grorrr:g
clauses. legal descripnnn. err. mm' 'rte piur a gut Mi., first paga »l the d muent ar nuns h placed rn adrinionai a re~•1 n1 tlrz rfncunienf. !.ow: 1 `se of lius
emir page adds one pas;r fn your decaunent mid \ r10 f" Me rerrniom fee 16rscarzcin Vmtah s. 59.41.
Wb stn Department or Commence PRIVATE SEWAGE SYSTEM County St. Croix
I Saley and Sulding Division
INSPECTION REPORT San" Parmit No:
579093
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No.
Personst information you Provide may oe used for secondary purposes (Privacy Law. s.15.04 (1Km)l
Pemat Hatoers Name: City Vaage Township Parcel Tex No
Patrick Traynor TOWN OF KINNICKINNIC 022-1057-10-200
CST BM Bw Imp. BM Ew. BM Description.- Sectia✓ro rtJRangeMaP No'.
M l G ST 20.28.18.3130
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER IN's CAPACITY STATION 9 HI FS ELEV.
Septic / Ir` T z , /ZS Benchmedc /.94 /0l•9G
L BM Z g q9,
or . P,Ilia k sz5 Sit l V. AA
V
Aeration Bldg. Seve1,1
Holding Stmt inlet 7.3 14-W.-
TANK SETBACK INFORMATION stmt Owlet 94 "Xis
TANK TO PIL WELL Bl- Vxd Air make ROAD Dt Intel
Septic (46l NR' Ld 1 5 Dt Bohan
Dosing HeaderlMan- gra 471.9t,
Aeration Dist. Pipe O 93 • %
Holding Bat. System
0 92., p
%'I 97r 1I
PUMP/SIPHON INFORMATION Final Grade 40 1 V. Manufadlser Demand St cover FJ{tles- 11 to
Model N r F/pts i A, 6 9¢.98 7/7
TDH Friction Loss System Head TD F(
Foraamaln Leng .et ro Was
SOIL ABSORPTION SYSTEM
oMEDErtNa NS W~ ~rroNpy No Of rraxJiea PITDY IoNS No. a mtloe `liquid Depth
a Z- rail
/z
SMACK SYSTEM TO PA. BLDG WELL LAKEISTRFIUA LEACHING me .1
INFORMATION Type Or System: ZS 7 J '6 ' CHAa NIT OR G
b UNIT ModN NumbY:
Cieak.',L9A
DISTRIBUTION SYSTEM r 9 g
HaWerAlaNdd 11 D'atiibuoon x Hato Stu x Now Spxing Verd w Air Intako
Lengdth~Dta 4 Lenaln _ Du Specinp tw/65,~- /d
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only ra --A ~
Depth Over Depth Over u Depth of xx seedaorS~oddod Mulch~ed y
aeNTranch CenW BedRrerWh EOtles` TopaoY *-%L- Na L=>•as F. No
COMMENTS: (include code disaepencies. persons presem. etc.) Inspection at Inspection s2: III
LOCaBOn: 243 HWY 65 r, L GOy1tJ~.. it e-'L Ova
1.) A% BM Description = ALI GS
2.) Bldg sewer length= Vb'(4j 0Aty> Fl P~ 'Is. ^'•~--A
- amount of carer = , Wu4[ .F. V
Plus ;.L SJI aI,~Y+r a,.L
Req Use otherr side loruadditional information. No /2. I~ I I LV
Dale 1 Sign Con. No.
SBD-0710 (R.3A7)