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HomeMy WebLinkAbout026-1002-50-000 A Wisconsin Department of Commerce Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count y INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar IX Personal information you provice may be used for secondary purposes ❑ [Privacy La s.15.04 (1)(m)]. 344 Per rpitttoLd s Nam,5 AVID & REBECCA El City U RiCHa e Town of: State Plan ID No.: CST BBM - Insp. BM Elev.: BM Description: MV Parcel Tax No.: 026- 1002 -50 -000 DU < TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY A &TATION BS HI FS ELEV. Septic e coo enchmark L '30 161 o b Dosin Z Z '' Aeration Bldg. Sewer 5,4 Holding Ht Inlet Z Y d TANK SETBACK INFORMATION a Ht Outlet TANKTO P/L WELL BLDG. Ventto ROAD Air Igtak Septic —zed IF 67ql 1 �t NA m Dosing A Header / Man. LTI Aeration N Dist. Pipe Z L00 Holding Bot. System LI Z q-Z Z PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand , b Mode ber M TDH Lift L os iction System TDH Ft Fo main Length Dia. me Dist. To Well SOIL ABSORPTION SYSTEM BED / E - N Width Lengt� No.O{Eenches PIT ION No. Of Pits Inside Dia. Liquid Depth DIM SYSTEM TO P/ L I BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK CHAMBER r INFORMATION Type of / del Number: System: 1,-, lG� 3 � OR UNIT e, X DISTRIBUTION SYSTEM Header/Manifold Distribution Pip -e(s�j x Hole Size x Hole Spacing I V nt To Air Intake Length A) / Dia. Length > f Dia. Spacing �r / Al /V o�_ � SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed/ Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: RICHMOND 1.30.18.11F, 1405 CTY RD GG 41� 6 = ✓II'l o-,., coyrey of • l2 00 o Zya- rr J I�" of Cove✓ Plan revision required? ❑ Yes ❑ No Use other side for additional information. 1 4 * 7 4 k I SBD -6710 (R.3/97) Date Inspector' gnature Cert. No. lip ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: , 8 , , , 3 _ , ...a fl e , 1 , 6 a g i # r i j a t € 1 e mm. 9 d W_....� .,. s...�w .... _. ., .�.. t = ...e._.... 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. PLAN VIEW L . o /\ M ; w� INDICATE NORTH ARROW �1 r Y ST. CROIX COUNTY ZONING DEPARTMENT_ AS BUILT SANITARY REPORT �� ~ ~✓ Owner I Property Address X9.3 n City /State a ° ) d, 1 1999 Legal Description: a Lot Block Subdlvision/CSM # z�vw ' /4, Sec. , TAN -)W, Town of g P SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: G � Tank manufacturer , 4?'ee�/ S Size ST/P& Setback from: House,,Z�fWell PAL a Pump manufacturer Model Alarm location (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM f � Type of system: Width Length Number of Trenches Setback from: House Well P/L Vent to fresh air intake ELEVATIONS Description of benchmark Elevation Description of alternate benchmark o Elevation 2'- Building Sewer 7 1 ST/HT Inlet �` �� ST Outlet PC Inlet PC Bottom Header/Manifold Top of ST/PC Manhole Cover Distribution Lines Q) Bottom of System V ) Final Grade Y ) Date of installation /// ermit number State plan number Plumber's signature icense number 7 Date /// Inspector I I- S Cm Complete plot plan �+ { SANITARY PERMIT APPLICATION Safet and Buildings Washingto Avenue 14sconsin P 201 W. O Box 302 Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8112 x 11 inches in size. • See reverse side for instructions for completing this application State sanitary Pe mit Number Personal information you provide may be used for secondary purposes ❑ Check if revision to previous application (Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION Propert y ner Nam Property Location E (Or /4 1/4,5 T Property Owner's Mijiling Address tot Numl5er Block Number City to Zif Code Phone Number Subdivision Name or CSM Number GuJ Q ( O II. TYPE OF BUILDING .(check one) ❑ State Owned it( Nearest Road Public 1 or 2 Famil Dwellin - No. of bedrooms 4 own orf/�� III. BUILDING USE (If building type is public, check all that apply) Parcel TaxNumber(s) 'i / / �0 1 ❑ Apartment/ Condo TT *, 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 line A. Check box online B, if applicable) A) 1. ❑ New 2. Ug Replacement 3 ❑ Replacement of 4 ❑ Reconnection of 5, ❑ Repair of an ------ System _ System _____________ Tank Only_____________ Existing System _____ Existing System 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 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12ji6eepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) c3 EI vatio T 5 © . .9 /� � Feet >.� Feet C VII. TANK apacit in gallon Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name concrete Con- steel glass Plastic App New Existin structed Tanks Tanks Septic Tank or Holding Tank r ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber' Name: (Print) Plum s Ignature: (No es) MP /MPRSW No.: Business Phone Number: O li r PI m is A dr s (S reet, City, St to Zi Code): u.G /r1 >✓� �� IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue s Issuing Agent Signature (No Stamp Surcharge Fee) proved ❑ Owner Given Initial -4 j' G c Adverse Determination J o��'/ I X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (8.11/97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 4 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit maybe, renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD -6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608 - 266 -3151. r i sanitary permit To be complete and accu ate this sa Y P application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. -Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon' tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. ---------------------------------------------------------------------------------------------------- GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges.are used for monitoring groundwater contamination investigations and establishment of standards. ' `• / /- ���GGd— 7d– chi / PLOT ` PLAN PROJECT / /�j/ ;�' ADDRESS !c >KlGd7/�ui7� 1/4 1 /4S / /T�� N /R W TOWN COUNTY MPRS Byron Bird Jr . 220527 DATE BEDROOM ? CONVENTIONAL M IN- GROUND AESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE LIFT TANK SIZE DOSE TANK SIZE HOLllING TANK SIZE LOAD RATE ABSORPTION AREA_ # of chambers � z ,BENCHMARK V.R.P. �, ASSUME ELEVATION 100' T p ❑ BOREHOLE O WELL '"H.R.P. � .,� � � p � ,� f 4 L,�� c � Vent SYSTEM ELEVATION >12" Sidewinder High of Cover Capacity Leaching Chamber with 31.8 ft A2 per chamber 6' Lang 16" „ Grade at System Elevation 3 � �fV/ 0 t 5� l� �I U 3 e.3 4wisre411 Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page / of Bureau of Integrated Services in accordant ' s. ILHR 83.09, Wis. Adrn. Code � 9 , __ County Attach complete site plan on paper not less than 8 112 x 1 in size. Pi aru'mli"st ^., include, but not limited to: vertical and horizontal refer nc�e Int (B d*tion and percent slope, scale or dimensions, north arrow, and dcatjbn and d arest road. parcel I.D. # dip APPLICANT INFORMATION - Please p ill it, fo'rmaiEn.� Reviewed by Date Personal informal' an rovide may be used for seconds u ses Pri YW P Y ( 1��1 m , Property Owner • 'tAlG QF�. Property vocation ' Govt: t LO 1/4� ('� 1 /4,S T . E (o 4d a - / 3 0 ,N,R Property Owner's Mailing Address { ) e'. ', L Block# Subd. Name or CSM# C 6_ .... --.�.� .j � City State Zip Code Phone Number ❑ City ❑Village KI Town Nearest Road New Construction - -� El New � Residential /Number of bedrooms Addition to existing building /1/ /� W Replacement ❑ Public or commercial - Describe: _�,¢ Code derived daily flow ° ^ L� gpd Recommended design loading rate = --7—bed, gpd /ft i q � trench, gpd/ft Absorption area required LIJ bed, ft �- ( trench, ft Maximum design loading rate 7 bed, gpd/fF • 0 trench, gpd/ft Recommended infiltration surface elevation(s) 7 _ft (as referred to site plan benchmark) Additional design /site considerations o l` Parent material C' L2' / 1-, 1 a J 2 S G Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In Ground Pressure AT - Grade System in Fill Holding Tank U = Unsuitable for system El S ❑ U ® S ❑ U ® S ❑ U ❑ S ❑ U ® S ❑ U ❑ S m U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD /ft in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots � � � :� Bed ,Trench O �U 7S `1i �' 3 Z /� Q �� _5 /L 2, n, k ' "n V - P r �' S Z, f Ground -y6 /-'7 0 /l e P15 ,sue m L — '7 Depth to limiting factor Remarks: Boring # S 7,-5 xr 3/ huh e 5bk v Gr C S I rr- TA Ground 6 p y - '/ o , Depth to limiting factor min. Remarks: CST Name (Please Print) Signatu� ? Telephone No. David J. Steel 715 - 246 -5085 Address Date CST Number I 1564 Cty Rd GG, New Richmond, WI 54017 ���7 - � CST #248956 PROPERTY OWNER SOIL DESCRIPTION REPORT l�a `� /' /� � Page z of PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Structure 2 Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Ground 4 y Sc Depth to limiting fa for , in. Remarks: "S S L Boring # Ground elev. ft. , Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /112 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # Ground elev. n. Depth to limiting factor in. Remarks: Boring # Ground elev. n. Depth to limiting factor in. Remarks: SBD -6330 (R. 07/96) viCf ¢ li�becCci `0, le' pcv�7 (�-� �iC`i mdr7GF' r� T o �rh� 35 3 `rG sloe Nk;l do .St Cor — y' S +h Si cJe o:Thouse- �n - Zvi EIv�. 3v, 1 7 yo 6' 132 (3 i ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Mailing Address Property Address ,L���G� �1oG �// ✓�' (Verification required from Planning Department for new construction) o�G- /aoa. -S� City /State Parcel Identification Number LI, GAL DESCRIPTION Property Location .� � ' /a, ' /a, Sec. / , T ON- R_ Town of Subdivision '— , Lot # Certified Survey Map # ,1 , Volume ''�`' , Page # Warranty Deed # `7 ©`fi ,Volume , Page # "— Spec house ❑ yes o no Lot lines identifiable yes ❑ no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank: as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. �Q A� id� SIGNATURE OF APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. SIGNATURE OF APPLICANT DATE * * * * * Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed zo 9TA" I-1M 11li3 iAak"ai IhE� !'fA r W.Nrr Wt dayo 8:30 AL Iltvid A. Wi per and Itbeoca 1C. Millar te nd and *rife - -- "'.. RETURN To tAe rrlN eaters in St • Croix County, e o01ABI�OORtNR: Tax Parcel No: F1art of the : of Sit , ,,Z Section 1730 more fully described as follows: irw 58 feet South and 225 feet East of the Nil corner of said SA of parallel thence pa with the Nly !Lis ct Str of 1t8 Feet to the point of beginning of the px rcel to be described: thence South parallel with the W y line of said SIA of SL-; 150, feat; Vu nce East parallel with the My line of S'rh of SA 48 Peet; thence North parall"l with said West line 150 feet; thence West parallel with said Nly line 48 feet to the point of beg ALSO a parcal of land located in the SA of MA-; of Section 1- 30 -18, more fully described as followst Conmencing at a point 58 feet South and 321 feet Fast of the Zed corner of said 344 of SA as the point of beginning: theme South and parallel to the West line of said Sf4 of SA a distance of 150 feet; thence East and parallel to the North line of said Sit% of S(% a distance of 96 feat; thence North and parallel to the West line of said Sh of SA a distance of 150 feet; thence West and parallel to the North line of said Mh of S4h a distance of 96 feet to the point of beg inning , including the right to use the � • a ccess road along the North boundary of lots platted in said .� I This deed is given and intended to correct Vie description contained in Warranty Deed dated 12- 24 recorded 12 -30-85 I r 729 on Page 229 as Document # 108111. ?f l — Am not. homestead prop ol. (18) (is not) Exception to warranties: Drnecf this _ —day of January 19 86 (SEAL) (SEAL) • Dale L. SeeWer (SEAL) _ (SEA€.) AUTHENTICATION ACKNOWLEDGMENT Sipnature(s). STATE OF WISCONSIN es. St. Croix County. authenticated this day of ,19 Personalty carne before me this o� day of January , 19 the above • Dale L. See TITLE: MEMBER STATE BAR OF WISCONSIN - — — (if not, to me known to be the person who executed the authorize: by 3 70&0e, Wis. State.) forepolr ument a now g he saMe- THIS MSTRLWENT �A A.S DRAFTED BY J : A sascr., F �ok e r —_ — John R. H aasch Notary Public_. County, Wis. (SignVurx s #"*y be 3uth••4k; Ie1 of asknow'e -i+ed. Both My Cgmmission Is permac-OA - (if not, state expiratlon are nut necessa dais: _ 14 -21 -1938 — .19- 11 °Harm% of Wgnns siof -IN in any capacity should be typed or p'Inted below their aignatur.s. NTF 2M STATE OAR OF'WISC:OmdiN Form too. 2 -- 1902, 1902, am + Nelto Fo, s 0. 80 Green Say, Wt SaJ ?Q7S