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HomeMy WebLinkAbout026-1020-90-000 ST. CROIX COUNTY ZONING DEPARTL ; 'f AS BUILT SANITARY REPORT r Owner Property Address o City /State . ° 6 r vl~ Legal De ri tion: g p Lot Block Subdivi ion/CS # Sec, T3 -RfW, Town of PIN # ^G6d SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: i Tank manufacturer Size ST/PC / 2 cY)/" Setback from: House Wel7Z4K P/L Pump manufacturer Model Alarm location (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air ' Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM � 2 Type of system: �' Width Length Number of Trenches Setback from: House 57;o Well //� P�II. / /D� Vent to fresh air intake /Go ELEVATIONS Description of benchmark 2m2 / Elevation Description of alternate benchmark Elevation mil. ST/HT Inlet ST Outlet d` PC Inlet Building Sewer - PC Bottom Header/Manifold�&. e:� Top of ST/PC Manhole Cover Distribution Lines () 7 L - �� () 1 3 ( ) Bottom of System( Final Grade Date of installatio>�2 // Per it number - � �/ State plan number Plumber's signature License number 0 Date/ �& Inspector /0D j Complete plot plan � 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. • benchmark if a Show alternate pp licable. PLAN VIEW �u t� Ir�5 S Y/ S Ito INDICATE NORTH ARRO Wisconsin Department of Commerce Safety hnd Buildings Division PRIVATE SEWAGE SYSTEM Count y INSPECTION REPORT St. Croix GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Personal information you provice may be used for secondary purposes (Privacy Law, s.is.o4 (1)(m)]. 353267 Permit Holder's Name: ❑ City []Village ❑ TXvvn of: State Plan ID No.: Swartz Kenneth I To wn of Richmond CST BM Elev.:- Insp. BM Elev.: BM Description: \ Parcel Tax No.: l� Qfl 0 ` , s. tee 1026- 1020 -90 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic ( Benchmark (g �, C7 Dosing Alt. BM Aeration Bldg. Sewer Holding St /Ht Inlet t `,n • TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom Dosing NA Header/ Man. ,gyp 2. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufactur r mand St cover Model Number GPM TDH I Lift L ction Sys TDH Ft Forcemain Length Dia. H Dist. To We SOIL ABSORPTION SYSTEM $I0 Width ( Le / N i.0 PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSI SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manu ur r: SETBACK _ \ INFORMATION Type O r � � CHAMBER Mo a Number: System: t " © 3b `'` OR UNIT DISTRIBUTION SYSTEM Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake _._. Length Dia. Len 36 SOIL COVER x Pressure Systems Only xx Mound Or At -Gra a ystems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil I ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS (Include code discrepancies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 965 Highway 64, New Richmond, WI 54017 (NW 1/4 NE 114 6 T30N R18W) - 6.30.18.72H 1.) Alt BM Description = 2.) Bldg sewer length = _ /► - amount of cover = > 18 S� U044 - S� CA AV%. eje. r „ c.a.>;.e W s Y Plan revision re uired? ❑ Yes gNo Use other side for additional information. ZZ T S SBD -6710 (R.3/97) Date Inspector's Signature Cert . No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: a ............... ........ � s ........�..�. s- ,- ...,...- ....�...,..- �..�. -4„ .....+- ¢ae.. -... «....$.m» -- ...'....,....... a. ��.«« �„..,„ �„-.-.. �...........,„,. t._...... �...... �...,'-,. W,....,. .i..M.w..- .,..�...�.«- ..�.e.... a c F ...�..- +.m.«� +w.... -�.�m. .....d. ..�.a..»y ..� ..............:.. ..a�.... »..o.,. �. � ew.. � �. �e...v.... �.„..„ � ..- ..�..m- »i„ «... ...e..m... #.� } r m� d 4� s r i Vi sconsin SANITARY PERMIT APPLICATION Safety and B i Division 201 W. Washin ton Avenue In accord with ILHR 83.05, Wis. Adm. Code P O Box 7302 Department of Commerce Madison, WI 53707 -7302 a Attach complete plans (to the county copy only) for the system, on paper not less County S� than 81/2 x 11 inches in size. See reverse side for instructions for completing this application State! Permit Nu er 3 53;�(v 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 Property Owner Name // Property Location �l VA ; 1 A, S t �' T Q,N,R E(o W Property Own ilingAddress Lot Number Block Number City State - Zi a Phone Number Subdivision Na e or mber a II. TYPE O F BUILDING: (check one) ❑ State Owned It O.F t Road ❑ Village P ublic or 2 Family Dwelling - No. of bedrooms wn OF I11. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment / Condo d O < 0� ' V 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 on line B, if applicable) A) 1, Q New 2:•§,$tplacement 3, ❑ Replacement of 4. ❑ Reconnection of S ❑ Repair of an System System ____ _________Tank Only Exi - ystem Sxisting 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 See age Trench 22 ❑ In- Ground Pressure 42 Q Pit Privy 13 ❑ Seepage Pit / 43 ❑ Vault Privy 14 ❑System In -Fi{I 01 9 — 3 /0 4/ 3� 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 /� 0 /� Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation v O ° . 6 ' "� Feet G Feet Ca acct V II. TANK in allo Total # of Prefab. Site Fiber- Exper. INFORMATION New Existing Gallons Tanks Manufacturers Name Concrete st n- Steel glass Plastic App Tanks Tank Septic Tank or Holding Tank /Zoo ❑ ❑ ❑ 11 El Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ E3 ❑ VI11. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber' Name: (Print) Plumber' ature: (N ps) MP/ PRSW No.: Business Phone Number: a �� oa /.s -a d.- s� P berAd� < (Street, City, State ip C de : / I� IX. COUNTY / DEPARTMENT USE ONLY E] Disapproved Sanitary Permit Fee (includes Groundwater Issuing Agent Signa re (No Stamps) Surcharge Fee) PDApproved ❑ Owner Given Initial Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: Hv x t � c Z ¢_ c . SBD- 6398 (R.11197) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumper INSTRUCTIONS ' 1- A sanitary permit is valid for two (2) years. 2_ Your sanitary permit may be 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 pumped 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. To be complete and acc rate this sanitary permit application must include: and P 4 Yp p 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, purnp/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. V111. 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 81/2 x 11 inches must be submitted to the county. The plans must p p p Y p 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. i i PLOT PLAN PROJECT Ken Swartz ADDRESS 965 Hiahwav 64 New Richmond Wi 54017 NW 1/4 NE 1/4S 6 /T 30 ,% R 18 TOWN Richmond COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE 12/1 0/99 BEDROOM 4 CONVENTIONAL XXX IN- GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1200 Gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .6 ABSORPTION AREA 117 # of chambers 32 BENCHMARK V.R.P. Base of Shed ASSUME ELEVATION 100' ❑ BOREHOLE (D WELL *H.R.P. Same as Benchmark Alt. BM Top of Vent Pipe @ 99 SYSTEM ELEVATION 91.5 Driveway to 64 Well 15' 60' Existing 4 Bedroom 38' House 18, 15' 20' T Vent ' 0 25' >12" Sidewinder High 0 15 of Cover Capacity Leaching g_ Chamber with 31.8 6' Long 16" ,t ^2 per chamber 50' Grade at System Elevation 2-3'X 104' 34" Trenches with 100' 6' Spacing 6 3 * B.M. B -2 �'+ Vent Alt. 90' NB.M. Shed 100' Property Line No Wisconsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page of Bureau of Integrated Services in accordance with Comm 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 112 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and 54. (� i7 percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I. D. # a 6- /e) - jo -C)OO APPLICANT INFORMATION - Please print all information Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). _ Property Owner Property Location Govt. Lot x,, 1!4 1/4,S T 3 0 ,N,R �� E (or) f Property Owne 's Mailing A dress �j Lot h # Block# Subd. Name or CSSM# 2 a City State ip Code Phone Number ty ❑ Village Town Nearest Road ❑ city IIC,CJ ❑ New Construction Use: Residential / Number of bedrooms _L Addition to existing building Replacement / � ❑ Public or commercial - Describe: Code derived daily flow 1X00 gpd Recommended design loading rate - S bed, gpd /ft trench, gpd /ft Absorption area required. /2-0 bed, ft G trench, ft ' J r ,� -- 'aximum design loading rate bed, gpd /fi � trench, gpd/ft Recommended infiltration surface elevation(s) .1 ft (as referred to site plan benchmark) Additional design /site considerations Parent material 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 ;®S ❑ U S❑ U S❑ U ❑ U ❑ S U ❑ S 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 r Bed ,Trench r� ho Y" S: Ground - 1 3 P r , h/ ; elegyy ft Depth to z limiting factor Remarks: Boring # ._ Ground S3 ' Depth to limiting factor ; ?j 4 4. Remarks: CST Name (Please Print) ture Telephone No. - / ` Address Date CST Number i SOIL DESCRIPTION REPORT PROPERTY OWNER �� Page of PARCEL I.D.# Boring Horizon Depth Dominant Color Mottles Structure 2 9 Texture Consistence Boundary Roots in. � ) Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench �-s c Ground ✓ A/,/ 4 4 s, Depth to limiting factor S Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # Ground elev. Depth to limiting factor in ' Remarks: Boring # Ground elev. ft , Depth to limiting factor in. Remarks: SBD -8330 (R.9/98) Soil Test Plot Plan Project Name Kenneth Swartz Shaw ird Address 965 Hwy 64 ZX New Richmond Wi 54017 CSTM #226900 Lot -4 Subdivision - --- - -- Date 12/10/99 NW 1/4 NE 1/4S 6 T 30 N/R 18 W Township Richmond Boring Q Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft. Base of Shed Siding System Elevation 91. *HRP Same as Benchmark Alt. BM Top of Vent Pipe @ 99.8 Driveway to 64 . Well 15' 60' Existing 4 Bedroom 8 ' House 18 , 'i f 15 20' ' T 30 a� o B 15' -1 0 ' 100' B.M. B- $ Vent Alt 90' M. Shed 100' or Property Line z ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT` OWNERSHIP CERTIFICATION FORM i Owner/Buyer Kw Mailing Address Property Address /`'/ L.(�i . S��/z ,�� (Verification required from Planning Department for new construction) / City /State l/ " [ � Parcel Identification Number ©, ' 7,9 '1q 0✓ odd I LEGAL DESCRIPTION Property Locatiou / %., Sec. , T 3 y N -R� , Town of Subdivision _ Lot # Certified Survey Map # �a / , Volume , Page # Warranty Deed # - Volume �0 2 . Page # Spec house ❑ yes,4Uxo Lot lines identifiabbl� 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, restrictedplumber or a licensed pumper verifying that (l) the on -site wastewaterdisposal 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. I/we, 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 day of the three year a iration date. J 0 SIGNATURE OF APP ANT 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, virtue of a warranty deed recorded in Register of Deeds Office. 7 ___� q SIGNATURE OF APPLICA1 DATE Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. ** Include with 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 ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certi that I have inspected the septic tank presently serving the 1 554- -1 residence located at: � / ,, Section , T _30 N, R 4K W, Town of Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced: � ��— Did flow back occur from absorption system? Yes � No (If no, skip next line) Approximate volume or length of time: gallons minutes Capacity: Construction: Prefab Concret Steel Other Manufacturer: (If known):�c� tip Age of Tank ( If known) .:;> ignatur ) (Name) Please print- /" 4 w� ( i tle) (License umber) Date Form to be completed by licensed plumber (s.145.06, Wisconsin Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative Code) — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank to the best of my knowledge will conform to the requirements of ILHR 83, Wis. Adm. Code (except for inspectio ening r outlet baffle). Name Signature MP 1MPRSda'6f00 ' /dot-- ' [ SrArs BAR OF w/+coNxw reew z- 1982 WARRANTY DEED DOCUMENT NO. Wesley A Halle d Lind _ coti%eysand warran to _ ------ MAY 0 8 1998 ----' m.o SPACE °ccEa.so FOR nsvo°u,*vDATA NAME AND RETURN °oo~pss the w/,"."uu,s,`/^o real estate ." c"""'» suvv[w/�"nun. -'--------- ' O2 Part of NWl/4 of NCl/4 of Section 6-20-18 described as follows: Lot 4 of Certified Survey Map filed January 23, 1978, in Vol. "2", page 540' � � ���� � | � | � � rhi" S not homestead propert csoP^»»m"urm/us Eueemcnta, restrictions and rights-of-way of record, if any' Dated this dav of prv�----'----------Ao,/»--Ag (SEAL) __-ree,�,_�s . Linda R. nalle____________ ecau ----------------�_--_-_'__-_____'apAc. auTusNrIcAT/(,m AcuNo*/.snCusnr yu"^mo(^) 5�ur� o� YVi,coo, ` ' �--------------------------------- S t' Ccoi' authenticated this u=/,. xo -��-------------- ``~'' umx.�u, �me m,x'o me m.^ __-_-���--.�- L1 ``' �d-Linda --O.__-_- � --'- ------------------- -------__� _ ,-buabonU ' ao�_vif� � T�cucuum^u/co�xurxacowy|n n - -Halle --- - o/nw. ______ �'�- ---------------' - '---- --- ° ,v/m"iz~ hpuroo.m,uustazI` - -'--------- - -----�--- ' . r |v the 5. / ' n,swsn=vwsNrw,Son^ TEoe' -- 'Attorney Kristi-*e 0#land-- -' ---Hudson ,WI-54010--�-__-__- n^u /1 _ pWL � - ----'~^ 'c`���td4y WWORein "wm`nvuo `/.,rm^,^�,/,``* 3��Ig2 CERTIFIED SURVEY MAP NW 1 /4 -NE 1/4 - SEC. 6, T 30 N, R 18 W W APPROVAL OF THIS MINCR SU3D;VISION W, N 1/4 CORNER � DOcS f�JT h1�/:N APP,.GVAI FOR w , o 0 SEC. 6 , � 1 UON Z R. R. SPIKE BUILDING S'JE 02 SEPTIC SYSTEM. z in REFER TO H62.20. W W o' ir z N W — Go�y �9 APPRO I z w o Im I JAN 18 1978 az� o 1 G ��. Jp�,: co o ml U' WW 1 ST. C -�OIX COUNTY z M E ° �� COMPREHENSIVE PARKS PLANNING Q H� N 2 -19 - 49 W AND ZONING COMMITTEE O H a 66.01' 89 °�/ N 88 37' -20" E 836.76' .. t *--/ 02 - 51 w 90 57 =09" , p6 N °� S 88 37 =2 0" W 428.15' 2� 3� `o ' ak' O cn cn o. %0 0" o i TOWN �� p c, . � � J �Q • •� • 1 2 �P. • ' 0 �l _ . w ROAD z 4 w rn �C` / c� 0 5.02 t 2 ACRES r N s '4 `O N I C ' �P DiViSION o.2 APPE;OVAL OF TI3 tigi L o " w ii t � O. SU � ° - 00' - 39" E DOES NOT MEAN k� . ,.OV,�L FOR * s � li t SITE O SEPTIC 5YJEM, o . 43667' ,Lg a cr•= H62.20. mss R.: �R TO ` o , pg 276.70' t~D 1 -4 ,� .,` y, �: _ J HOME EXISTING 6 6 g �o C w 2 '( N 88°- -37 -20 �� E /� 117.18' — v �1, •' N�. ' a \ LOT 4 8.62 ACRES m 1� S 88°- 00' -39" W \ \ 832.06' \ \ N 25x•40 -03 " W \ 3� 82.97' NQ�P� PNOS \ v 200' 100' 0 IOU 200' LEGEND SCALE IN FEET • FOUND I" IRON PIPE O I" X 24" IRON PIPE SET, WEIGHING 1.68 LBS. /LIN. FT. THIS INSTRUMENT WAS DRAFTED BY R.M.W. • FOUND R. R. SPIKE JOB NO. 77 -66 AT AS.LE�fi C. 2 PAGE 54 ib , ' ' TFIED SURVEY MAPS 'OTX COUNTY, WI. ca � r, 's ti ���