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HomeMy WebLinkAbout030-1062-30-050 ST, CROIX COUNTY ZONING DEPARTMENT \, 9 � AS BUILT SANITARY REPORT 110\ Owner Property Address City /State � \'L 1 - T Sq b,r ' Legal Description: Lot — Block Subdivision/CSM # ' t /4 N F- t /4, Sec. 1, T10 N -R 1 9 W, Town of 54 PIN # &3 a ; ,(O 6ro� -3 - OS c7 SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION Tank manufacturer LU LfSAr Size ST/PC Setback from: House - Well N P/L gj 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 Type of system: I yx �t Width Length / Number of Trenches °;� Setback from: House ZO Well v P/L !65 Vent to fresh air intake JOlo ELEVATIONS Description of benchmark A,,& e. a� 5�� Elevation J 00 Description of alternate benchmark Elevation r, Building Sewer 7, ST/HT Inlet �� ST Outlet b ` / PC Inlet �'— PC Bottom �� Header/Manifold �� Top of ST/PC Manhole Cover �� 3 Distribution Lines (t) 23 l3 W '' , ` 13 () Y Bottom of System (I) '? a- (2) Q ( ) Final Grade (n 2k (2) Date of installation Per ' number q S �� State plan number Plumber's signature License number dti� ���,z Date //f/ p9 Inspector ears Complete plot plan � 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. A)& PLAN VI W DVA `1 3 ' r 7 ' 90' INDICATE NORTH ARROW t 1 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count Safety and Buildings Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: 5T. CROIX Personal information you provice may be used for secondary purposes (Privacy Law, s.15.04 (1)(m)). 344575 Permit Holder's Name: ❑ City ❑Village K Town of: State Plan ID No.: MYER, BANNER ST. JOSEPH CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: (5 , ' = c5r Q1tiL 030- 1062 -30 -050 TANK INFORMATION 0 ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic w jz� Benchmark r? o c(. r CfD.O' Dosing '�- 6 ' 9 qg -s AerationBldg. Sewer t r N Holding St. /Ht Inlet �• to q3' TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. A I to ntake ROAD net Septic >/Wb IF ? >2-1 NA UL Bottom 4 Dosing NA Header /Man. �O.e� 3. 2 Aeration NA Dist. Pipe r � Holding Bot. System q �r PUMP/ SIPHON INFORMATION Final Grade. Go 95 7 3 , Manu cturer Demand �� S +ZS 0 /1.2 Model Number GPM TDH Friction Sy TDH Ft e rcemain Length Did. Dist. To Well SOIL ABSORPTION SYSTEM ( ,� �h t � BED/TRENCH Width r Length , No f enches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSION LEACHING Manufact rer: SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM h INFORMATION Typeo / r CHAMBER delNumber: System: V.� po' (o � OR UNIT DISTRIBUTION SYSTEM Header s) Distribution Pipe( x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length 1 ia. pacing t 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.) LOCATI% JOSEPH 24.30.19.219B -10 1477 85TH STREET — LOT 1 © 3 z . (7 � , Jib" Lle " f y -�•`e t',se�ei /Up t ate i.1 � 't ftO C, � VVVV - 1`I -q 4 . Plan revision required? ❑ Yes C<No — Z � Use other side for additional information. a. p1,3 SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. t � ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: .w E ° e mm t e� k 3 € � R o E ' g i , z . E E a S r E t a .,. °.°,,., e f � Stj $ t @ y g [ E �, k s i w, q g � r a 333 t s t r t e E � f { e 999 } g p ( S b s` t s � __. r- � ° e E g ° x § E x 3 t i € Y 6 9 t t t • �•— j E � 6 t ( � 4 �3 Safety and Buildings Division Vi PERMIT APPLICATION 201 W. Washington Avenue n In accord with ILHR 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 Count than 812 x 11 inches in size. tT C (0 c • See reverse side for instructions for completing this application State Sanitary rm i Personal information you provide may be used for secondary purpqses ❑ Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. %� / V State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATI N PropertiLD nerName Property Location � >n r (- i4 A , E 1i4, S o� T _30 N, R 1 E (org) Prope,AtyOw?er's Mailing Address ^� Lot Numbe' Block Number l r (03 r K :--- Cit ,State I Zia Code Phone Number Subdivision Name or CSM Number OI '7 ( II. YPE F BUILDING: (check one) ❑ State Owned it y Nearest R el oad Public 1 or 2 Family Dwelling - No. of bedrooms ° Tow of T III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo ®3O —10 (o..' ) -3 _0S a 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. (g' New 2. ❑ 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 12,XSeepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 15c__> 43 ❑ Vault rivy 14 ❑ System -In -Fill 6 CZ ) L2M & r 751. I> K 30 VI. ABSORPTION SYSTEM INFOR A ION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate S. Perc. Rate 6. System Elev. 7. Final Grade 4/50 Required (sq. ft.) Proposed sq. ft.) (Gals/ y /sq. ft.) (Min. /inch) Cl Elevati9n Q / Vs t Feet 5,f 1S Feet VII. TANK Capacity in gallons Total # of Site INFORMATION Gallons Tanks Manufacturer's Name Conc eta Con- Steel Fib Plastic Appr New Existin structed Tanks Tanks eptic Tank TMehling�errt� Q'br0 ' I ',Q rs ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber El El El El El VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. PI u ber's Name: (Pri Plu er' Sign ure: o St mps) MP /MPRSW No.: Business Phone Number: C� � 53 ?�s s' 13S Plurrjygr's Address (Street, City, State,jip Code): �� r - ^ � � O / l.v IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit (i n c l u des Fee S r hare a water Fee) �� Issued Issuin en Signat a (No mps) Sta j, Approved E] Owner Given Initial S d� / Surcharge Fee) 4V / Ira Adverse Determination (/ X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: SBD- 6398 (8.11/97) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber i 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,Eode 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 accurate this sanitary permit 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 thane 1/2 x 11 inches must be submitted bp 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 16ss; pump performance curve; pump model and pump manufacturer; D)_crosssection 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) fora 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. P T pla kN st crd;x � �k ct OPAZ R -30 o C oOu � C;� - `r'b 9016 36 r t P� O 7 ^_^`` W J C � S lJanuI --� E p �- co ki NEB° 0 m s 7-� o O CO �. oc�o x cfl co Lo E cts -a co N M q �' vOi N CO >' U r V �,� J T oc +' o c�a C �= U N U O C "= co V- ' fd(n ^ -O ca ? C c U CO 0)-0 CO cCO x a� 0) v L 0 m a) L. .JJ c'n (75 ? r- 0 - • • • • 3 • N E a T N E U� & O E Ym rl ro 800 'a ® ' lJ L A U ®z m m ro 0 L pppp � I ^ n 32 g 0 Q m �.� G ' 1C1 ' [ m N W ro O „. � U d a a ' OD .� ' 0 y !I E o o o c 0 T ro cc Z C— W LLL w ro a M CD �m c Co to J �f p W _6 wiscf nsin;,r4artment of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page of Bureau of Integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # 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 G U N e Govt. Lot 1/4 1/4,S Al T ,N,R ` E (c6� Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# City State Zip Code Phone Number ❑ cit Village g �° Town Nearest Road ❑ &A/ /1 c m 5 0 6 . os New Construction Use: BResidential /Number of bedrooms Addition to existing building Replacement ❑ Public or commercial - Describe: Code derived daily flow !. Z '5 gpd Recommended design loading rate ✓ � bed, gpd1fl trench, gpd/f1 Absorption area required �7,0 bed, ft ;74 trench, ft Maximum design loading rate • . T bed, gpd/ft trench, gpd/ft Recommended infiltration surface elevation(s) G ft (as referred to site plan benchmark) Additional design/site considerations Parent material �9 c -c w/ d a-��� Flood plain elevation, if applicable S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system S❑ U as ❑ U 0S ❑ U la U ❑ S UR U ❑ S IO U SOIL DESCRIPTION REPORT Boring # Horizon. Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench O G tr �-L- li li Ground / I j kev. Depth to limiting factor 3 Remarks: Boring # o — m ' 13 - -.� S Ole. A� Ground elev AMP �- _v t� Depth to)��` limiting factor n. Remarks: CST Na (Please Print) gnature Telephone No. /� ` 9 s �517��� 610 �� r Address Date CST Number L r SOIL DESCRIPTION REPORT + PROPERTY OWNER ._� Page of PARCEL I.D.# Boris # Horizon Depth Dominant Color Mottles Structure 2 Boring in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed ,Trench Ground g elev. Q�ft. Depth to limiting g factor y `7 Remarks: Boring # m Aex ` low Ground elev Depth to limiting factor Remarks: Horizon Depth Dominant Color Mottles Structure PD /f 2 Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # O Ground elev. ft. Depth to limiting fact r 7' "' Remarks: o ng # 13 Ground elev. ft. Depth to limiting factor in ' Remarks: SBD -8330 (R. 07/96) t /Z71 ����� Vim � � r Ga �rPG tr go 40 Aj 64 c C�! V ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM r Owner/Buyer Mailing Address `1 l93 N y�,�o,� l,�T S qo' 7 Property Address 7 O S� (Verification required from Planning Department for new construction) City /State Parcel Identification Number _�3Q — 10 (Q - 3 0 — 05 D LEGAL DESCRIPTION Property Location IV VD' /,, IVY ' / Sec. , T_ -R__LaW, Town of ST JOS4 Subdivision G S Y'Y\ , Lot # Certified Survey Map # 5 S `� S , Volume , Page # 3Q 3 - 7. Warranty Deed # 'S ty(o `TS� , Volume _ a h9 , Page # S () Spec house ❑ yes 9 no Lot lines identifiable K 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. '( -7/N/ SIGNATURE O • 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 SIGNATURE O�ANT 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 IN I' A 2 R;'G1'-;rE,q OFFICE Thk indeniaze, \t 29t[ -,o Sept,? ROIX Co., W1 A! ST. C D 1,)_97___, Bas s D airy F rm, I nc. Ra-c-d Y A cotp, I, i il OC"'T 10 1597 organutd and evqm und-•r and by viru�e of - ,!lc !jws ,,f i y i of it New Rich and paz of the f pa*, and 11:45 , Am Banner E._Myer and Carolyn M. Myer, hu- and wife as survivorsbip ma-ital Property oft -;":t-d PArt Witnesseth, That the -.ud party of lie r,rst part for Ind in of trile s of one dollar and other valuable considerations to it p,,id by the said piit•PS ol th,- )R A and h Is NAME AND AODOAtSS and ir t nfirmed. and b% tlh,�s4! Y "'d l unto the aid f-art-i!�S— ofth. - j p.iri their heirs arl as:igns !0rever, (,he ,!(l in the Co-,no- of St. Crol-c �e of Part. of the W 1/4 of NE 1 /4 of Section 24-30-19 deg „- a f• - Lot I cl Certl-Cie, Sur. , - Map 030-1062-30-050 filld Ap 1 21, 13',! --1 Vol. "Jil”, pae 3,1 7 —L OFN - .tF:CA' kl:,� T 8 A "'i "'F E R Together -th a!l an,: ijiiAidar the and All tl'ceszate 0 ri - lll. title, InIc -"' clxnl or if ether in law or equity, either in k ic6-.,�isiori or txfx tAnc of in i: t t' eh-L .e r1j To hike and io f--Id vc de��rO'ct] - 'he unto pin-les-, of the sel:ond 1—t, � 1 1- - fxlr; an " ' _ t A- 0- said - aaj ry, Farm ,-- I pit!Y of the iirsl sari 'I"!; '11A its n 3'jj r lit Jrd With the >3id PJiL of t"i � ':Llnd Owl, Lh e Lr Xh: As; ih- st th .:rte o( crs - j::ng 1�� d o prl:��nts It is A,. 'il ch F1 1 1 'Vized of the pfeml:"'; as jj _ l ! _jlj,A: -:;i n, , state zi the la,v,in fee si. jrd vlat the saran are free and il, 1! from A 1;1"Is'brancel, afrat :cr. ,: dl:. the p., the e xt snd F C. i)cs5e of tlle -a: of the secon,; part r and '%en pe--cn, or J"rTs"-ns hwfu;ly ;!•�c '111) Pit- it % fo,r-r and MTEND lit Nkin,es ' ;ji,,j __ __ __ - Base :,' - --s - D a - i ry F4 ric, _ . ,)i3 y c i the E,I i j )art. !il I-, ------- -Al an C .-Bas e I 1 o r I •a R 3 e y vi Richlaiind 29th di of S e t Pmb e r i,nd iticorj. sc.ki to be hert:iunzo aff zu,, p " AND li F[1, iN PRE FNk+ -Ba<_ie I q_Da-Iry , ria, Inc. A e- Alan C. Basel p, 29.011 day of S e p P In 1 ) r I - . - - - -- - --- -- - A D i Q9 7 ,,i Glo R. - Ba C.- 1 --ry of the al'ove to "'w ll:-< %kill. M " and j" ?"�' �. :i-v- for'- :i. ."Ch Okil`r' JS OX Lll:"d Of NA" C. i tI-l" - j'K W. Vj- 1) i".,\ & V, u v S.c. S C- Boll, 1 j 2-1 i� L v V 558255 CERTIFIED SURVEY MAP Located in part of the Northwest Quarter of the Northeast Quarter of Section 24, Township 30 North, Range 19 West, Town of St. Joseph, St. Croix County, Wisconsin. Prepared For: Gloria Basel OWNER: 1479 95th New Richmond, WI 54017 Nk Corner Section 24 LEGEND T30N, R19W O PK Nail Found 2 Iron Pipe found - CURVE DATA ON R/W O 1 x 24" Iron Pipe weighing 1.68 LBS /linear ft. set Radius Length = 266.00' Wetland Central Angle = 28 ° 50 1 37" Chord Bearing = S14 0 25 1 18.5 11 W Chord Length = 132.50' Arc Length = 133.91' Bearings are referenced to the North & South Quarter �I o Tangent Bearings = SOUTH, S28 ° 50 1 37 11 W Line of Section 24 assumed to bear SOUTH. I c t I �''� SCALE: 1" = 100' N ^ A SI 4 West line of the NWk of the NEk H M1 100 50 0 100 I 00' ( UNPLATTED LANDS I I S89 0 51'50 "W 528.60' 33.00' I -- ; IIII soar 495.60' -•. H ?' 100' setback from R/W N ti j c LOT 1 N 134,250 Sq. Ft. (3.08 Ac.) TOTAL wl o 130,684 Sq. Ft. (3.00 Ac.) Excluding R/W W H� d'I E � N rn -t� tai / ' Q � o I ' ' O o z �r 4.00 437.51' w � N89 0 51'50' E 527.51 = I 3L UNPLATTED LANDS ------------- - - - - -- a AI J HI - HI Each parcel shown on this map is subject to State, County, and 0 � I Township laws, rules and regulations (i.e., wetlands, minimum p I o lot size, access to parcel, etc.). before purchasing or developing any a 'j ; parcel contact the St. Croix County Zoning Office and the m I % appropriate Town Board for advice. 0 w tZ Sk. Corner w� o S 24 w ise , T30N, R19W O I- a�' DOUGLAS J. y ct' W. ZAHLER Z D S -2145. HUDSON, z WI5. S 3� IM T FILED A APR 2 1 1991 ► 2 KIQFNM K VIh M :� Repi�erotoeeds 3 SLOMiX00,1N1 Cn I� VOL. 11 PAGE 3237