HomeMy WebLinkAbout030-2086-30-000 (2) ST. CROIX COUNTY ZONING DEPARTMENT
AS BUILT SANITARY REPORT
Owner �� e} Al2 rz ptcl�k ;✓'
Address
City /State \�uv5 ow \ S f - t
Legal Description: Ile
Lot Block Subdivision/CSM #
% % W . Sec. 3a . T 3ll N -R j W, Town of S or IN #
3 a. �.v cg� z33
SEPTIC TANK -- DOSE CHAMBER HOLDING TANK INFORMATION:
Tank manufacturer Size ST Q (4 1 4 ) Setback from: House Well (o a' P/L 5 )! (-
Pump manufacturer .Model
Alarm location, - - �
(HOLDING T ANKS
S - Service road Vent to fresh air in e • e - �--- -.
Meter location
Alarm location
SOIL ABSORPTION SYSTEM:
Type of system: Nf '�l tn�� Width Length Number of Trenches
Setback from: House Well a P2 ent to fresh air intake V
ELEVATIONS:
Description of benchmark J o p of 1) WR p S"� p p Elevation 100-
Description of alternate benchmark Elevation
Building Sewer
ST/HT Inlet ST Outlet 3 PC Inlet J
L. t
PC Bottom Header/Manifold 9 L .0 0 4 6 -U Top of ST/PC Manhole Cover ( 0 � • 3
Distribution Lines (L)
Bottom of System
Final Grade
Date of installation !Z: / Sg Permit number I 3 iS2 State plan number
Plumber's signature p Utw° License number o a U Date /� �i/
Inspector KAV
complete plot plan or
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.
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PLAN VIEW
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INDIC E NORTH ARROW
Wisconsin Department of Commerce
Safety and Buildings Division PRIVATE SEWAGE SYSTEM County:
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: ST CR IX
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)).
Permit Holder's Name: ❑City []Village [ Town of: State Plan ID No.:
CRAWLEY, LYLE & KARI ST. JOSEPH
CST BM Elev.: Insp. BM Elev.: BM Descr ption: Parcel Tax No.:
TANK INFORMATION EL VATION DATA A9900093
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic 0 4 0 ZdrO Benchmark D o .
Dosing
Aeration Bldg. Sewer
Holding St / Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
TANKTO P/L WELL BLDG. Ventto ROAD
Air Intake
Septic „�, (� ' NA rNt
Dosing NA Header/Man.
Aeration NA Dist. Pipe
Holding Bot. System ! .Z
26 9Y:�s
PUMP / SIPHON INFORMATION Final Grade S , 9' Ir
Manufa rer Demand -7''� .G p 6
Model Number GPM
TDH Lift � Ion L ea em TDH Ft
Forc aln Length Dia. Dist. To Well
SOIL A RPTION SYSTEM Z
TRENC Width Len gyS��, / No. f T enches IT No. Of Pits Inside Dia. Liquid Depth
DIM 'f"S DIM ENSION S
SETBACK
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type O — r / CHAMBER
t Mod Number:
System: f K G2 OR UNIT
DISTRIBUTION SYSTEM , 1•73
Header / anifold Distribution Pipe(s) x Hole Size x Hole Spaci Vent o Air Intake
Length Dia. Length Dia. pac 8 01
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: ST. JOSEPH 32 .30.19.733,NW,aW 413 ROLLING HILLS LANE
2- 3 -1� - �--
Plan revision required? ❑ Yes X No
Use other side for additional information. pa
SBD -6710 (R.3 /97)a cast Inspector's Signature Cert No
i
C �S
Safety and Buildings Division
201 E. Washington Ave,
SANITARY PERMIT APPLICATION
N* sc � ons i n In P.O. Box 7969
r with tLHR . dm. de
acco 83 05,
Wis A
Dep2rtment of Commerce Co Madison, WI 53707 -7969
• Attach complete plans (to the county copy only) for the system, on paper not less County C� e
than 8 v2 x 11 inches in size. ,
• See reverse side for instructions for completing this application State sanitary Permit Number
338829
The information you provide may be used by other government agency programs ❑ 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 Own r Na e r Propert Location
�� !a W1l4,5 T 3(3,N,R�� E(or)W
Property wrier' ailing Address Lo Number Block Number
7
o �n SON S1 IU tiA
City, State Zip Code Phone Number Subdivisi me or CSM N
L% e S 4 1 (76 > $'" At CON 1'/o
11. TYPE F BUILDING: (check one) ❑ State Owned 0 C ity earest Road
C] Village 0 � //
Public 1 or 2 Family Dwelling - No. of bedrooms Town of v_ o J `AN
III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) - 72 . --!o . V° _ - 7 Jj
1 ❑ Apartment / Condo (53 0` d 0 %- 3 0
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. ® New 2. ❑ Replacement 3, ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
....... System ___,____System _____________ Tank Onl�r-------------- Existing System ________ ExlstinaSystem
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 ®,Seepage Trencht f��p��>` 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) Elevation
Goo 75o 7 50 • 6 •75 Feet ?. S Feet
VII. TANK Cap acit in gallo Total # of Prefab. Site Fiber Exper-
INFORMATION g Gallons Tanks Manufacturers Name Concrete Con Steel glass Plastic App
New Existing structed
Tanks Tanks
Septic Tank or Holding Tank — f coq W C ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ 1 ❑ 1 ❑ 1 ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: (No Stamps) MPlMPRSW No.: Business Phone Number:
yVjtor� SM ou>naa�o� 7 8G- god
Plumber's Addres (Street, Cit , State, Zip Co e): �^
1070 W IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved s�tary Permit Fee (includes Groundwater ate ssue Issuing Age Sig ature No S
/
Surcharge Peel o m w
roved , [:]Owner Given Initial a.
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
(FL 11/96) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
I
INSTRUCTIONS
A
f
1. Asanitary 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 4n 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 year=__
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:
L Property owner's name and mailing address. Provide the legal descriotion and parcel tax nurrmb�Fr 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.
111. 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.
V11. 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 81/2 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; frjction loss; pump performance curve; pump model and pump manufacturer; D) cross section
of the soil absorption system if required bythe county; E) soil test data on a 115 form; and F) all sizing information.
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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
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AddrUonN Remarks:
RECOMME•N ED SYSTEM TYPE:
Other Site f eatures:
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System Elevation r slur! al! ign! *140hOnlNo.
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CST Name (Prlm) City State Z ip
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37
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer _ L- Lr Kk¢1 0,9-P W LtY
Mailing Address l b - 7 VA krLSO N �)t N
Property Address ' [k La vi
(Verification required from Planamg Department for new construction) AqP
City/State _ r H Duo ) Parcel Identification Number O
LWAL DESCRIPTION
Property Location J j f d %., S W %, Sec. 3 . T U N -R-LLW, Town of :3 S
Subdivision �0 N s o w PA n Lot #
Certified Survey Map # N Volume . Page #
Warranty Deed # -S 6 7,1 Iq I Volume page #
Spec house 0 yes t no Lot lines identifiable 10 yes O. no
SYSTEM -MAWMNANCE
<Improper use and mandam ceof your septic system could result is its prematumfailure to handle wastes. Pi opermainteaanee
consists of pumping out the septic tank every &= Yeats or sooner, if needed by a licensed Pumper. What you Put into the system
can aff xt- a function of the septic tankas . a treatment stage in dM waste disposal_ system.
TLe PmPatY owner agrees to submit to St. Croix Zoning Department a certification foam, signed by the owner and by a
ma;tcr plu mber, lOu meyman. Plu mber, restricted plund= or a licensedpumpervai6* that (1) the on -site wastewaterdisposal system
is is in War operating condition and/or (2) after inspection and pu raping. (if necessary), the septic tankis Iess than W 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, b er+ein, 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.
C AAOLA,
SIGbMURE OF APPUCAgr 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.
SIGN OF APPLICAW DATE
« « « « «« Any information that is mis- represented may result in the sanitary per nit 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
3
{ V3L 1 1 -71 ?ArFlS9 �
r �. REGISTE ?'lz CFFiCE
C) x141 WARRANTY DEED ST, CROiX c0., W!
Recd IQ,
e
OCT 2 0 1997
Document Number
9:30 AM y
Re
�ter ^ee `a ra t j
Return Address KRISTiNA OGLAND *'
Zilz, Estreen & Ogland
P.O. Box 359 z>
Hudson, WI 54016
Parcel I.D. Number. 030 - 2086 -30
t .
Sandra A. Johnson, a single person, conveys and warrants to Lyle J. CraN �rry and Kari K. Crawle},
husband and wife, as survivorship narital property, the following described real estate in St. Croix
County, State of Wisconsin:t
a K�
Lot l?, Plat of Johnsun Parkway in the Town of St. Joseph. St. Croix County, ��r'isconsin.
This is not homestead property.
xce tion to warranties: Easements, restrictions and rights -uf -way of record, if any.
E p
I'
Dated this _day of October, 1997.
?, Sandra A. Johnson
AUTHENTICATION •=
Sandra A. Johnson, a single person,
Signature(s) f
authenticated this �" t day of October, 1997.
Kristina Ogland ,
"} TITLE: MEMBER STATE BAR OF WISCONSIN
THIS INSTRUMENT WAS DRAFTED BY:
Attorney Kristinz Ogland 3 _
Hudson. WI 54016
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OCT.29.1997 3 :34PM CENTURY 21 HUDSON 'N0.686 — P.1
��� Post -!t Fax Note 7671 � ►
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, SCALE- IN F ET Pte• pftm l
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100 50 0 50 100 200
CERTIFIED SURVEY I AP N VvLl
LOT 4 .OT R `
NORTH LINE OF THE E
SaS 6' 571' W
175. 580.41'
t
LOT 3
130,682 S0.
/ LOT 4 EL. 3.00 ACRES H
133,116 30. FT. ma9 °24'WE
3.06 ACRES 50,00'
/ 989 0 .0 0 ' 1
' 65'x: 5
— 165.00' -- --�` � I5.95 1
N89 ° 55' 13 ,
- PUBLIC
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/ EL. - 936.6 •••., I . J �• ` LOT 12 - p
130,696 60. FT.1 u!
3.00 ACRES N,
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LOT 5 5°
262,295 SO. FT. �• I
6.02 ACRES
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