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HomeMy WebLinkAbout030-2059-40-000 L ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT Owner R Property Address City/ State St ' Legal De cription: Lot Block ,R Subdivision/CSM # - ALJt /a IvF t /4, Sec. Q 7 TAN -R 6ROW, Town of SY je> PIN # C-3 SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer W UL- Size ST/ya A Setback from: House -00 Well 3� P/L Q_ 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: hV Width Length Number of Trenches Setback from: House 5 ? Well S'a P/L 4P Vent to fresh air intake 9 ELEVATIONS ' Description of benchmark 5� W -kkS(J Elevation Description 6'�� ��"� -�— Description of alternate benchmark Elevation 9' 2,1. a_ Building Sewer ST/HT Inlet cl 7 , 8 ST Outlet PC Inlet PC Bottom Header/Manifold Top of ST/PC Manhole Cover /cc • e 4 Distribution Lines q Tf () ( ) Bottom of System Final Grade Date of installation 3/AS/ t7 Permit number 33 8 ; r a7 State plan number �- Plumber's signature License number aao S'3 7 Date .5 Inspector 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. PLAN VIEW N 3 a . L S9' 3 l G am , l 5d INDICATE NORTH ARROW Wisconsin Department of Commerce Safety and Buildings Division PRIVATE SEWAGE SYSTEM Coun INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: ST. CRO EX Personal information you provice may be used for secondary purposes [Privacy Law, s. 15.04 (1)(m)]. 338927 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: OSTENDORF, DANIEL ST. JOSEPH CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: ' 030 - 2059 -40 -000 TANK INFORMATION LEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic a /� blj) Benchmark � ) xs '�i �. IL)5,dv5 Dosing Aeration Bldg. Sewer Holding St /Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet 155f TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic -/ �aS NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe a'd� 12 9 .09 d Holding Bot. System f0 ,0 // ' PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand < /pp � Model Number GPM TDH Lift Lrictio Syestem TDH Ft oss Forcemain Leng Dia. Head To well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length , No. renches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSION SETBACK SYSTEM TO P/ L BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION Type O , } CHAMBER Moe Number: 4.-m System: _ -m >./- r/ �a �!�t' OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia- Length Dia. Spacing 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 27.30.20.571,NW,NE 1373 MAIN STREET — LOT 17 Plan revision required? ❑ Yes ET"No / Use other side for additional information. SBD -6710 (R.3/97) Date In or's Signature Cert No. r ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: I I t € e f e i E a f f e F S e � f e 3 e m.I i ms F � e j i € e n S E ? 3 m ea b a. f i i _ m.sy, �...... .... -r.. .,. ..,, .. �. ma.m._. .,F * , „®. ,. ... , ._ . ._ ee� a-., d . f � m € € E 1 s s e..m fie® � e 3 � { a ; F € e ..F.....� 2.-... € e..«.«... A........ i __a .dm. � E } 3 � s` 6 € e e P i � y t ..a . ,...er. e ._. � .. .m g E a < e i F s t t Safety and Buildings Division Asconsi SANITARY PERMIT APPLICATION 201 Bo Washington Avenue 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 81/2 x 11 inches in size. ST 0 ` • See reverse side for instructions for completing this application state sanitary Permit Numb Personal information you provide may be used for secondary purposes 33 yci 27 ❑ Check it revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Prop Owner Name Property Location Imo,. Nw /4 1/4, S T d, N, R E (or� Property Owner's IVISli A d ess �� Lot Number� Block umber c Cit , State Zip Code Phone Number ` Subdivision Name or SI�A Number (' ) (� II. TYPE F B ILDING: (check one) ❑ State Owned E] it s+ p Nearest Road Cj Public 1 or 2 Family Dwelling - No. of bedrooms own of w III. BUILDING SE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 0 3 O — a O SQ —00 - Q00 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. pK Replacement 3 ❑ Replacement of 4 E] Reconnection of 5_ ❑ Repair of an ------ System System Tank Only 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 n Seepage Bed 21 ❑ Mound 30 ❑ Specify Ty a 41 []Holding Tank 12 Seepage 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) Elevat�jr S� 70 --^ WS Feet Jai Feet ac t VII. TANK in Ca gallo s Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existing structed Tanks Tanks eptic T k V - t i es t^ ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ 1 ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for igstallation of the onsite sewage system shown on the attached plans. Plumber's Name: (Pr i Plumber's Si natu : (N Stamps) MP /MPRSW No.: Business Phone Number: v . 53 15 c'a k S'I Plum er's Address (Street, City, State, Zip Co t 4 [ C1 (4 1 L3 � P1'LAMo,-A_ IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued suing A�� Signature (No Stamps) Surcharge Fee) / / �pproved E] Owner Given Initial astSD / �/� , Adverse Determination J M `f X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.11/97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber 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 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. 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. 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. j p lat p1 ` Y• � / wl N a 7,T3a -a0 w �a �n1 e � Q��'2•, a or � � 14 icid a n V 4LY Iw U�I� "�► +^ —,X0 59.3 s 37 , h�� , • DOO Lu� ! Y X 37 Ll5ah - J Gycfrye Roh P ,T W ,, 4ys �Ga�r 61 cry OP o �—' � v 3 S l PAGE OF C r vSS Si 101'1 p F(4&h Alt Inl011, And ODlurallon PIP• Nom' N T30 aZQLl1 Minimum IZ• Apor• A➢➢ror4/ V•nl Cap final Grade 20- 42' Above Plpr _ 4` Coal bon To final Oloda V•nl PIP$ warm No Or S mA.rk Cor•rin win 2 P AOar•Gol• 01•I114YIlOn Or•r IP• PtPa o 0 0 Too _ b' AYYrapola 84n•41 6 Plp• ° P•iloroba pip, l"Jorr o — Corpina T•rminoOInv AI 601lom Of Shalom P POP0 ep P1 n,. 9rA(.1< VcjJ Ion SOIL FILL p•� DI PIPE Pe 7, APPKOVED SIMPETIC COVCR 2 AGGREOME /" OR 4" OF STRAW OR MARSH �{qy ELEV. oF�FELT rerroP ,t -2'i2 AGGRCGATE F --- -- � / � . ..................... PIPE TO BE AT�LEAST AQU AT LEASTtO IAJGHES BUT 1.10 MOR N y2ENC1 BELOW FINAL GRADE FINAL GRADE 1wimu/H DEPTH OF EXeAVAT100 FXoM OKiGi AL 69NVa WILL BE 8� INFl1MVM ©EPTIi OF EXCAVATImN f-p 0 j4 IWAL G RAPE WILL BE - --Lil? ILICHES INCHES LIGEAISC IJUMBEK: 5� DATE: 1 - Wisconsin Departmentof Commerce SOIL AND SITE EVALUATION Division of S^.� and Buildings . Page of 3 Bureau of Integrated Services in accordance with s. ILHR 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 S * C V O x percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. If 0 - aO S� 3v - APPLICANT INFORMATION - Please print all information Re ' ed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). J� Prop e Owner Property Location I Govt. Lot (j 1/4 /jr 1 /4,S ;0 T 30 ,N,R eZ V Sor) W Property Owner's Mailing Address Lot If Block# Subd. Name or CSM# ato 2 9 17 7 P1 0-t o City State Zip Code Id Phone Number ❑ City Village ❑ Town Ne est Road I m OutZ (6s, p - /fo2 O to, 3_5 ❑ New Construction Use: Residential / Number of bedrooms .— Addition to existing building Replacement Public or commercial - Describe: Code derived daily flow Q gpd Recommended design loading rate 17 bed, gpd /ft r trench, gpd /ft Absorption area required Gy 3 bed, ft S� trench, ft Maximum design loading rate _____ _ ? bed, bed, gpd /ft gpd /ft Recommended infiltration surface ele ions) ft (as referred to site plan benchmark) K Additional design /site consideration 61 97, (e rif f Parent material � � nod plain elevation, if applicable Ji _ ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system S; J U S❑ U OZ S ❑ U ❑ S K U ❑ S Ki U ❑ S A U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell ou. Sz. Cont. Color Gr. Sz. Sh. Bed Trench ........................... 5 � J� -37 p y► sb —' � S4K m�rr 1 3 S . � Ground 3 �' � /o y r 5 La 4 stiff m p h J fir' � 5 A•a elev / ol�JB ft. g Depth to * zW h V s rr' 7 limiting factor in. (o Remarks: CF Boring # • 13 IN 3 sbk ' a • 5 :,� Ground J OD a C , s elev Igo. S lovt D M Depth to limiting fac tor in. Remarks: CST Name (Please Print) Signature Telephone No. 1 u� 1p Y,6 -_5/ Address Dide CST Number AJ 164,A M 0 nd Geld' a! 7 PROPERTY OWNER DaN% Oslevsalnok SOIL DESCRIPTION REPORT +Page_.'Zof PARCEL I.D.# 630 Boring Horizon Depth Dominant Color Mottles Structure 2 9 Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ( Bed ,Trench f S 1 4 S bK Ground 3 2-Ar S 6 K S elev. o Depth to "S 9 r �. Q ~ O limiting factor �in. ' Remarks: Boring # 13 Ground elev. ft. Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. a Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # 13 Ground elev. ft. Depth to limiting factor in. Remarks: Boring # 1 Ground elev. ft. ' Depth to limiting factor in. Remarks: SBD -8330 (R. 07/96) OW A)W s -37 - T34 s +i 11 WaAcot " I-et 17 S f -6v- %.V P Dies — 0"'10,5' 3o —d0a L� 6a w► K sue. i S-° 5 3,7 3 111 r'�� A SAP 154 -- 61, gym' s v cc JU tp •- �--- r. VAN- r ! O d Pr ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT 1k`tiGecoi� cA AND OWNERSHIP CERTIFICATION FORM Owner/Buyer On n 1�2 i t�S 1P2 VnA 0 e Mailing Address og le �( k eAw. y LAL V-6c Property Address ? v, (Verification required from Planning Department for new constructs n) City /State �,� '� -a..� Parcel Identification Number 0105 LEGAL DESCRIPTION Property Location AW '/4, _ '/4, Sec. a?7 , T _. �b N -RAW, Town of a {�. Subdivision , Lot # l ? Certified Survey Map # , Volume , Page # Warranty Deed # , 00 3 , Volume 7 4 1 , Page # o�O Spec house ❑ yes no Lot lines identifiable 0 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. 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 th your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days o th three ar expiration date. Ago f .5! ; SIGNATURE OF AP ICANT DATE OWNER CERTIFICATION e) 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 p pe desc ' ed above, by virtue f a warranty deed recorded in Register of Deeds Office. .5//3/ 9 SIGNATURE OF A PLICAN 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 Tbis 3nbenture made this .. ...........�v ............ ....... day of ........ ......... Au g ust ........................, 19...8....., orge J.; Game : anti Ratricia E. Game,, husband and wife between .............. Ge ...................... ................................................. ............................... .......................................... ............................... 3 N of the Count of HO.M. ePi.KI ......................... _ ........... and State of Mi17a e.. q. Qta............ ............................... part.1Q.5 of the first part, and.......... Daniel Gene Ostendorf .... ... and Eileen Ostendorf.................................. ........... ....................... ........... ........ .......... ............................... hu.$band....a,nd wife ....... ....................... ........ ...................... :......., of the County o .. ............................... .....,................. f ............. Croix .... ...................and State o .....wisconsin 1 a f .......................... .............................., parties of the second part, Mitne000J, That the said part.i.e..9. of the first part, in consideration of the sum of ............... ...... ........ ... Qne....D.olla.r .... and... other .... v ab. 1 e .... cA n. aide.r. a.ti ..... I.. ..... Q. O.)... := .- .- to .lh. = ...................i.n hand paid by the said parties of the second part, the receipt whereof is hereby acknowl- edged, do............ hereby Grant, Bargain, Sell, and Convey unto the said parties of the second part as joint ; tenants and not as tenants in common, their assigns, the survivor of said parties, and the heirs and s assigns of the survivor, Forever, all the tract...... or parcel...... of land Lying and being in the County of o S.t...0 .S� ..... ..........................and State of Xtffflzwxi� described as follows, to -wit. wisco risizi Lot 17 and the North 58.5 feet of Lot 16, all in Block 7 of Plat of Village of Houlton on file and of record in the office of the Register of Deeds. - e a � This document satisfies land contract dated 18th July, 1980, Recorded October 8, 1981, Document #373767. � o babe anb tooID tlje $came, Together with all the hereditarnents and appurtenances there - unto belonging or in anywise appertaining, to the said parties of the sect-4 part, their assigns, the sur- vivor of said parties, and the heirs and assigns of the survivor, Forever, the said parties of the second part taking as joint tenants and not as tenants in common. .gnd the said ........George J. Game and Patricia E. Game, husband and wife ...............................................................................................................,............... ............................... . ................................................................................................................................................................................................. ........................ ............................... part of the first part, for........ their heirs, executors and administrators do............ covenant with the said parties of the second part, their assigns, the survivor of said parties, and the heirs and assigns of the survivor, that... they are well seized in fee of the lands and premises aforesaid and ha Ve.... good right to sell and convey the same in manner and form aforesaid, and that the same are free from all incumbrances, r?nd the above bargained and granted lands and premises, in the quiet and peaceable possession of the i said parties of the second part, their assigns, the survivor of said parties, and the. heirs and assigns of the it survivor, against all persons lawfully claiming or to claim the whole or any part thereof, subject to ;I Encumbrances, if any, hereinbefcre mentioned, the said part.. es o f the first part will Warrant and Defend. It TeMittlonp Mbtrt f, The said part... of fir t part V9.... hereunto set, the 4 - r......... hand ... s the day and year first above zvritten. In Presence of .......... e . r • , .. 1. c .......... .............................. _'. ' .............................. 'rca . �..Oa e ........... .......................................................................... ............................... ............................... ............................... ji i hhh'_ _ iz,pyy, Tieu�,r e el t rizat -rWZ Ve � �s � �or>•c�t :z�rescnC�tGon, � z4: �, _�. �� . �� withee.r and distawees aizdrtuantdies 7 23 • •.• ere, 15re"t"e 1B 1 7 F' c . r � it S lTEET ~ � 1 ,. � ` � �. Way' • TON 3 I'�^ -' kAx I F } 9• { r �.. A r .: � STREET; .•`,�. x --. '