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Home My WebLink About030-2059-90-000 FF ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT Owner Property Address ; - City /State COUNTry Legal Description: Subdivision/CSM # / -- Lot �. �? Block . '/a t /a, Sec., TAN -W, Town of PIN - SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer Size ST/PC, �? / Setback from: House � Well --s� P/L r 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: �- Width Length — 75= Number of Trenches Setback from: House 5_ Well 11rZ P/I, : � Vent to fresh air intake /m ELEVATIONS Description of benchmark 4Z2 42,4 ,,�Laz Elevation Description of alternate benchmark Elevation /l Joe 9e -f/ Building Sewer ST/HT Inlet ST Outlet PC Inlet PC Bottom Header/Manifold Top of ST/PC Manhole Cover Distribution Lines Bottom of System ( ) ZZ �_ () 9-7 %� ( ) Final Grade () 9,4? ---� 3 () 99,;2--? ( ) Date of installation 1 Pe it number _ Ss'�� State plan number Plumber's signat re Z x x License number � Date Inspector 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. PLAN VIEW 6 - V s Y INDICATE NORTH ARROW r ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify at I have nspected the septic tank presently serving the residence located at: Section ;: ,27 , T 4� 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): --- Age of Tank (If known) : ( ignature) (Name) Please print (Title) (License Number) 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 inspection pening,00ver outlet baffle). Name ✓ - S ignatu MP /MPRS Wisconsiri Department of Commerce Safety and Buildings Division PRIVATE SEWAGE SYSTEM County: 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.15.04 (1)(m)]. 353253 Permit Holder's Name: ❑ City ❑ Village ❑ xTown of: State Pl ID ID Nom_ Matthe I Town of St. Joseph CST BM Elev.-.- Insp. BM Elev.: BM Description: I Parcel Tax No.: �� 0 ! = tST = 1 i 030 - 2059 -90 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic I avv Benchmark o1 oz- S1 /&0. c7 � Dosing Alt, BM Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet (p -!3• q6, ye TANK TO P/ L WELL BLDG. Ventto ROAD Air Intake Septic 7 6 •�" NA Dosing A Header /Man. to 9 �t( Aeratio NA Dist. Pipe •IS Qs, S8' Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade J 3 `?a•� Manufacturer I Demand St cover Model Number GPM TDH Lift Fr' System TDH Ft ead Forcemain Length Dia. Fi Dist.Towell SOIL RPTION SYSTEM ( (Z_ BENCH Width L ngth r No. f T enches PIT No. Of Pits Inside Dia. Liquid Depth IME DIMENSION LEACHING nu ure SETBACK SYSTEM TO P/L BLDG WELL LAKE/ STREAM INFORMATION Type O r CHAMBER Mod Number System: / OR UNIT DISTRIBUTION SYSTEM Header anifold Distribution Pipes) x Hole Size � xHole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing 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 N Bed /Trench Center Bed /Trench Edges Topsoil I ❑ Yes ❑ No ❑ Yes ❑ No j COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: /Z/ 8 /ggInspection #2: — �--f Location: 1379 Main Street, Houlton, WI 54082 (NW 1/4 NE 1/4 27 T30N R20W) - 27.30.20.576 1.) Alt BM Description — r /�' y 2.) Bldg sewer length= _ 4� - amount f cover tot wcts S 17 �4 T -tvc a �+� � taw%A) •� \ ril �'1° /1�Mdln'+ "��•QW- 1 �t�t t (�1t . �I�/1M 5� tA- Plan revision requ 7 ❑ Yes 00 � Use,oth Id for dditi nal formation. 1 0, 5 02- 0 Z to- Date Inspector's Signature Cert No. f SBD -6710 (R.3/97) ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: - - ------- - T i- T 4- EE JL- 7 t i r � .tee 3 I F Safety and Buildings Division Vi sconsin SANITARY PERMIT APPLICATION 201 W. Washington Avenue °� — - P O Box 7302 Department of Commerce In accord with Comm 83.05, WI dm, cope i Madison, WI 53707 -7302 • ` Attach complete plans (to the county copy only) for the syst ; cin pap Co lot less my tl than 81/2 x 11 inches in size. • See reverse side for instructions for completing this applic4tion Sta anitary Permit N6mlz Personal information you provide may be used for secondary purposes `w_ ❑ GfiQ k it revision to previous application [Privacy law, s. 15.04 (1) (m)). e rr State Ian I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL ` FOR ftr: Prope O ner Name .� 'Property Locati d . M v4 1/q T , N, R g(or Property Owner's Mailing Add ess tbo umber Block Number WA _ s� 7 - z City, Sta Zip Code Phone Number Subdivision t1ame or CSM u r ( ) II. TYPE OF BUILDING: (check one) ❑ State Owned Ej it Neare Road Public 1 or 2 Family Dwelling - No. of bedrooms Town OF C III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo b30 -2OSq —Oro 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 pj 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 IN Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. AB SORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Pert Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min./ nch) Elevation G Feet Feet VII. TANK Capacity in gallons Total # of site INFORMATION Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper New Existing Gallons Tanks Concrete strutted glass App. Tanks Tanks Septic Tank or Holding Tank ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamberl I I ❑ ❑ 1 ❑ 1 ❑ 1 ❑ 1 ❑ VIII. RESPONSIBILITY STATEMENT I, the ndersigned, assume responsibility for ins /1/1a ion of t onsite sewage system shown on the attached plans. Plumber' 7me P ri Plumb 's natur St MP /MPRSW No.: Business Phone Number: J ` Plumber's ddres et, ity, Stat Zip Code . IX. COUNTY / OtPARTMENT USE ONLY ❑ Disapproved Sa ary Permit Fee (Includes Groundwater D ate Issued Issuing Agent Signature (No Stamps) pproved [:]Owner W Given Initial b`I] Surcharge Fee) lZ -6—��' �. Adverse Determination ) _ -,% TI I PPR AI. / �tE " -vo FOI�PPF�OVAI t � ` 2 la�oo�1�G2siteY►- T . " tw r� r'^�` �- oc�t — .SBD -6396 (R. 4199) 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 maybe renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Ad Mini strative•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 rribintained 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 608-266 -3151. -- - To be complete, and act -urate this sanitary permit application must include: I. Property owner's nathe-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 completedimensions, 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 o"n'a 1 15 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. < (A No Ito Z L _ ., 0 c I � N W o r "tWisconsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page —/— of Bureau of Integrated Services in accordance with Comm 83.09, W 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. If p 6'3o -- ��J l 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 ner Property Location l 1 Govt. Lot 1/4 1 /4,S T ,N,R E (or}J P roperty Owner's Mailing Address Lot If Block# Subd. N me or CSM# City Stale Zip Code Phone Number s ❑ Ci / ❑ Village ® Town Neare Road ❑ New Construction Use: Residential / Number of bedrooms Addition to existing building Replacement ❑ Public or commercial - Describe: Code derived daily flow gpd Recommended design loading rate -5 bed, gpd /f1 —'_ trench, gpd/ft Absorption area required DD bed, ft �SD trench, ft 2 Maximum design loading rate bed, gpd /ft trench, gpd/ft Recommended infiltration surface elevation(s) 46S ft (as referred to site plan benchmark) Additional design /site considerations Parent material au ,�,�/� Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In- Ground Pressure I AT -Grade System in Fill Holding Tank U = Unsuitable for system 0 S ❑ U S U 0 S ❑ U Z) S U ❑ S M U EIS ® U SOIL DESCRIPTION REPORT Bonn # Horizon Depth Dominant Color Mottles Structure GPD /ft g Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench Ground elev. r ft Js�� Depth to limiting.98 • ,08 factor Remarks: Boring # INN 0 . I 1A Al Ground — elev. 9 1A2- ft- q< og z.o8 Depth to limiting factor yin. Remarks: CST Name (PI se Pri ) Signature - / Telephone No. i— �Llj'c � . . Address� Date CST Number ', SOIL DESCRIPTION REPORT I PROPERTY OWNER �— Page ; of PARCEL I.D.# Boren # Horizon Depth Dominant Color Mottles Structure 2 9 Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Y 0 0 141 Allf, - Ground elev. — , Depth to limiting factor Remarks: Boring # Lj 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 # i Ground elev. ft. Depth to limiting factor in. Remarks: Boring # I R om Ground elev. ft. Depth to limiting factor in. Remarks: SBD -8330 (R,9/98) !� 3S \ �\ ,\ � \ °Y � �� ,�. �� . � �. � �o � �� .� � u g �� m 0 o� �� ` ,- ;� � � �� `� � � � E _ � (�V�( �� ._ �� l 1 � � � � yQ � \ t U 0 `' �� S� 1 S �� s � . v `� � I � � �� _ w �� N � n y w� �� - � 0 �v Chamber SAS SYSTEM ELEVATION AND SIZING CALCULATIONS Below Grade Chamber Soil Absorption Systems Permit Number 12/6/99 Date x "x" Gravity Distribution only 1 Pressure Distribution 3 ft Suitable Soil I Note 1: Bury depth as per manufacturer 18 in Chamber Height 2 8 ft Maximum Bury Depth 3 450 gpd Estimated Daily Peak Flow 0.60 gpd /ft Wastewater Infiltration Rate 750.0 ft Code SAS Size 40 % Down Sizing Credit 300.0 ft Reduction ( -) 450.0 ft Min. SAS Size 94.18 1 ft Proposed SAS Elevation Soil Surface Acceptable Finished Grade EL 4 (ft) Boring Grade Limitation SAS Elevation (ft) System Minimum Maximum Number Elevation (ft) Depth (in) Lowest Highest Elevation? 97.18 103.68 1 98.02 112 91.69 95.85 Yes 2 1 98.02 114 91.52 95.85 1 Yes 3 98.68 114 92.18 96.51 Yes 1. Depth of suitable soil required below the infiltrative surface for treatment. 2. Total height of chamber in inches. 3. Maximum bury depth as per manufacturer's recommendations. 4. Based on chosen system elevation, and chamber height. Top of chamber is equivalent to top of aggregate. The addition of fill for cover or the reduction of finished grade may be required to meet minimum or maximum code standards. k ' s f CROIX COUNTY SEPTIC T ;',NI< MAINTENA1vCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address _ 1 27 y A�'f; ;v, I lb u� nV1 � Property Address SC',-M (Verification required from Planning Department for new construction) _ City /State &,, 1T�2,T- zc) Parcel Idcnti(ic:ttion Nurnber 7 �b :2C�• 76 LEGAL DESCRIPTION 03o_ S - cre9 Property Location !� '/ ' /4, Sec. -,:�-7 , T3 N- R Town of 5_4 J os p Subdivision d ,? 4 � ,Lot 4 2 Certified Survey Map # Volume , Page # Warranty Deed # /S , Volume � _ , Page # Spec house 0 yes 27 no Lot lines identifiable 0 yes X no SYSTEM MAINTENANCE Improper use and maintenanceof'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, it' needed by a licensed pumper. What you put info 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 tier and by a master pIomber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site was rewater&,posai 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. f /vie, 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 Commer,:e and the Department of Natural Resources, State of' W isconsin. 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 yea expiration date. SI ATUR OF L,ICA DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. 1 (we) am (are) ti;e owner(s) of the property described above, by virtue of' a wananty deed recorded in Register of Deeds Office. SI ATURE OF APP ANT DA "t is ' *** ** 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 fi,,m the Register of Dceds off ice a copy of the certified survey map tf reference is made in the warranty deed i i �DOCUMENT NQ. STATE B.Ai OF WISCONSIN FORM 1 --1962 THIS rs.tE REURYED rpa RIECOsDI CAT4 WA>> PANTY DEED 463 06 1Nti 93 REGISTER'S OFFICE ' This Deed, mad. between ( ........ ST. CROIX CO., W I Esther A. LaValiey, unmarried Reed for Record OCT 0 91990 Grantor, 11:35 A. M antimp.,'thew C. Gillstrom and Ronda R. Gillstrom, ♦ !. husband and wife as joint tenants Grantee, W itnesseth , That the said Grantor, for a valuable consideration_ _-. .. .......... • Croix cunve;s to Grantee the following describeu $t RETURN TO real estate in __ ....- __ .... .. ... .... .. County, State of Wisconsin: Tax Parcel No: ................................... Lots 22 and 23, Block "7 ", Village of Houlton t This _ _ is __._..._.. homestead property. (is) (is not) Together w,th all and singular the ).ereduaments and : =ppurt,nances thereunto belonging; And_.. ..._ _ _ -. ..... ... 'Aarrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except and will warrant and defend the same. flared thi: da;- of October _. -_, 19_ 90.. (SEAL) "-9 �T1z' J --(SEAL) Esther A. LaVall - - . iSEAL! __ _ _ _ -. _(SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) - -- -- - --- .... STATE OF R7t MIWOM awilm / — ss. - •----- --- ----- --- -- -- ----- i� c'CAunty authenticated thii ------ ..day of --------- .. . 19 --- -__ Personally came before me this ._ ........ day of October , 19. 90__ the above named k - ... -._.. ------ -- ----- _- . - - -._ Esther A. LaValley_ __ -__ -- . .... . ... - -- TITLE;: SiF.3EEtER STATE. BAR OF w(tCOtislN (If nut, ....... _ _ -- - -- -- - - authorized by 3 706.06, W i;. bt.,ts.' to me known to be the person .. who executed the fore',,in; instrument and acltA•�ie it " e. - E$ *► er_A.. LaVAlley... _ , ------ _. _ `ota' E' Ili< , :' l CbQt7, Wis. ( i_nxt,rr; may be wit6enticn'rd or :nmt; -_ I. 1 „tk �T =; Ozrn ..nn is ; n1.8! ,t. 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