HomeMy WebLinkAbout032-2109-80-000 (3) ST. CROIX COUNTY ZONING DEPARTMENT
AS BUILT SANITARY REPORT ��.`� 17
Owner MELT ,z�A ; �
Property Address '7 "' '`
City /State !,C)mNot - W-`C
Legal Description: 0 t
Lot Block Subdivision/CSM # E OLL VALkf F - -S
�JG '/a �Jc= ' / a, Sec. ti, T a `N -R l'l W, Town of SO NV- PU�-7
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SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION:
Tank manufacturer wF K, Size ST/PC 1Z --- Setback from: House /U Well P/L IA
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: TAFA)C Width ,.3 Length S y Number of Trenches
Setback from: House ( Well P/L Vent to fresh air intake
ELEVATIONS
Description of benchmark Z „ 5TA0 6n) `54y r h P /L. Elevation 10 0
Description of alternate benchmark Elevation
Building Sewer ST/HT Inlet / 07 , Z ST Outlet d o - ` 5" PC Inlet
PC Bottom Header/Manifold Top of ST/PC Manhole Cover /ck 53
Distribution Lines ( ) () ( )
Bottom of System O �/• �� O ( )
Final Grade O 9 O ( )
Date of installation {Z/ / Permit number .5 State plan number
Plumber's si ature -JA4 License number LUCS 22 ,32-42, Date
Inspector
Complete plot plan �
X
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
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INDICATE NORTH ARROW
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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count
Safety anti Buildings Division
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)]. 353242
Permit Holder's Name: ❑ City ❑ Village ❑ 4own of: State Plan ID No.:
Barritt, Melissa Town of Somerset -
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
'(Qo � v r �
2 " K 2 " 032 - 2109 -80 -000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV.
Septic ton Benchmark a (off 14 00
Dosing Alt. BM
Aeration Bldg. Sewer 0A
Holding St/ Ht Inlet o ,.ZO�
a .OS t'
TANK SETBACK INFORMATION St/ Ht Outlet Outlet(-A ,3 44 •45 -*'
TANKTO P/L WELL BLDG. Ventto ROAD
Air Intake
Septic �5' ,�, �p,p' r•-- NA
Dosing — 0� r ) NA Header/ Man. �• 93.30
Aeration NA Dist. Pipe q 9 3, 2,(0 r
Holding Bot. System O, 9 �(,
$ - 4--6
PUMP/ SIPHON INFORMATION Final Grade a , s • 9s0
Manuf emand St cover C � b" 1�8.5
Model Number GPM / ?3
TDH Lift L ricti S stem TDH Ft ad I -T-
Forcemain ngth Dia. Towell
SOIL ABSORPTION SYSTEM _
TRENC Width Len th No. f renches PIT No. Of Pits Inside Dia. Liquid Depth
r g
IMEN I
DIMEN
SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREAM LEACHING Many ' 4a urer
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INFORMATION TypeO �J � CHAMBER e um er:
System: �'
CHAMBER
DISTRIBUTION SYSTEM
Header / Mao�l K Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia Len Dia. Spacing 1 c r
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 E] Yes El No ❑ Yes E] No
COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: 17–/ 2/ Inspection #2:
Location: 1769 46th Street, Somerset, WI (NE1 /4, NE1 /4, Section 5 T30N -R19W) - 5.30.19.1026
1.) Alt BM Description= r -T,
,
2.) Bldg sewer length = Ifl �, \
- amount of cover = -� �� t (p )
3 .
Plan revision required? ❑ Yes q No / Z
Use other side for additional inform tion.
SBD -6710 (R.3/97) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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Safety and Buildings Division
Itisconsin SANITARY PERMIT APPLICATION pOBo Washington Avenue
Department of Commerce In accord with Comm 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 8112 x 11 inches in size. ^ - (fko t
• See reverse side for instructions for completing this application State Sanitary Per �N
Personal information you provide may be used for secondary purposes E] Checit revision toprevi application
[Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Property Owner Name Pr operty, Location
Ad Euj SC, �� ` /Ili 1/a j 1 /4, 5 T 30 , N, R ) 7 E (0
Property Ow er's Mailing Address Lot Number Block Number
s 1 (-
City, State I Zip Code Phone Number S bdivision NamR or CSM Number
. TYPE OF BUILDING: (check one) ❑ State Owned ❑ It� Neare
E] Vil age 7
Public 1 or 2 Family Dwelling - No. of bedrooms own OF Stan 'R� �T
III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo " 8� 5 0. (l
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 aNew 2 ❑ Replacement 3 ❑ Replacement of 4 ❑ Reconnection of 5. I] 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 RSeepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit i e- Z 43 C] Vault Privy
14 E] System -In -Fill �, rP� = JZ S
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
/a7Q Feet ' /,!57 Feet
i Ca acit
VII. TANK in allo Total # of Prefab. Site Fiber-
INFORMATION g Gallons Tanks Manufacturers Name Concrete Con steel glass Plastic Exper.
App
Ne w Exi Ta nk s structed
Tanks Tank
Septic Tank or Holding Tank /zoo ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ I ❑ ❑ I ❑ 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 ature: (N Sta ps) MP PRS Business Phone Number:
'Err I 1 3 X15.91-3 i)
Plumber's Address (Street, City, State, Zip Code): IVV
Z 5 RC S�Ek W' )
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sani ary Permit Fee (includes Groundwater ate slue ZAgentS na a (No Stamps) A Approved E:] Owner Given Initial Surcharge Fee) T
Adverse Determination z�S
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD -6398 (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 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 vvherf6ve'r"
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 - 31&1., - • • - - - -
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 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 Joss; 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.
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We.-A w Depaadment of Commeroe SOIL AND SITE EVALUATION Page 1 of 3
Division of Usty and Buildings in accord with Comm 83.05, Weis. Adm. Code
Euvinomeoal By Desiga
Attach complete wile plan on paper not less than 8% x 11 inches in size. Plan must
include, but not invited to: vertical and horizontal reference po and d to nearest road. $t. Croix
(BM), direction and Canty
percent slope, so north arrow, or dimensions, no arrow,
e Parcel l.D.#
APPLICANT INFORMATION - P f `
}�,�`►t ail informatbn. D�
PersoM Yslomudun you proWs may be used for ?may pis�e LA*0 a. 15.04 (1) (m)). / 1/2
Properly Owner Property Location
Bmitt Mellissa Govt. Lot NE t/4 NE 1/4 S 5 T 30 NR 19 W
Property Owner's Mailing Address ; ' F/ Lot # Block # Subd. Name or CSM#
83 Hickory St .: 8 Cedar Voft des
CRY State Cgde �] City ❑ Vi lape NTown Nearest Road
Saint Paul MN 5511 .651 �- 7; ` Sam t80n Ave
t New Construction use M Res W ` J "Nll er' " noorrts 4 Fl Addition to existing Wang
❑ Resent ❑ Pubic or arum! n;ial describe
Code Derived daily flour 600 gpd Recorrrended design loading rah .5 bed, gpd/lla 6 trench. W ff
Absom area required 1200 bed, fl= 1000 trench, ft2 Maximum design loading rate •5 bed, .6 bench,gpdNf
RecomMended intdiradon strrface eieval on(s) 91.75 ft (as referred b sit- plan Wrichrrar
Additional design / SOB Consideration Site has been cut so as to obtain suitable soils Replaceent systemm as per Gary Steel's (not dated) soil test
Parent material Outwash sands Flood plain elevation, if applicable Na ft
S - - Suitable for systm 7 Conventional Mound In- Ground Pressure , AT -Grade System in Fill Holding Tank
u =unsuirable for Syslern j [AS El u ® S El u N s o u N S❑ u i EIS N U o S N u
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Boundary Roots GPD/(F
Boring# Horizon in. Munsei Qu. Sz Cont Color Gr. SL Sh. Bed Trends
l 0-90 7.5yr6/6 - s 0sg 1w - - .7 .8 �psorl
7
Ground
elev
94.75 ft
Depth to
limiting j
factor
>90
Remarks:
2 1 0-90 7.5 - s 0sg nd - - .7 .8
Ground
elev i I
94.85 ft I I ! I I
Depth to
limiting . a-
factor
>90 '
Remarks:
CST Name (Please Pry Signature: Telephone No.
Thomas C. Nelson 715 -246 -2454
Address Envkomn otal By Design Data CST Number Ref #
1432120th Street, New Riclmmd, W] 54017 J f 7387 271
PROPERTY OWNER. Bvqo t tt ssa SOIL DESCRIPTION REPORT I z�' I Page 2 of 3
PARCEL LDS Design
Horizon Depth " Dominant Color " MOWS $VUeture GFDi1P
In. Munsell Qu. Sz Cont Color Texhtre Gr. Sz Sh. Rows Bed : Trewh
1 0-90 7.5yr6l6 - S* asg ml - - .S 6
Ground
elev
95.10 ft
Depth to
limiting
factor
Ile
Remarks: " with bands of Ifs 7.5yr4/6
Ground
else
Depth to
limiting
factor
Remarks:
Ground
elev
Depth to
limning
factor
Remarks:
Ground
else
Depth to
limiting
factor
Remarks:
INVIRONA[MTAL �Y Of5i6H
1432 120' STREET, NEW RjCH 40 - ,vqD, WISCOI
715- 246 -2454
Tom Nelson
Certified. Sod Tester 227387 -- Registered Sanitarian SR00713
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