HomeMy WebLinkAbout032-1006-95-200 ST. CROIX COUNTY ZONING DEPARTMENT
AS BUILT SANITARY REPORT
Owner CL" aAA T TAR! `
Property Address z nro AME
City /State c SO/` 6 /R SG T GUi ` .5 yd2
Legal Description:
Lot _& Block - &A - Subdivision/CSM # 1/0L 33,f
" %a JL I /a, Sec. 3 . T,LN -Rjj W, Town of PIN # 63A. -- M06 —,
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION:
N o r
Tank manufacturer GU E'e ' J Size ST/PC /004/ Setback from: House IL Well iw P/L
Pump manufacturer A4 4 Model
Alarm location
(HOLDING TANKS ONLY)
Setbacks: Service road Vent to fr me
Meter location
n
SOIL ABSORPTION SYSTEM
Type of system: TRFwcrosFs Width 3 Length Number of Trenches �
Setback from: House f lo.S Well r P/L YB Vent to fresh air intake 1'2D l "
lAf,
ELEVATIONS
Description of benchmark TQ //y //� PlP�" Elevation O
Description of alternate benchmark T Poe— Elevation 00
Building Sewer ST/HT Inlet ,t j0, / 3 ST Outlet a !D 4. %t PC Inlet AIA
PC Bottom AA Header/Manifold Top of ST/PC Manhole Cover
Distribution Lines ( i) Zwl . 5 3 (,j 5- 3 ( )
Bottom of System (1) A 0 ( )
Final Grade (f) 9 r/ (2) _ 9!? ( )
Date of installation / Permit number 3,�- f fy,5 D y State plan number
Plumber's si nature r License number .2117`/1 Date f
Inspector
Complete plot plan
1
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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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count
Safety and Buildings Division
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary 3445 Permit 0 IX
04
Personal information you provice may be used for secondary purposes [Privacy La i s.15.04 (1)(m)J.
Per e: E] City ,� Town of: State Plan 1 D
`WA� ', JOHN S849
CST BM Elev.:- Insp. BM Elev.: BM Description: Parcel Tax No.:
J, . O , ` t 032- 1006 -95 -200
1" 11 TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic aul) Benchmark r 1 C3(•7 Oa , D'
J*
Dosing �1 2 po1•�1
�
Aeration Bldg. Sewer
Holding St / Ht Inlet t
5• Qe
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P / L WELL BLDG. Air I to ntake ROAD
ir
Septic ` NA
Dosing NA Header / Man. 57-If r
S• F •GS
Aeration NA Dist. Pipe 7-3 f5 S2
.SL
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
/u
Manufac er Demand 5T_Cdll941_
Model umber GPM to l. OS
TDH ft Friction stem T Ft
L
Forcemain Length Dia. Dist. To well
SOIL ABSORPTION SYSTEM tt,\jtj rS e"_tiA1JP1%
RENCN Width ( Length t No. f I� Tenches PIT No. Of Pits Inside D;a. Liquid Depth
DIMEN J DIM
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manu ctu er:
SETBACK CHAMBER
INFORMATION TypeOf >5 > 15D 5 (5 - 0 OR UNIT o del Numb%
System:
DISTRIBUTION SYSTEM
Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Lengt ia. Spacing 7 �57 jP
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.)S`i,�
LOCATION: SOMERSET 3.31.19.42C NW SW 524 23 ND AVENUE — LOT 2
Plan revision required? ❑ Yes % No
Use other side for additional information. < W M
SBD -6710 (R.3/97) Date Inspector's Signature Cert. No
SANITARY PERMIT APPLICATION Safety and Buildings Division
�. 201 W. Washington Avenue
`� sconsin P O Box 7302
Department of Commerce In accord with tLHR 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. & n,�
� 1
• See reverse side for instructions for completing this application State Sanitary Permi Number
�f 5b
Personal information you provide may be used for secondary purposes [I Check if revis previous ap lication
(Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Property Owner N e Property Location
1/4 114, S 3 T 3 , N, R E (or
Property Owner's Mailing Address Lot Number Block Num r
S
Ci , State Zip Code _ Phone Number Subdivision Name or CSM Number OL / P '3:7$
II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ it Nearest Road
C1 Vil
Public a 1 or 2 Family Dwelling - No. of bedrooms K Town OF D Ls 3 b
111 BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) ::�. ::M. }q . W
1 ❑ Apartment/ Condo (S3:Z. — 1006 —j?,j .ZOd
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 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 UrSeepage Trench 22 ❑ In- Ground Pressure n 42 E] Pit Privy
13 [] Seepage Pit 5 1 A 11 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) 1 16 - ,6 - Elevation
YSO S' ,SQ Feetj 98 Feet
VII TANK Capacity in gallons Total # Of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturer's Name Concrete Con steel glass Plastic App
New Existin strutted
Tanks Tanks
Septic Tank or Holding Tank moo 14900 W[--ex's R ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber I I I I 1 ❑ 1 ❑ I ❑ 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) PI is Signature: (No to PRSW N Business Phone Number:
t ftf Y 44
Plumbers Address (Street, City, State, Zip Code :
s yo
IX. COUNTY/ DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater D ate ssu Issui g Agent Signa a (No Stamps)
Approved E] Owner Surcharge Fee) Owner Given Initial rfj �cJ 1 19
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD- 6398 (R.11197) 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 - 2664151.
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 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.
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-� isc6V%in Department of Industry ml Z _ SOIL AND SITE EVALUATION S•S 3
Gabor and Human Relations Page ( of
Division of Safety and Buildings LM - 7 7 - 1 / in accordance with s. ILHR 83.09 Wis.
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County D
Include, but not limited to: vertical and horizontal reference point (BM), direction and -ST' CFO r
YPPAL t slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I. D. #
432
INFORMATION - Please print all information. Revie U Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). �� CJ
Property Owner � J*Vms :ry C • Cla Property Location
9/
Na,PM I k06-,,t- Govt. Lot NLII 1 14 T `fir ,N,R �9 E (or) W
Property Owner's Mailing Address Lot # Block# I Subd. Name or CSM#
&A 2 6o tt, s`r' • P� to&- 6e AEG CSM Vol 12-
City / State Zip Code Phone Number Nearest Road
ds�G ��• S�DZ� �7�s )Z7�' �!d ❑ C' Village D To X32
New Construction Use: 24esidentlal / Number of bedrooms 3 Addition to existing building
❑ Replacement /!si> r ❑ Public or commercial - Describe: ,, t f3 ej N
Code derived daily flow / V gpd Recommended design loading rate _2_ bed, gpd/ft gpd/11
Absorption area required _bed, ft .750 trench, ft Maximum design loading rate ' '7 bed, gpd /ft ' a trench, gpdff1
2 t p,,
Recommended infiltration surface elevation(s) AOL 3 • , �- 1� D� ft (as referred to site pl n benc rk)
Additional design /site considerations �-s� �N NI VP s W l A� 0 X -V (S T -
Parent material • K Flood plain elevation, if applicable X ft
S = Suitable for system ConVen�tonal Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
U = Unsuitable for system 9 ❑ U ElE U (in U 2t__E1 U aru U [Js
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Structure GPD /ft
Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
,
r o 12. rov,2 313 — s zsbe S CS , s ; , C
Ground 3 Z'3 10 Y 6 fI 1.
elev.
Depth to
limiting
factor
7 .2 t-i__ in. ;
Remarks:
Boring #
° 'r'- 100 313 /-s ,/f' S 1 f •S
Z 1 o r3/ zs / GP A c5' /7C ' .7 .8
Ground
elev.
lk
Depth to
limiting
factor
7Cf�in. Remarks:
CST Name (Please Print) Signature Telephone No.
Address Date CST Number
rc
Private Sewage Consultants
655 O'Neil Rd.
Hudso . 54016
S
C/°
s� (JCS s2 ��kovx `a U f��0
to Go `G � ` /T qk / i
SOIL DESCRIPTION REPORT P �'
PROPERTY OWNER �`� "'�" Page?'of
PARCEL I.D.#
Bonn # Horizon Depth Dominant Color Mottles Structure 2
Boring in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots
Bed ,Trench
1 o•L� /0 ,Q GS �
f�' 44- f 2 f
3 � 3
y• a 3 LS d-5 cS ' •8
Ground
elev.
160 .0 -n.
Depth to
limiting
factor
7 � in. '
Remarks:
Boring #
Ground
elev.
Depth to
limiting
factor
7 ls',q — in.
(V Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Tre
Boring # 0 , /0 /0Y?— '
C'Cc) •S'
Ground
elev.
Depth to
limiting
factor
in. Remarks:
Boring #
Ground
elev.
Depth to
limiting
factor
In. Remarks:
SBDW -8330 (R. 08/95)
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
--� OWNERSHIP CERTIFICATION FORM
Owner/Buyer N _ 'q /U : TA/2 /
Mailing Address Sad 2 3 .2 ,ra A &�E
Property Address .5gy22 22 .v a - A ahE
(Verification required from Planning Department for new construction)
City /State c, Parcel Identification Number
LEGAL DESCRIPTION
Property Location iv us '/4, jW 1 / 4, Sec. , T_-Li_N - R_Lg_W, Town of j01'7�RSE:Z::
Subdivision , Lot # z
Certified Survey Map # ,S 6 2f Q i!� , Volume L9 , Page # 33 ,5
Warranty Deed # 6 O 3 90 , Volume ! N 2� Page # ? s O
Spec house ❑ yes K no Lot lines identifiable Pa 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, j ourneyman 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 tha yo eptic syst has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
days o e e y�e f e rion dat .
SIGNATURE OF 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 prope a ed o by v' of a warranty deed recorded in Register of Deeds Office.
/ 9
S ATURE OF APPLICANT 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
. Vol. 1 427PAGE 350 6.3350
KATHLEEN H. WALSH
REGISTER OF DEEDS
ST. CROIX CO., WI
RECEIVED FOR RECORD
DOCUMENT NO. WARRANTY DEED 05-19 -1999 9:30 AM
STATE BAR OF WISCONSIN FORM 2 -1982
WARRANTY DEED
EXEMPT #
RETURN TO; CERT COPY FEE:
ATTORNEY'S TITLE OF AILLWATEF COPY FEE:
1835 NORTHWESTERN AVENUE TRANSFER FEE: 135.00
STILLWATER, MN 55082 RECORDING FEE: 10.00
PANS: i
TAX PARCEL NO. 032 - 1006 -95 -200
Richard F. Rodrique,a single person, conveys and warrants to John P. Banttari
and Joyce C. Banttari, husband and wife the following described real estate in
St. Croix County, State of Wisconsin:
Lot 2 of Certified Survey Map filed Vol. 12, page 3390, Document No. 569106,
located in part of the NW 1/4 of SW 1/4 of Section 3, Township 31 North, Range 19
West, St. Croix County, Wisconsin.
This homestead property
(is /is not)
Exceptions to warranties:
Dated: 23, 1999
Richard F. Rodrigue
ACKNOWLEDGEMENT
STATE OF Minnesota )
) ss.
COUNTY OF Washington )
Personally came before me on _April 23, 1999 the above named Richard F. Rodrigue
a single person to me known to be the persons) who executed the foregoing
instr ment and acknowledge the same.
DANETTE L. MULACK
otary public NOTARY SEAL NOTARY PUBLIC-MINNESOTA
0 My Commission Expires Jan. 31, 20M
This instrument was drafted by:
Attorney's Title of Stillwater, 1835 Northwestern Avenue, Stillwater, MN 55082
ti F 4.ILG Pr r- l]i -'i'? J V e 1f'�f•i f, :� 4 39 3 01 7, fi 1: 77E, Z Pa 9e .
s FILED 2
mov 2 b 1997 10 I
p 01 W-1
569t06 SL CMil C4.
CERTIFIED SURVEY MAP�r,,
Located in port of the N rthwelt O u c r t C r Of the Southwest u*rter or Section 3, o W ip /� •• ��
Range 19 West. o
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LOT 2 ._.
R.O. W
- -wf ST 114 CORNER Nee 58'53'W
SEC. ,7 x ,31 -19 f
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SOUW LINE Of JNE NrV J/� Of WE SW 1/v
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1 ��N uNPLAT�Q �ANp� �GO1V
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4$ (ALUM. CO. MOM) {O Q
VIM �. Np ov A' 6 11%
/4Ort" The parcel(s) :pawn or this mop Is /ore subject to State, Ilze, ,r,11 s #4.e ~`
and Townehlp taws, rules and r*gulotione ( Le. we, �toct the St.
to parcel, elc.). 9efore purchosinq or deve ` o ote Town Board for toc t
Croix County Zoning Office and the opp P adv
NOV 2 b '97
County Section Corner Monument
of Record yn 'Cr - CN% - ' ;U' �'�' N
• Set I" x 2 iron Pipe welgninq Piannii* " y
a minimum of 1.'3 pounds per 2aNny,and
linear foot. a p
t
.106 097 of not reearde4
Prepared by. , r,ittMOV"wwot GRAPHIC SCALiB I50 feet
det
A & E j"Mute► SCALE M FEET: i Inch =
LAND SUR`EYIN3 6r CIV1L ENGINEERING LAND 9EARIN0S ARE REFERENCED TO THE VEST LINE OF THE
Phone No. (715) 245 -4319 nusuandvadSW 1/4 OF SECTION 3, TOWNSHIP 31 N., RANGE 19 W.
t09 Cost Thira Street, p•0. Box 325 WHICH IS ASSumE0 TO 9EAR S- 0313'42' W.
New Richmond, Wt 54017
Sheet 1 Of 2
Vnl • 12 Pacts 3390