HomeMy WebLinkAbout032-1092-70-000 r
ST. CROIX COUNTY ZONING DEP
AS BUILT SANITARY REP, RT /�O
Owner L EON 13 R ezu FA
Property Address
P rt3'
v7y A l /Bv .4UE• q
City /State S!)t=dSET 11)i
1141y
Legal Description:
Lot A(A Block &A Subdivision/CSM #
V4 Tc t /4, Sec. ,U,, T3LN -R -W, Town of
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION:
Tank manufacturer Size S ac om: House Well PAL
Pump manuf Model
ocation
DING TANKS ONLY)
)
Setbacks: Service road V r m e Water Line
Meter location
on
SOIL ABSORPTION SYSTEM
Type of system - ff arxew Width A— Length Number of Trenches a 2 _
Setback from: House 30' Well /dD ` P/L 77 Vent to fresh air intake 26 �
ELEVATIONS
Description of benchmark &TT_C1 o f Sfaarc- a" 11®us,- Elevation 1 e0 , 0
Description of alternate benchmark %_ ,PUC 4V g; Elevation 92.06
Building Sewer ST/HT Inlet ST Outlet 93,E PC Inlet 1(
PC Bottom &A_ Header/Manifold o2, 5' Top of ST/PC Manhole Cover
Distribution Lines 7 (2) 9
( )
Bottom of System (1) j /:13 (1.) 3 ( )
Final Grade (/) l (Z) l s ( )
Date of installation M Permit number 3,5 3 State plan number VA
Plumber's signature - License number Date 2_9,j
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
SG gGE / yQ!
77 `
EXrsri�r4 Novo C.e s. -.
30 �
B� 3
3
J
C
Q
/gyT# qve
INDICATE NORTH ARROW
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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count y
Safety and 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)). 353103
Permit Holder's Name: ❑ City ❑ Village IN Town of: State Plan ID No.:
BREUER SOMERSET
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
d a6 of S,` - 032 - 1092 -70 -000
TANK INFORMATION - Z �'- f I ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic G0 o Benchmark Q, 3 /0
¢, Or 2 ; 1
Aeration Bldg. Sewer
Holding (/ Ht Inlet
TANK SETBACK INFORMATION Ht Outlet �, �3 �L
TANK TO P/ L WELL BLDG. Air I to ntake ROAD
ir
Septic �Q / 6 `{- l NA
D NA Header / Man. 444 Z G
Aerati N Dist. Pipe 'r( }' I
z L -3
3t
Holding Bot. System -rI 'I" - Q0, 9S' r t 3
PUMP/ SIPHON INFORMATION Final Grade S Z
nufacturer errand
f
Model Num M
TDH Lift L oss ric ' System TDH F
m ead
Fo ain Length Dia. ell
SOIL ABSORPTION SYSTEM 1s
BED/X RENCY Width Len th No. Of Trenches -3 No. Of Pits Inside Dia. Liquid Depth
DIM Z DIMENSION
SETBACK SYSTEM TO P/L I BLDG WELL LAKE /STREAM LEACHiNfi M nufacturer.�
rF all
INFORMATION Type Of ,� r r AMB Model Number:
System: L J 7 �� Z j -OTCUN
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole acing Vent To Air Intake
Length _�� Dia t/ Length Dia. � Spacing > 7 7 > -7
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 11 No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
SOMERSET 33.31.19.437B,NW,SE 474 184th Avenue
Gft� Wt�� W44
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD -6710 (R.3/97) D ak nspector's ature Cert. No.
Vi scons i n SANITARY PERM ' 20 eE w sBngtonA Division In accord with ILH 3. _�tNis A m. Co e •, •' ; P.O. Box 7969
Department of Commerce �� r Madison, WI 53707 -7969
• Attach complete plans (to the county copy only) for t temA74 0not less County
than 81Q x 11 inches in size. — 4 54 . Cro I
• See reverse side for instructions for completing this a pikati$G ' i 0 State Sanitary Permit Number a I
� 1fi
The information you provide maybe used by other government agency iog� s t;`I' N'� ❑Check if r vision t pre sous v ication
[Privacy Law, s. 15.04 (1) (m)]. 7 7 State FFI4%'=
4INT Plan I.D. Number
I. APPLI ATION INF RMATION - PLEASE N RM I N
Property Owner Name Property Location
14 �, 1 i4, S 33 T 31 , N, R E (o W
Property Owner's Mailing Xddress Lot Number Block Number -
r Aa
CI State Zip Code Phone Number Subdivision Name or CSM Number
' o ( 7r VA V7 —12
11. TYPE OF BUILDING: (check one) ❑ State Owned ❑ cit Nearest Road
❑ Village 7,0
Public 1 or 2 Famil Dwelling - No. of bedrooms 3 Town OF E
III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 - 2 ,
1 ❑ Apartment/ Condo 031 — — —00
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_ CC Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5 ❑ Repair of an
______System -------- ------------- Tank Only Existing5ystem ________ Existing
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYRE OF SYSTEM: (Check only one)
Non - Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 K Seepage Trench 22 ❑ In- Ground Pressure C � i.�/ 42 ❑Pit Privy
13 E] Seepage Pit ,� a J 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
50 . - a3 9 f / 3 Feet Feet
VII. TANK Capacity gallon Total # of r Prefab. Site Fiber - Exper.
INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existing strutted
Tanks Tanks
eptic Tank ❑ ❑ ❑ ❑ ❑
L ift Pump Tank /Siphon Chambe ❑ I ❑ F ❑ 1 ❑ 1 ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
57 Plu ber's Name: (Print) Piu e s Signature: (No mp M N Business Phone Number:
—
P umber's Ac dress (Street, City, State, Zip Code):
cE' - S O
IX. COUNTY / DEFYARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued Issuin n ignature Wo Stamps)
a Owner Given Initial ^ _ surcharge Fee) �0
Adverse Determination daS t I C?=> Q
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD -6398 (R.11/96) 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 i.f 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.
K. County/ Department Use Only.
Complete plans and specifications not smaller than 8 112 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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ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
roll 1IT11,17.11TION (IF AN RXISTTN(: S1i1 "1 TANK
This is to certify that I have inspected the septic tank presently
serving the 1 in residence located at:
_ 1/4, _ 1/4, Sec. 33 T L_ N, Rj_� W, Town of
mERS'a i 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: /00
Construction: Prefab Concrete X Steel Other
Manufacurer (if known):
Ag of Tank ( if known) A6 ° x /� IPS,
_ y
R �a"VIAI Sctdr>j r T
( ignature) (Name) Please Print
/!
VpR - 1u �U/?y/
(Tile) (License Number)
! 2= . Z-a 9
(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 opening over outlet baffle)
Name ammaj, f - -TC—A 17 '7 Signature f MP.� ,,2Zi7��
5/88
Wisconsin Depdrtment of Commerce SOIL AND SITE EVALUATION
Division of Safety and Buildings Page J_ of 3
Bureau of Integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code
i
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 V , (fro"*
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
APPLICANT INFORMATION - Please print all information. Revie d by Date
it
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Prop rty Owner Property Location
Govt. Lot N J,) 1/4 - 1 /4,S _33 T _7 / ,N,R !�
Property Owner's Mailing Address Lot # Block# Subd. Name or CSM#
5 /46 4ile
City State Zip Code Phone Number ❑ City :1 ty Village Town Nearest Road
�Drree� e � J I g e��' (, /S) d y7 -S /f/6 --l A de
ome
z r
❑ New Construction Use: gResidential / Number of bedrooms Addition to existing building
Replacement ❑ Public or commercial - Describe:
Code derived daily flow. 0 gpd Recommended design loading rate — bed, gpd /ft gpd /ft
Absorption area required b r ✓ bed, ft .57 trench, ft ? 2 / Maximum design loading rate • bed, gpd /ft gpd /ft
Recommended infiltration surface elevation(s) �. JJ ft (as referred to site plan benchmark)
Additional design /site considerations
Parent material 0 r�, Flood plain elevation, if applicable ft
S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
U = Unsuitable for system ®S ❑ U 2 S ❑ U 0 S � U I ®S ❑ U ❑ S R' U
.SOIL DESCRIPTION REPORT
Boring Horizon Depth Dominant Color Mottles Structure GPD /ft
g Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench
0/0 161el? 31
Ground 3 !7 a ,z / ' Ds An L✓ - 7 .
elev.
f) .eft. -y o R s-/y --'— –
Depth to
limiting 79
fat r
tw ig.
in•
Remarks:
Boring #
w r 3
Ground 12
e ev.
q ft.
Depth to
limiting
factor
y -in- Remarks:
CST Name (Please Print) Signature Telephone No.
_
Address Date CST Number
57v '� S,H® -- 149 a?a?7X12 �
SOIL DESCRIPTION REPORT J
PROPERTY OWNER L �f3r1 Q�euNr- Page � _of .3
PARCEL I.D.#
I
Boring # FHorizo Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
3 /o Iz 3 13
Al
Ground �S-
elev.
�S eft , y 35=9 /A, E A/
Depth to
limiting f
f acto
in.
Remarks:
Boring #
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 #
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in.
Remarks:
SBD -8330 (R. 07/96)
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer L ,6F,9N 13f{FNE2
Mailing Address 199" U�
Property Address `f 7 AUL
(Verification required from Planning Department for new construction) /Y1
City /State d1l Parcel Identification Number
LEGAL DESCRIPTION
Property Location SW '/4, .24 '/4, Sec. 33 . T_U_N -R__LLW, Town of 5tMaue7
Subdivision , Lot #
Certified Survey Map # Volume _ . Page #
Warranty Deed # . Volume , Page #
Spec house ❑ yes R Lot lines identifiable 0 ❑ 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
masterplumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal 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 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.
NATURE 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 property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
SkN ATURE OF APPLICANT ATE
** * * ** 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
ii DOCUMENT NO. STATII BAR CW WISCONSIN — FORM 2
VOL 589 IrVE119 WASALWW ssns
It"IS 9PAC9 11*64041110 1000 GATA
354859
REGISTERS OFFICE
UVJQ�CQd.ARd..uUrQMarriCd ST. CROiX CO., WI&
WA for Retard Ns lat
. .... . .............................................................................................. . ......... 1, — I
................................................................................................ . .......... . ... day of _LAb A.D. 19 _J9
conveys and warrants to --- .............
a
. ...... P . ................................................ ......... I 3:00
.............................................................. ............................................ . ...
............................................................................................................ ....
................................................................................................... .....•...• ...
MWINIft" TO
.......................................... . .................................................... . .......... . ...
Anderson-Freitag, Inc.
New BJW=nd, Wkt,_5 7
the following desexibed real estate in ... ;�t . .............. . ......... county, A2L
State of Wisconsin: Part of the North Half of the
Southeast Quarter (A of SEh) of Section Thirty-three T jCS
(33), Township Thirty-one (31), Range Nineteen (19)
described as follows: Commencing at the East Quarter
corner of said Section Thirty-three (33); thence N 89 V on the North I P e of I
said Southeast Quarter (SE4) 1205.04feet to Place of Beginning; thence S I 4S
714.79 feet; thence Westerly on Northerly line of proposgd town road on a 1333.0
�
foot radius curve, concave southerly, chord bearing N 89 2S 270.31 feet, ZL or
270.17 feet; thence N 88 0 14'20 "W 48.09 feet; thence N 1 45 680.4 fact; thence
S 89 30 on the North line of said Southeast Quarter (SEA) 317.08 feet to place
of Beginning.
it
Subject to easements, restrictions, reservations and covenants of record, if any.
TRANS
FEE
This .__..__.. ............... homestead property.
(is) (is not) a First Mortgage to Tri-County Savings and Loan Association
Exception to warraN sties: dated March 21, 1975 and recorded in the office of the
Register of Deeds in and for St. Croix County on April 23, 1975,
in Vol. S22 on page 255, which mortgage grantees hereby assume and agree to pay
IE according to its terms and conditions.
Feb
Dated this -------- i ------------------------------ day of --------------------- t ------------- - ---- - ------ 1 29 ..
- - - - - ------ - -------------------------------------------------- (SRAL) ....... ----------
............ a ---. (SZAL)
- ---- - ------
« ----------------•--------------------------------------- - - - - -- - ------------------
------ ---------------------------------- -------------------------- (SEAL) (SEAL)
-- - --- - --------------------------------------------------------- • ...... ... &9JAICAL -------------------
AUTHENTICATION
ACXMOWLSDOURNT
Signatures authenticated this ------------------ day of STATE OF WISCONSIN
--- -- ---------------------- - ----------------- ........
•.. St. CrqJ
............ ---------------- C4MtY.
................................................................................
Person all cam before me - this ----- of
• .................................................................. FebN@�ry ......
------------------ the above named
TITLE: MEMBER STATE BAR OF WISCONSIN ----------------------•.....___ _____._---- °.--- ------ _-- ---• --
(If not ------------------------------------------------------------
authorized by § 706.06, Win. State.) e
..Ronleaki,-.di3torce&-an&.iinre—rxJ
d
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THIS INSTRUMENT WAS DRAFTED BY to me known to be the person .S_....._.. who esseuted the
rument
and acknowledge the same.
Anders foregoing inst
............... ------
. .............
New Richw Wisconsin
.............. ------- - ........................ ........................
...... Owy Pubes
(Signatures mar be autbentIcated or al W.tb Notary Public --------- ty, Wis.
are not necesask-1 My Commissiu,8410;
(mum
date -----------------••--•---- --- ---- ----- ...... --•....., I-------
•xomes of Verson afenfor in ar- ra„4elty Amid be t.-,1 or vrIYtte,'tA*w t', - airnatum.
WAFrtAXTT XMM STATE BAn OF % 0149111
FORIA No. a - -: :+^ MYW"k6% Wk. (jo► 8.vv")