HomeMy WebLinkAbout036-1040-50-100 ST. CROIX COUNTY ZONING DEPARTMEN';��
AS BUILT SANITARY REPORT N (g
Owner
Property Address o
City /State .�� ' �, /�/ f �i4 // .ou
Legal Description: x �
Lot _� Block Subdivision/CSM #
%4 /0, Sec. �, T,44N -R W, Town of PIN # d . 0 0 —/6
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION:
Tank manufacturer /Gg'�' - z� Size ST/PC /> Setback from: House f Weld P/L
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 522 - Number of Trenches
Setback from: House H Well , 5r P/L ✓ Vent to fresh air intake
ELEVATIONS
Description of benchmark �� r " or �° `�`'�' °�`'`' levation
Description of alternate benchmark Elevation
Building Building Sewer 215 // ST/HT Inlet ✓� ST Outlet - PC Inlet
PC Bottom Header/Manifold Top of ST/PC Manhole Cover
Distribution Lines (�) d �) ( )
Bottom of System C/ ( )
Final Grade
Date of installation ermit number r l !� State plan number
Plumber's si nature License number 2 Date 1
Inspector
Complete plot plan
I��
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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oza Zi�
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INDICATE NORTH ARROWG,
Wisconsin'Department of Commerce County
PRIVATE SEWAGE SYSTEM
Safety and Buildings Division
INSPECTION REPORT ;�f. LYE )e
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)]. 19V' &
Permit Holder's Name: ❑ City ❑ Village N Town of: State Plan ID No.:
V I H4d,62
CST BM Elev.; Insp. BM Elev.: BM Description: - Parcel Tax No.:
C7D . c7 0D r AIw Q 1� to - 1
TANK INFORMATION ELEVATI DA A
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic 44 ) / - 5 LOD Benchmark �,$ p 3 $ 00 JD
Dosing j ;6 .29
Aerati n Bldg. Sewer Zj
Holding St /Ht Inlet �, j 96, ?S
TANK SETBACK INFORMATION St/ Ht Outlet c t6 • Sf3
TANK TO P / L WELL BLDG. AirI to ntake ROAD net
Air
Septic NA D
Dosing NA Header / Man. 2
Aeratio NA Dist. Pipe / �is is q
Holdin Bot. System.
PUMP ! SIPHON INFORMATION Final Grade
Manufac urer Demand
Model Number GPM
TDH L' Friction Sys TDH Ft
Fie
Forcem 'n I Length Dia. Dist.To
SOIL ABSORPTION SYSTEM
TRENCH Width / Length No Of renches PIT No_ Of Pits Inside Dia. Liquid Depth
DIMEN 1 �-� DIMEN
SETBACK
SYSTEM TO P / L I BLDG WELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION Type O 7 20 �S OR UNIT CHAMBER Mod Number:
System: ,
DISTRIBUTION SYSTEM
Header/Manifold u Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Lengt Dia - Length
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 01- L" Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
j
s Ob >�
,- >
5E we,' .
Plan revision required? ❑ Yes No
Use other side for additional information. t 1 !70 2 6
Al 1 SBD -6710 (R.3/97) Date Inspector's Signature Cert. No.
I v
Safety and Buildings Division
NOsionsin SANITARY PERMIT APPLICATION 201 Box Washington Avenue
In accord with ILHR 83.05, Wis. Adm. Code
Department of Commerce 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. G✓'o sX
• See reverse side for instructions for completing this application State sanitary Permit Number
3Y�� Z
Personal information you provide may be used for secondary purposes ❑ Check it revision o previous application
(Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Prope ner Name Property Location
') r rye /4 /4, S T3 , N, y 7 E ( W
Pr perty Own is Mailing Address of Number Block Number
Ci i�cf� ` Zip Code (hone Number D Subdivision Name or CSMM Number
. TYPE F BUILDING (check one) ❑ State Owned v �a e ,C ,[ Meares Road !� f-
Public 1 or 2 Family Dwelling - No. of bedrooms own of �/k �r !d o?/D S
III BUILDIN USE: (If building type is public, check all that apply) Parcel Tax Number(s)
a
A
?�.._tao
1 C] Apartment/ Condo �6 11,
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. p Replacement 3_ ❑ Replacement of 4_ E] Reconnection of 5_ [] Repair of an
Syfstem ______i__'_System ^ ____________ Tank Only _........ ------ ExistingSystem ________ 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 M Seepage Trench 22 ❑ In- Ground Pressure _ 42 C] Pit Privy
13 Seepage Pit _ _ ��' Z� 43 ❑ Vault Privy
14 ❑ System -In -Fill �i vit k < ,,� v r
VI. ABSORPTION SYSTEM INF MATT : f �d L �•� f
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
0
Required (sq. ft.) Proposed (sq. ft.) (Gals/day/ ft.) in. /inch) evation
v �jl� Feet Fee
Capacit
VII. TANK in Ca gallo s Total # of r Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existing strutted
Tanks Tanks
30 1 Septic k X _ 1:1 11 11 ber ❑ 11113111 ❑ ❑
VI11. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plum is Name: (Print) Plum ignature: (No 5 mps) =MP/MRSW No.: Business Phone Number:
u er's Address (Street City, State, Z ode):
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (IndudesGroundwatef D ate Issued Issuing Agen Signature (No Stamps)
X Approved ❑ Owner Given Initial Surcharge Fee)
Adverse Determination ZZ Uv
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROV :
SBD- 6398 (R.11197) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
PLOT PLAN
PRO f C'r - ^�/ � i�tG /Cr ��" ADDRESS /`�LrJ ✓(� ��l v G S `�O17
1/ 4 S Z I /'1' �� / N/ R / `7 W TOWN C O U N 1 1 Y
MPRS Byrom Bird Jr. 220527 DATE
— BEDROOM
CONVENTIONAL )= IN -GROUN RESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE --rte LIFT TANK SIZE DOSE TANK SIZE
HOLDING 'TANK SIZE LOAD RATE ABSORPTION AREA ,.!�"� # of chambers g'
hk ! LL
BENCHMARK V.R.P. .g ASSUME ELEVATION 1 00 ,
❑ BOREHOLE O WELL *H.R.P.
Vent
SYSTEM ELEVATION` S�
>12"
r Sidewinder High
Capacity Leaching
of Cove
Chamber with 31.8
ft ^2 per chamber
16"
34>
Grade at System Elevation
1
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0
r
4
z- z
fl
I
02/'o 7-,?
Wisconsin Department of Commerce SOIL AND SITE EVALUATION
Division of S-*ety and Buildings Page of
Bureau of Integrated Services in accordance with Comm 83.09, Ws. 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 n F
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
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)). f _ - .7
r � 7 , �i_ _ �«. �• .
Property Owner Property Location
Govt. Lot , 1/45�� 1 /4,S`� N,R E ( �/
Property Owner's Mailing Address Lot # Block47TSubd. Name or CSM#
C tate Zip Code Phone Number
� El city ❑ Village ,Y Town Nearest Road
74u
❑ 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 — bed, gpd /f1 gpd/ft
Absorption area required F 44 3 bed, ft trench, ft s- 3 — , Maximum design loading rate bed, gpd1ft 14ench, gpd/tt
Recommended infiltration surface elevation(s) S ft (as referred to site plan benchmark)
Additional design /site considerations
Parent material 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 S❑ U ,❑ U '2� s❑ U V S ❑ U ❑ S U El S _WU
SOIL DESCRIPTION REPORT
Boring Horizon Depth Dominant Color Mottles Structure GPD /ft
g Texture Consistence Boundary Roots
i in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
,41 ...,
Ground t �
illev.,?
Depth to
limiting
/ fa ^ t�o
x "0 in. or
41`,,� Remarks:
Boring #
1. ii . LAI
a n
Ground
elev. /
ft•
Depth to
limiting
facto
>lin. Remarks:
CST Name ase Print) 1 ature Telephone No.
Address f Date C T Number
SOIL DESCRIPTION REPORT
PROPERTY OWNER r`� �—r' 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
Ground < l / 1000q �+
elev.
ft.
Depth to 2 • Z
limiting %� 3
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. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
' Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in.
Remarks:
SBD -8330 (R.9/98)
Soil Test Plot Plan
Project Name
B r
y ou ird Jr.
Address ,,-�, � ajo �� --
CS
Lot �
Subdivision Date O�oZ �
T
/4 1 /4 S�T , N/R W -,— Townshi
Boring O Well PL Property Line County
BM or VRP Assume Elevation 100 'ft. • �5� � ^ter °�'/
System Elevation *HRP
i
qQ
V
1
Scale 1/4" = 10 Ft. When Dimensions aren't state
ST CROIX COUNTY
r y
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION CERTIFICATION FORM
0hvlter /Buyer (2 d y—e i`
Mailing Address
Property Address
(Verification required from Planning Department for new construction)
City /State / 'I�e`r/ /C <G��1'ta � Parcel Identification Number
LEGAL DESCRIPTION
Property Location `` /a, `4, Sec./ , T 1 z '_ W, Town of �� .
Subdivision Lot #
Certified Survey Map # �G,��,�1_c��o� Volume , Page #
Warranty Deed # h�7�S� , Volume /030 , Page # S�
Sl)ec house ❑ yes no Lot lines identifiable yes El 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 iii proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
Pwe, 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. CertlflCSL1011
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. 9 —,
I' /—Z�-
SIGNA URIC OF APPLICANT llATE
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.
SIG '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
l
vOL 1 12-30 FA C f 7)
DOCLIMENTNO. STATE BAR OF WI SCONSIN FOR. A 2 - 1982
WARRANTY DEED
557458
ST� CROIX
1P
Richard Derrick and Robert Derrick,
I APR 9
as tenants in common APR 2 1W
All? 9: 30 A M
convoys and warrants to
Alexander Greer and Ruth Greer,
huaband and wife as survivorEaip
marital property
AETUAN TO
the following described real estate in ST. CROIX
County, State of Wisconsin: Amcelcan litle & Ab3tract
1812 Brackett Avenue
Eau Claire, Wl 547()l
TaxParcelNo: 0
Part of the SW 1/4 of SW 1/4 of Section 17-31-17, Town of Stanton, St.
Croix County, WI described as Lot I of Certified Survey Map filed July
29, 1992 in- Volume 9 of Certified Survey Maps, Page 2515, as Document
No. 486482, subject to right of way for town roads and all other
easements of record.
NOTE: This deed is given in Satisfaction of an Original Land Contract
dated June 1, 1992 and recorded September 14, 1992 in Volume 968 of
Records, Page 558 as Document #488446. 1 4,
FEE
J Q trint homestead property.
This (is) (is not) EXEMPT
41ir
Exception to warranties:
Easements, covenants and restrictions of record.
Dated this day of Cf)a(,-kJ_, 1997
(SEAL)
(SEAL)
(SEAL) (SEAL)
Robeki Derrick
Z
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN
E C icx I r �Z County, S3.
Wit-
authentical )d this day of Personally camer before me this t 2!�? day of
1997 theabovenamed
Richard Derrick
Robert Derrick
TITLE: MEMBER STATE BAR OF WISCONSIN
(if not,
authorized by Subsoc. 706.06, Wis. Slats.) who executed the
to me known to b4f the person
foregoina instuyiner.1 andackgowle j2� the same.
THIS NSTRUMENT WAS Z�AAFTED BY
MICHAEL J. -V-1XQPZ.L,-- J, /14"
t -C ( 1 r 4�� County Wis.
ATTORNZY— AT—LAW---- Notary Publilv.� , A
Commissiun II; pe 41J. fi 1 d t
(S', natu may b , authentice i-ad or acknowledged V3,)Ih My rmanon,.. Pita ion a e
are not necos%3ry.)
* Narri� of pe—na signing in any capacity shouki be typed of pirinted beiow the �Watuires
JUL N 91992► 3
JAMES aco%ELL
Register of Dceds 4
St Croix Co., WI
486482 �, s
CERTIFIED SURVEY MAP
Located in part of the SWh of the SA of Section 17, T31N, R17W,
Town of Stanton, St. Croix County, Wisconsin.
x Wi Corner of LEGEND N O
Section 17
t9 Aluminum County Section Monument Found ° o
N d
Qx Large Nail Set at Section Corner s
(Positioned from section corner ties.) +' H
rz
4�. O 1 x 24t Iron Pipe Set, weighing 1.68
v
lbs. per linear foot.
IL
IL g ° Existin Fenceline
a> ,
p� .«
Q d
Ti it N v�
$ (� ..................•.• Roadway Setback Line
�
m 2. ° Li
m
N pp'� 6 b O
p N _. �_ '19 C. ,� m O N
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OWNERS N H
Richard E Robert Derrick 3
.t' 4 "'* '** "T310 Hwy. 116511 N13I}:JOr3, r , i
New Richmond, WI 54016 " Wis.
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N89 0 23'47 "W 479.03'
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Crib c
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QI W I 4.61 Acres Inc. R/W co
_J1 4j = 200,609 Sq. Ft. &= E- -I
4 - o Barn o
C °o l r ' Ji =
11 d' ° ° 3.92 Acres Exc. R/W
° 3 170,895 Sq. Ft. rl 1 1 s
do F-I o
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L 10 $90 438
2 AVENUE _ 2167.61'
SW Corner of ;,, S90 00"E 474.41' S90
Sec tion 17 "' So line of the SW o Sectio 17
. 7 Si Corner of
CSI ss'
Section 17
t3 11 I I T T CD I I D'`
F -1 X1)1 ��I�La 1 1 La.v�S
4I Z
JI <I SCALE IN FEET
L1..1 -J I VOLUME 9 PAGE 2515
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_� 0 50 100 200