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HomeMy WebLinkAbout038-1049-55-100 n N O 3 d O i K � N Q � N 7 M N O No -0 0 3• N CD � i � O N CD C ') L y CO a i o> 3 g m ,2 * °o � m m m ° z D CD cc: ° f - O O n> 3 r � Q O CD -�" ! ° C7 r O z c(°o (D Z ',' N c CD T • OOO�' Z CD o o o f�q N o N D N ° W cr O ° w ° o ° m = cn t►i m j a Q Z ° z z Z D ° d m N 0 Q U) lr 3 ° a ? CD �• a) ° m c CD CD 0. v CD w ° ° �' CD n c a 3 z 3 ° CD j, z N o' m 3 c) — ao m � o z O » Cl) — N O m 00 z CD O � �mw � y 3co� rn m n m am � o �CDCD v a T ° 3 . o CD o �a mo - 0 30 0 N z 3 f 3 ° ° n - a CD 0 CD O x m i ° ° t 3j V l ti O� Q' A N N CD 7 O V A O� b cu CD 7: w (D 0,0 rJ fA 0 t" O i N CD o O CD 'o I Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: Safety and Buildings Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary338 12 IX Personal information you provice may be used for secondary purposes [Privacy La s.15.04 (1)(m)). Perrbf'IWt nk , GARY ❑ Cit )§yAVAlag jWTV: State Plan ID No.: CST BM Elev.:- Insp. BM Elev.: BM Description: Parcel TcNSI_ZO49 -55 -100 UatS AQ 003 72 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St /Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. vent to Air Intake ROAD Dt Inlet Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft I f Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED /TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSION SETBACK SYSTEM TO P / L BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION Type of CHAMBER model Number: System: OR UNIT DISTRIBUTION SYSTEM Header/Mani . fold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing 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.) LOCATION: STAR PRAIRIE 11.31.18.209C,SE,SE 2211 127TH STREET — LOT 2 Plan revision required? ❑ Yes ❑ No Use other side for additional information. _. Date Inspector's Signature Cert . No. Safety and Buildings Division SANITARY PERMIT APPLICATION 201 W. Washington Avenue A i tcbnsin In accord with ILHR 83.05, Wis. Adm. Code P O Box 7302 Department of Commerce Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, on paper not less County t than 8112 x 11 inches in size. G • See reverse side for instructions for completing this application State Sanita y Permit Number 33 $I 17-- Personal information you provide may be used for secondary purposes ❑ Check if revision to previous application (Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Owner Name Pro enyLoc bon /4 �1/4,S T , N, R o Property Owner's Mailing AdVess // � l Lot Numbe � Block Number -- Cit tate r d Zip Code ( Phone Number Su von Nam i C M N m r aLo l7 VV , . TYPE OF BUILDING: (check one) ❑ State Owned ° v lage C7 Neare oad Public IX 1 or 2 Family Dwelling - No. of bedrooms Town OF �'u rh! -' 111. BUILDINGUSE: (If building type is public, check all that apply) Parcel TaxNumber(s) tv. L 1 [] Apartment / Condo �� S_ l © �� `s`S�" " O 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. NK New 2. ❑ Replacement 3. ❑ Replacement of 4_ E] Reconnection of 5_ [] Repair of an System System - _____ _________ -_ - _Tank Only__ ____________ Existing System_ is^gSystem ________ Exti 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 j 12 (Seepage Trench 22 ❑ In- Ground Pressure 1 / —f 42 [] Pit Privy 13 E] Seepage Pit 1 �°t� "25 a 43 E] Vault Privy n' 14❑System -In -Fill /r �G / �p� �j ( t°U) ((am - 3I• � 14 VI. ABSORPTION SYSTEK4 INFOR ATIO 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 17 . Final Grade Require (sq. ft.) Proposed (sq. ft.) (Gals/day/ q. ft.) (Min. /inch) �i Elevation _ / Feet 7 5 - 5 1 Feet VII. TANK i Ca Sett n alto Site Fiber- Total # Of Prefab. Exper. INFORMATION g allo ns Tanks Manufacturer's Name Concrete con steel glass Plastic App New Existing structed Tanks Tanks Septic Ta & 40 Q6 t ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ 1 ❑ 1 ❑ 1 ❑ 1 ❑ VI11. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print / Plum Signature: (No Stamps MP /MPRSW No.: Business Phone Number: PI is Address (Street, City, State, Zip Code): IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued Issuing e / C ignature (No Stamps) Surcharge Fee) � Approved Owner Given Initial �� c %� � ❑ Adverse Determination X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: e• eeno ro 4 4 rn'7% DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM c; ;2 y6 ' yyy� Owner/Buyer �i 2 ; �T1'(C`��/PS j�j Mailing Address (' Gr�l�- f�NC_ �� rt.� f 4A2W _ s vDi7 Property Address ✓'` 5 /�� /�,.2 2fli � (Verification required from Planning Department for new construction) r City /State �� 'C Parcel Identification Number 0— LE GAL DESCRIPTION Property Location ,� ' /,, '/4, Sec. �, T.IYI N -R�W, Town of Subdivision G S� , Lot # Certified Survey Map # ,�y� /��, Volume , Page # Warranty Deed # Q d° ,Volume , Page # Spec house ❑ yes ❑ no Lot lines identifiable ❑ 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 masterplumber, journeyman 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 that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of he three year tration date. S S GNAlb E 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 owners) of the pr rty described above rtue of a warranty deed recorded in Register of Deeds Office. X� S11019,7 SIGNATME 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 I