HomeMy WebLinkAbout038-1185-50-000 ST. 'CROIX COUNTY ZONING DEPARTMENT
AS BUILT SANITARY REPORT
Owner &A Q-t SA G
Property Address I Z Z //
City /State 410 cv & S Yo�7
Legal TBlock ription:
Lot Subdivision/CSM #
'/4, Sec. /2-1 T 31 N -R Town of 6 PIN #
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION
Tank manufacturer /f�lirca 7r Size 69/P end / Setback from: HousO G Well PA1, 0
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: le Width A ' Length 3 Number of Trenches
Setback from: House 4 /Z- Well P/L mss Vent to fresh air intake 7d
i
ELEVATIONS
Description of benchmark % foe Elevation 100 3
Description of alternate benchmark Elevation
Building Sewer /HT Inlet �7<1- 9'S' ST Outlet c i S! Z S'' PC Inlet
PC Bottom Header/Manifold 9 '�/- d 7 Top of ST/PC Manhole Cover
Distribution Lines ( ) c ) 3 O ( )
Bottom of System () 7 `- 0
Final Grade
Date of installation - h7 / Permit number 3 ° S State plan number
Plumber's signature License number V x Date //7/
Inspector
Complete plot plan �
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
3C.,
INDICATE NORTH ARROW
` Wisconsin Department of Commerce
Safety and Buildings Division PRIVATE SEWAGE SYSTEM County:
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) S 338
IX
Personal information you provice may be used for secondary purposes [Privacy La s.15.04 (1)(m)]. 3 3 8 9 9 0 O 5
Perrr�t q's Nangk El City p Villa e Town of: State Plan ID No.:
CC::A EEY, llA S:1'AR � IRIE
CST BM Elev.; Insp. BM Elev.: BM Description: Parcel Tax No.:
a ,aLJ 038- 1185 -50 -000
TANK INFORMATION " EL VATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic 7 � j Benchmark
Dosing
Aeration Bldg. Sewer 95 - 6 'I
Holding St /Nt Inlet ns' V.5
TANK SETBACK INFORMATION St isr outlet 7,a5
TANK TO P/ L WELL BLDG. Air Intake ROAD Dt Inlet
Air
Septic NA Dt Bottom
Dosing NA Header / Man. �_ yy ' y, a 7'
Aeration NA Dist. Pipe rj,57� qj3
Holding Bot. System �412' 9 -U F
PUMP / SIPHON INFORMATION Final Grade J rb ' 7,JCa�
Manufacturer Demand
Model Number GPM
TDH Lift Lrlc n System TDH Ft
Forcemain Len Dia. Fi Dist. To Well
SOIL ABSORP ION SYSTEM
BED / TRENCH Width Length s No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIME N ION S / DIMEN I N
SYSTEM TO P / L BLDG WELL LAKE / STREAM LEACHING Manufacturer:
SETBACK CHAMBER
INFORMATION Type O /Y/ V.0 Mode Number:
System: '75 �� OR UNIT
DISTRIBUTION SYSTEM
Header / Manifold 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 13.31.18.936,SW,SE 1382 211TH AVENUE
C� d y -
r i�.y S ks ' -.. H �/� ..1C�.k c.: e. t..
Plan revision required? ❑ Yes g , ,
Use other side for additional information. / 7 9' �. a
SBD -6710 (R.3/97)
Date I tt `s Signature Cert No.
N*L consin Safety and Buildings Division
SANITARY PERMIT APPLICATION 22010 B Washin in Avenue
Department of Commerce In accord with ILHR 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 8 1/2 x 11 inches in size. S7
• See reverse side for instructions for completing this application State Sanitary Permit Number
3:; Iin d !!�-
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 INF RMATION
Property Owner Name Property Location
C c1$ tk S 1/4 S,6r" 1/4, 5/ 3 T 1 r N, R /8' E (or)
Property Owner's Mailing Address Lot Number Block Number
j C4 y, State Zip Code Phone Number Subdivision Na or CSM Number
r Syoi 0 iJ - 19 1 /6- ( 1 4 /6 0
II. TYPE OF BUILDING: (check one) E] State Owned ❑ !t� Nearest Road
Public 1 or 2 Family Dwelling p VII age - No. of bedrooms Town OFS s
III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) I.�. ti g 4
1 ❑ Apartment/ Condo 0 36
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, 4n New 2. ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5 ❑ Repair of an
______ System -_- - Tank Only -------- - - - - -- Existing System - -- - - -- Existing --- - - - - --
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
1105eepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 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.) Pro osed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Q Elevations
' Z/7 , / y Feet ° l7. 6 S Feet T ANK Capacit VII. NFORMATION in g llo Total # of Manufacturer's Name Prefab. Con- Steel
Fiber - Plastic Exper.
New Existin Gallons Tanks Concrete glass App.
strutted
T nks Tanks
Septic Tank jr Holding Tank 600 /Do 6 El 11 El El 11 11 Li ump Tank /Siphon Chamber ❑ ❑ ❑ 1 ❑ 1 ❑ ❑
VIII. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: ( Stamps) M MPRS o.: Business Phone Number:
I 74
Plumber's Address (Streewity, State, Zip Code):
/ D ll�� 5T /);; / i Lv_1 S'S�oo
t
IX. COUNTY/ DEPARTMENT USE NLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater =Issu Issuing Agent Signature (No Stamps)
Surcharge Fee)
['Approved [ Given Initial Z�5 ��
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD- 6398 (R.11 /97) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
3T31 N/�
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DISYRIf.KUTIgN P1Pt TO SE AT LEAS? /° WC� w t 1
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^6441 AT 1L.EA,g7L0 IWCNt3 1UT 1.10 MORC THAW 4t t1 ' 4 0 4 " MtOW rOdIkL ORADE
MAMA OWN OF OCCAV AT100 FROM OAMWAL 6KAUL w'k L be ..�_ IucmEs
1'YN /r1UM AVTM OF 1XCAVA'r(ON FR OM 04141MI�L Ci R4 OE BE tN
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LIC Cl,JSE WUMBER:
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Wisconsin Department of Commerce
p SOIL AND SITE EVALUATION Page 1 of
Division of Safety and Buildings in accord with Comm 83.05, Wis. Adm. Code
Attach complete site plan on paper not less than 1 ' in size. Plan must Dille Truck & Excavating, Inc.
County
include, but not limited to: vertical and horiz retgrenCe ppiro ), direction and __ St. Croix
percent slope, scale or dimemsions, no nR�( hnd location aod. nce to nearest road. parcel l.D.#
APPLICANT INFORMATION lase / W1brMii1p
- - - -- - . - - - -- - - - - --
Personal information you provide may be figi seconda 'par s0. nvac 15.04 (1) (m)). Reviewed By Date
Property Owner Property location
; - _
y
Case D an , o- ' ` 2 Go vt. Lot SW 114 SE 1/4,S 13 T 31 N,R 18 V
Property` Owner's Mailing Address's ! Lot # Block # Subd. Name or CSM#
323 S awmill L an e f �r,�., �'l1 ��'
_ C� 5 � Prairie Flats
City State 1p� PhoneNurr)lr City ❑ Village NTown Nearest Road
New Richmond WI 5 7 r 77 - Star Prairie J Hwy 65
New Construction Use: N Residential I um
Nber of bedrooms 3 ❑Addition to existing building
Replacement I I Public or commercial describe
Code Derived daily flow 450 gpd Recommended design loading rate .7 bed, gpd/f 2 8 trench, gpdtftz
Absorption area required 643 bed, fF 562 trench,p Maximum design loading rate -7 bed, gpdtW .8 tr ench, gpdtft
Recommended infiltration surface elevation(s) It (as referred to site plan benchmark)
Additional design / site considerations
Parent material -wash 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 MS El U ❑ S U ❑ S❑ U ❑ S u I ❑ S U ❑ S® U
SOIL DESCRIPTION REPORT
Boring# Horizon Depth Dominant Color Mottles Structure GPDtft
in. Munsell Qu. Sz. Cont Color Texture Gr. Sz. Sh. onsistenc Boundary Roots
Bed Trench
1 1 0 -10 7.5YR2.5/1 -- - - - - -- SIL 1 MVFR AW 1VF .2 .3
2 10 -25 7.5 YR4/6 - - - - - -- CL 1FABK MVFR AS 1VF 2 .3
Ground 3 25 -96 7.5YRS /3 ---- - - - - -- S O -GR ML - - -- - -- 7 8
ele— - - -- - - - -- - -- -` -- _
1
A
Depth to _
limiting — — -
factor
r T - --
96 in.
Remarks: —
2 1 0 -9 7.5YR2.5/1 ------ SIL 1FAB M VFR AW 1VF .2 .3
—
2 9 -23 7.5YR4/6 --- - - - - - - CL 1FAB MVFR AS 1VF .2 3
-- - -- -- -- 3
Ground 3 23 -96 7.5YR5/3 --- - - - - -- S O -GR ML - - -- - -- .7 .8
v 3s
Depth to
limiting — - -- -- - - - -- -- --
factor
96 in . — -
Remarks: __ - - - -— -- - -- - - -- - -— --
CST Name (Please Print) ture: Telephone No.
DENNIS GI LE �._i _ /f - � a2�8 GG 3 7 —
Address ; p t CST Number Ref #
A1 0 T A pt -, k/I svoo Da 6/97 31 106
PROPtRTY OWNER: Casey Dan _ SOIL DESCRIPTION REPORT Page 2 of
PARCEL I. Gille Tmcking & Excavating, Inc.
Horizon Depth Dominant Color ` Mottles Texture Structure onsistence Boundary Roots GPD/ftz
in. Munsell Qu. Sz, Cont. Color Gr. Sz. Sh. Bed Trench
3 1 0_11 7.5 YR2.5/1 -------- SIL 1FA MVFR AW 1VF .2 .3
2 11 -22 7.5YR416 --- - - - - -- CL 1FABK MVFR AS 1VF .2 ; .3
Ground _ - -- -
3 23 -96 7.5Y ---- - - - - -- S O -GR ML - - -- - -- 7 8
y°'�_ — —
Depth to
limiting
factor ;
96 in. i ��-� -- - - - -- - -- - - -
,
Remarks:
4 1 1 -10 7.5YR2.5 -- - - - - -- SEL 1FABK MV FR AW 1VF .2 .3
2 10 -26 7.5YR4/6 --- - - - - -- CL 1FABK MVFR AS 1VF .2 3
Ground
elev 3 26 -98 7.5YR5/3 ---- - - - - -- S O -GR ML - - -- - -- .7 .8
�j7 /S' — —
Depth to
limiting -- -- -
factor
,
99 in. -- �� - - - -- -- - - - - -- - - -- -- - -- - -- - - -
,
Remarks:
1 0 -11 7.5 YR2.5/1 -- - - - - -- SIL 1FABK MVFR AW 1 VF .2 ; 3
5 - – - - - -- - - -... —T —
2 11 -24 7.5YR4/6 --- - - - - -- CL 1FABK MVFR AS 1VF .2 .3
Ground
eleV 3 24 -96 7.5YR5/3 -
- - - - - - -- S O -GR ML - - -- - -- .7 .8
-_
i
Depth to
limiting
factor
96 in
,
Remarks: - _ - —_ -_-
,
Ground - -- - -- —- - - - - - -- -- —_.� -- --
elev
Depth to
limiting —
factor
Remarks:
I
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer
Mailing Address 32^3 zm-t —
Property Address 3 6
(Verification required from Planning Department for new construction)
City/State Parcel Identification Number (2 .3 a 3 -5" a -o 6 p
LEGAL DESCRIPTION p
Property Location ,5W '/4, S� '/4, Sec. �.� , T3/ �N -R / � W, Town of ST % /a: r
Subdivision / d.z�c�r , Lot #
Certified Survey Map # .P( , Volume , Page #
Warranty Deed # �P Volume 7.5 C_ , Page #
Spec house ❑ yes ❑ no Lot lines identifiable g7- 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, 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
of the three year xpiration date.
� oe l l9q
SIGNATURE O PPLICANT 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
V,, roperty described above, by virtue of a warranty deed recorded in Register of Deeds Office.
.S'' / s9
SIGNATURE VOAPPLICA
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
' DICCU VIT no. NTA S UP, OF W FORM t—
.�"s aromas sasaaaas MO ate.» a�+w
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Office
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Camille Re nen_Snith, ......... .- ... _-... ... _ .... _ _.....- ..__........ ST a� W 0a., Wis.
..... .............. ....................... ...._...-... ....................---- ._..... W& fW Record 13th
$st ies !!: ton ,.
as Person Representative of the estate of � o f Oct 19
..
...... Or ..................
4:705 P
..... -_ .................................. ................ - - - -- -- - - - - -- - -- - - --
.._. .....- ................................................ ( "Deeead+nt'
fw a valaabW eon idarsUm convoys, withont warranty, to ---- D,an.iel-..s.......
_..- CasiLy -.. and.. Bet ty-- jl- •-- Casey4•.haaband..and --- ife.,.....
..as..aurs' Karshi p . �azital-- Prosgriy�- -------------- --- -- - - - ---
_._•••----•-•...•-•-•..._...---•--•_...°---•-• ..................... ..••-•-- •-••--•__.-•-•••- -_..., Grantee, WTUR+ To
the foliewiag described real a tats in .......... t_... C r o i x ---- ....._. Coa2tt�,
State of Vnwonsin (heteinatter called the "Property ") : _
Tar Pared No: --- ---- _- -.-- -- :.:: :.__. »..
The Southeast quarter of the Southeast quarter (SEh of SW of
Section Thirteen (13) and the Southwest quarter of the Southeast
quarter (SWk of SE-ii) except a strip 12 rods East and West and
20 rods North and South in South corner thereof all in Section
Thirteen (13), Township Thirty -one (31) North, Range Eighteen
(18) West.
FEE
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it
1 Personal Representative by this deed does convey to Grantee all of the estate and interest in the Property which ,
the Decedent had immediately prior to Decedent's death, and all of the eaute and interest in the Property which the
Personal Representative h since acquired.
I Dated this ------------- 79 day of ............... ........ 1 ... 1
ii X_ 141 o4!2�&_ -- -- (SEAL) ................ ................ (SEAL)
J
i Camille Renee Smith
I •
-------------- ---------- --------- ---------------------- ............................................................
Personal Representative Personal Representative
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AUTHBNTICATION ACHNOWLBDOMBNT
Signature (a) ---------------------------------------------- STATE OF VMM14d(13�CIXX COL ADO
a&
i
-------------------- ----•------------------------ _.-- -------- - - -- -
- - - - - -- WIM-------- - - - - -- county.
authenticated this -------- day of ... ______ _______- ------_-- 19 ------ Personally came before me u - - -1St .day of
October -- the above named
-._,
--------------------------------•-------------------------------------- - - - - -- Ce.. x I1 a 7�e.. ee m a th
TITLE: MEMBER STATE BAR OF WISCONSIN
f (If not, -- _-------- -••-•- -_- - -- ------ _--- -- ------ ------ - - - -•- --------------------------- - ---- - -- -- - - -- ......................
authorized by 706.06, Wis. State.) to me known to be the person __. ......... who executed the
foregoing / } ' % � strument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
BAKKE , NORMAN & SCHUMACHER , S C. ` ' ��' a 13t'
? ....:
1 2015 Heritage zive •--- .....__�ar.Ql -- ,,.Fartune. . ....... sa •-
- - - - -- New - Rrirchmonc.- ,-- -W1 --- 54017 - -- -- --- -- - - - -- Notary Public - -- .......... Garfi -eld__ ] kt - .
(Signatures may be authenticated or acknowledged. Both My Commission is permanent. If notZstate ezVration'
are not necessary.) M ane. -i9 ;�
date: ............
�i •Names of persons signing In any . capacity should be type'] or printed below their signature, r� v
NCSa+ie. tu.'+ STATE BAR OF WISCONSIN
........ t °^9ayl'Yil - FORM No. 5 — 1382 Stock Nth. 13005
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