HomeMy WebLinkAbout038-1174-20-000 i ST. CROIX COUNTY ZONING DEPARTMENT.
AS BUILT SANITARY REPORT !
Owner
Property Address 11,.V7 fi
City /State C= q - ''' 9
Legal Description:
ti
Lot _Z Block Subdivision/CSM # x� �� �"
0 t /4 S,c t /4, Sec. )5 T,jLN -Rff W, Town of x I�I
SEPTIC TANK -- DOSE CHAMBER -- BOLDING TANK INFORMATION:
Tank manufacturer L ST/PC Setback from: House Well P/L�t
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: a Width Length f7 Number of Trenches
Setback from: use - 51S Well z— P/L _- j:jz' Vent to fresh air intake
ELEVATIONS
Description of benchmark Y -' Elevation L0,15
Description of alternate be nchmark IJ4sz, L2 L Elevation 1f 4
Building Sewer , ST/HT Inlet Z 92-5 - 2- 57 7 ST Outlet / , / PC Inlet
PC Bottom Header/Manifold Age, 9q Top of ST/PC Manhole Cover o
Distribution Lines () /PP, Z q () ( )
Bottom of System (} 99, 9 () ( )
Final Grade () f�2 I? () ( )
Date of installation /ZilTi ermit num er '7 State plan number
Plumber's signature License number ; 29 l2 Date ,r/9
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
orl/
44 $
s
i 37
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INDICATE NORTH ARROW
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count yST. CROIX
Safety and Buildings Division
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) SanitarZa
Personal information you provice may be used for secondary purposes [Privacy LXv, s.15.04 (1)(m)].
ergit I ftdName: [STA(fo jpRAIRIlown of: State Plan ID No.:
CST BM Elev.:- Insp. BM Elev.: BM Description: Parcel —
o U /00.00
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV.
eptic S Benchmark / 00-00
Dosing Q 4 e r. & G`7 2.03 G�1
Aeration Bldg. Sewer .ZZ 109'_ S
Holding t Ht Inlet
TANK SETBACK INFORMATION 31 Ht Outlet s �03•I
TANKTO P/L WELL BLDG. Vent toke ROAD
AV ptl ( NA tom
Dosing NA Header / Man.
Aeration NA Dist. Pipe , 23r ip 0 .
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade _:57 ZO /L � �
Manufacturer De and
Model Number GPM
TDH Lift Lrictio st TDH Ft
Forcemain Len la. Dist. To Well
SOIL ABSORP SYSTEM
/ TRENCH Width Len th No. Of Tr nches PIT No. Of Pits Inside Dia. Liquid Depth
MEN I N`� DIMENSION
SETBACK
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type Of r r CHAMBER Number:
e
System: em v � OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length � Dia. _i� Spacing f jr Z # I ,r —/
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
i Bed /Trench Center Bed/ Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: STAR PRAIRIE 15.31.18,SW,SW 1127 212TH AVENUE
:sill
vas
Plan revision required? ❑ Yes K1 t
Use other side for additional information. g �l
SBD -6710 (R.3/97) Date Inspector's Signature ert No.
Safety and Buildings Division
Vi seonsin S ANITARY PERMIT APPLICATION 2 1 Box Washington 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 8112 x 11 inches in size.
• See reverse side for instructions for completing this application State Sanitary Permit Number
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
Propert Owner Na a Property Location
7 1/4 1/4, S T , N, R E (oro
Property Owner's Mailing Address lot Number Block Numlller
City tate Zip Code Fber Num Subdivis n N me or SM Number
)
(. TYPE B ILDING: (check one) E] State Village State Owned ❑ it TNe4 rest R oad
, ,�
Public 1 or 2 Family Dwelling - No. of bedrooms Town OF
111 BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment / Condo
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. 0 New 2. ❑ Replacement 3, ❑ Replacement of 4_ ❑ Reconnection of S. ❑ 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 jZSeepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In- Ground Pressure /� r �� 42 ❑ Pit Privy
13 E] 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.) Proposed (sq. ft.) (Gals✓day /sq. ft.) (Min inch) Elevation
t 7 Feet Feet
Ca acit
VII. TANK in allons Total # Of Prefab. Site Fiber- Exper
INFORMATION New Existin Gallons Tanks Manufacturers Name Concrete strutted Steel glass Plastic App
Tanks Tanks
eptic Ta ® 1:1 El 13 1:1 1:1 Lift Pump Tank /Siphon Chamber ❑ ❑ 1 ❑ I ❑ I ❑ ❑
Vill. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for in allation of the onsite sewage system shown on the attached plans.
Plumb 's Na e: (Pri Ptum er' �gna =� rMP/MPRSW No.: Business Phone Number:
3 _
Plumber's Address (Street ity, State, Zip Code)
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issue Issui g A nt Signature (No Stamps)
pproved E] Owner Given Initial Surcharge Fee) �V !
Adverse Determination t75 11 CV
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD- 6398 (11.11197) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
4 Al 4W- 4Z IA9!J Lk'r�Iu ✓� c� /O � f7`
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Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT P L of
m -3
Labor and Human Relations —
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
sr.cRorx
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION PLEASE PRINT ALL INFORMATION ,��`%± j j IEWEDBY DATE
PROPERTY OWNER: PRO R ATIO X, 1:v
k 5 v 7 Go 5c�t� 1 #4, +� 1 3/ ,N.R /g E (0 W0
PROPERTY OWNER':S MAILING ADDRESS BLOCK # SUB
3S3 w ,4 7 T.P. {
CITY, STATE ��S ZIP CODE PHONE NUMBER QV LLAGE N REST ROAD
tfv So.J Syolco (7� )s�F 4-�73 1 _PR t wy. cc
Ipt<dew Construction Use ( q-�esidential I Number of b6drooms 3 +0 4 �,� ` ( f "Addrtiori r<q sting building
( ) Replacement ( ) Public or commercial describe ,
Code derived dally flow T " gpd Recommended design lading rate bed, gpd/ft trench, gpti/ft
Absorption area required k5T bed, ft a trench, ft Maximum design loading rate .7 bed, gpd/ft • f trench, gpdM
Recommended infiltration surface elevation(s) S4� � ..3 ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material $CS Q 1 6'VRKti,4^97"- Flood plain elevation, if applicable ft
S = Suitable for system C M IN G PRESSURE AT - G �D E S -- M FILL HOLDING TANK
U= Unsuitable for stem H S O U OS ❑ U us ❑ U 0"S O U as [] U O S
SOIL DESCRIPTION REPORT I VIR = ,v il'E� oHpLCN�gf)
Boring # Horizon Depth Dominant Color Mottles Texture Structure �� Roots GPD /ft
in. Munseii Qu. Sz. Cont Color Gr. Sz. Sh. Bed terldl
Ground /d S
elev
loo , � ft. �- p / p S/
Depth to
limiting
factor
Remarks:
Boring #
:::::::::fi 3 y y 3� 7sy,� y/� - y c� D s �lL eS - • 7
Gro nd
elev. -yo /o y/� S� S , CJ S' 'f- _ _ : 7 • �'
/o y$ ft.
Depth to
limiting
factor
Remarks:
CST Name: — Please Print R CJ Q -�.� Phone.
Address: �.�--
Signature: Ulbrichl & A SSOCIatfis Date: CST Number:
PrivrAts Sewage Consultants
655 VNell Rd.
Hudson, Wis. 54016
ORIGIN
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PROPERTYOWNER RJ�I,PD S-fz��T SOIL DESCRIPTION REPORT pa z of 3
PARCEL I.D. # lDT /2— /E I V CF- 8L - .VJP
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence BWwriddarY Roots GPD /ft
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. g� �
L . .......... J 2 �� 1F l0 3/fl - - �s /�, �-� cS _ , � 0
round 3 7 S ye CS — • � ,
102 elev.
Depth to
Imi6ng
factor ,i I
� GJ1 3
f�- I
3
Remarks:
Boring # ,
o /o yp 3/� -
3- Z(p /o YR 31
c _ 7 , • �'
7 ye
Gro D s
/o/, (0e "�� i0 S/� .S . Q S fL ,
Depth to I
limiting
factor „ I
� f
Remarks:
Boring #
Gro
elev. 9
/0 . 90 ft. i
Depth to
limiting
factor
Remarks:
Boring # ,
13
i
Ground
elev.
n.
Depth to
limiting
factor
Remarks:
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERS141P CERTIFICATION FORM
Owner/Buyer _
Mailing Address q ( f�a"%I<et R utJSe 0
Property Address 'a1a �F N
A )CA r" 6 V
(Verification requiL Planning Department for new construction)
City /State NQvJ (� 'AArr Parcel I dentification Number "52w
LEGAL DESCRIPTION
Property Location_ ' / <, ,� ' /a, Sec. �/ , T -R Town of -w��
Subdivision P�n�� R \3 t S" " Q , Lot # ► aS _
Certified Survey Map # , Volume , Page #
'Wai i i ,nib weed # S��' // , Volume �� , Page # l /�?
Spec house 5q yes ❑ no Lot lines identifiable V yes ❑ no
SYSTEM , MAINTENANCF
Improper use and maintenanceof 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 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.
41 "N —1�v � % 1. rc,- - a/ 19/99
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 p rty described above, by virtue of a warranty deed recorded in Register of Deeds Office.
4
SIGt4ATUR.E P 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
U2i1 15.4 !1 524-.362= REMAX TEAM I REALTe PAGE
0 02/19/90 FRI 15 FA2 713 386 4647 K3Q5Tf;R % VLb-V5 0
ML 1404PAU6t?
"t Qi Ansromv" px)sw 1 1951 1 KATHLEEN H , WALSH
WARRAtM DEED MISTER OF DEE
S . CROIX CO.*
aocumr!NT NO qM190 FM MM
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CORICY5 ■.d wunrMs to
&PACE RESIA'U. f Ok
Rz1jAK ANKO
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tk. lalkvmng cord" fia C cr%D-L
Lot 12, Plat Of Rppyg Rivet bend. v0•rl Of
Eta/ Prairie, St. C C,
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is pot
easements, J;W#t rights-of and ccv*ngntS
f of record.
th - AD,
it Richard U. $tout (51FAL; MAL"
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fi ACKNOWLEDGM9,NT
ATJTHYNI ICAT ION
State of WLslzon$191
Croix
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