HomeMy WebLinkAbout038-1179-70-000 ST. CROIX COUNTY ZONING DEPARTIVOT
AS BUILT SANITARY REPORT,
Owner
Property Addr9ss
City /State
Legal Description:
Lot (p2f Block — Subdivision/CSM #
A ( L t/4 s�L t /4, Sec. �, T2LN -RAW, Town of PIN #
SEPTIC TANK — DOSE CHAMBER — HOLDING TANK INFORMATION:
Tank manufacturer ' - Size ST/PC / F,1a:� / Setback from: House Well - d.�l 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: 6xo Width z : ,2 Length i 7 — Number of Trenches
Setback from: House /- 2 Well P/L -7,� Vent to fresh air intake ,- >-g
ELEVATIONS
Description of benchmark 1,r7- :5ZA,; Elevation ZM_
Description of alternate benchmark A, . �' ��)b,(f Elevation
Building Sewer 3 ST/HT Inlet .�_ ST Outlet /6-7 a 7 PC Inlet
PC Bottom Header/Manifold , /� /,��/ Top of ST/PC Manhole Cover /03, Z C
Distribution Lines ( ) , /� /_ O ( )
Bottom of System ( ) ,Z, 0, ,2- O ( )
Final Grade () 14:Z2 e/ () ( )
Date of installation / ermit number State plan number
Plumber's signature License numbe / Date / /
Inspector d,/ ev
T" 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
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INDICATE NORTH ARROW
• Wisconsin Department of Commerce
Safety and Buildings Division PRIVATE SEWAGE SYSTEM count .
I INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanita i .
Personal information you provice may be used for secondary purposes [Privacy LXw, s.15.04 (1)(m)].
PeSmit_t-IoTyWame: ®T�❑ wn of: State Plan ID No.:
CST BM Elev. Insp. BM Elev.: BM Description: Parcel 0 .:
TANK INFORMATION ELEV TION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic o Benchmark
91, Ile
Dosing
Aeration Bldg. Sewer
Holding St /Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P/ L WELL BLDG. Airi to ntake ROAD Dt Inlet
Air I
Septic Y �� / �/ " a .. �c NA Dt Bottom
Dosing NA Header/ Man. Q /
Aeration NA Dist. Pipe
w
Holding Bot. System
PUMP/ SIPHON INFORMATION �.f -- "Y Final Grade S�
Manufacturer Demand ,
Model Number GPM
TDH Lift F System TDH Ft ad
Forcemain Len Dia. H Dist. To well
SOIL ABSORPTION SYSTEM
BED/TRENCH width Length , No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth _ DIMENSION l DIMENSION
SETBACK SYSTEM TO P / L BLDG I WELL LAKE /STREAM
LEACHING Manufacturer:
INFORMATION Type O CHAMBER Mod Number:
System: " /o' 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 E] No ❑Yes E] No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: &TAR PRAIRIE 15.31.18,NE,SW 1150 212TH AVENUE
L4.
Plan revision required? ❑ Yes d N 0
Use other side for additional information.
SBD- 6710(R.3/97) Date On cir's signature Cert No
Safety and Buildings Division
V sconsin SANITARY PERMIT APPLICATION 201 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 81/2 x 11 inches in size. ,
• See reverse side for instructions for completing this application State Sanitary Permit Number
you provide may be used for seconds 3 ��
Personal information
y p y second 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 RMATI N
Prope j Owner Name I Property Location
/4 1/4, S T , N, R 1
�(or
Property Owner's MailinAdd re of Number Block Number
" Phone Ci , tate Zip Code umber Subdivision ame r CS umber
' 17 ( )
I. TYPE OF 6 Ill I G: (check one) ❑ State Owned ❑ i t Nearest Road
❑ village
Public a 1 or 2 Family Dwelling - No. of bedrooms --S Town OF
III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 15. SL. I S . 1Fg2,
1 E] Apartment/ Condo 038— AL
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 Eg New 2. ❑ Replacement 3, ❑ Replacement of 4. ❑ Reconnection of 5_ ❑ 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 [,g Seepage 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.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Mi . /inch) Eleva ion
V Feet /B Feet
g
VII. Capacit TANK in llo Total # of Prefab. Site Fiber- Exper.
INFORMATION Gallons an Manufacturer s Name concrete Con- Steel glass Plastic App
New - Existin structed
Tanks Tanks
Septic Tank or Holding Tank is ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ 1 ❑ 1 ❑ 1 ❑ ❑ ❑
Vill. RESPONSIBILITY STATEMENT
I, th ndersigned, assume responsibility for i to ation o he onsite sewage system shown on the attached plans.
Plum s Nam 7!) Pl�m' r'§ n t ps) MP /MPRSW No.: Business Phone Number:
I -
Plumber's Address ( t, Ci ,State, Zia Code):
D
IX. COUNTY / DEPARTMENT USE ON
❑ Disapproved Sa nary Permit Fee (includes Groundwater D ate Issue Issuing ent Signature ( St
pproved ❑ Owner Given Initial Surcharge Fee) w /
Adverse Determination Sri
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD- 6398 (R.11/97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
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W=scontn Department of Industry SOIL AND SITE EVALUATION R Page of 3
Labor end Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis. A o �f1
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan I ludeyp
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not limited to vertical and horizontal reference point (BM), direction and % of slo e, Is or ARCEL . .
dimensioned, north arrow, and location and distance to nearest road. el
APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION IE DATE
s r cF�ch
PROPERTY OWNER: PRO
/'G lr.4 Rl7 .5 U T GOVT. 1/4 T ,N,R /V E (00
PROPERTY OWNER':S MAILING ADDRESS LOT i S 1 CSM fl
1 35'3 1 4 w,4 7 leEs= TAP. 44x W". +D a.
CITY, STATE ZIP CODE PHONE NUMBER []CITY OVILLAGE N NEAREST ROAD
ti~v SorJ /��s. 5yof� (715)54'? (,731 PRht t.E 11cvy. cc _j
(poew Construction Use 1 4- - f iesidential / Number of b6drooms 3 to q I J Addition to existing building
I J Replacement ( J Public or commercial describe
Code derived daffy flow Y �� gpd Recommerded design loading rate 7. bed, gpolft • trench, gpd/ft
Absorption area required gy� bed, ft2 7 .4`29 trench, ft Maximum design loading rate ' 7 bed, gpd/ft . trench, gWI
Recommended infiltration surface elevation SE 3
(s J ft (as referred to site plan benchmark)
Additional design / site cons rations
Parent material -5C-' I t C ETEe i' 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 fors stem JOSOU I OS OU OS OU OS OU F OS OU OS OU
N
SOIL DESCRIPTION REPORT �/c' = No% iPEOOi`•t•/��,v�Ej)
Boring # Horizon Depth Dominant Color�� Texture Structure cons Bw Roots GPD /ft
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed TWnch
i0 yle 3 /� S / fs6,� s cs z� . y • 5- 2 /0 Yie 3 /3 5'
Ground 3 -� /0 / 3 S i/ h , , t die cS U7 - G
elm 7 y /D S. D, S
Depth to
limiting i
facto 4!!�;
Remarks:
Boring #
/ 043 /0 We 313 S/
z z
13 z6 /0 9 3 13 51 1. 2 fs4& _66e
3 l 3/
Ground' - 3 0 S / 2
j03 . _q,;- ft.
5 • a If
Depth lo . S Q'� � — • 7 . g
limiting
� factor
� , 7_1
Remarks:
ST Name: - Please Print R c 4 t R T Phone. 715'= 3&_ S t S y r.
Address: esmAl I . e.;_
Signature: Ulbricht & A SSOM 083 Date: CST Number:
Private Sewage Consultants
"I' 655 O'Neil Rd.
Hudson, wls. 54016
ORIGIN
Rr P 50 0T
PROPERTY OWNER �� 4 SOIL DESCRIPTION REPORT p Z 0 1 •�
PARCEL I.D. ! Go )` 2 g iE l f1 E� 8L".UfJ
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bouchry Roots GPD /ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed rTW6
Ground 3 - o /o /Q .S. o, S . i 7 . S
elev.
Q - Q yve 516 S. Q S . 7 € . ,?
Depth to
limiting
factor
Remarks: !
Boring #
313 S �fs6,� . ads �s a f .4
vxe 3/ S Rv�y / s�.� fie �s If . s' . S"
Ground
elev.
/0.2. - Lift.
Depth to s
DrAng €
factor
s
Remarks:
Boring # � Dyo /Oye �j /3 S� /7`56, �S C � • �/
✓� z o - t o log 31 Si/ f Aw c/ eS /f • S' G
Ground
Depth to O /O rj . s, a
limiting t
factor
Remarks:
Boring #
13 i
Ground
elev.
h.
Depth to
limiting
factor
Remarks:
con 000nio nc rn�•
it
c v E s� 7 - 1 - . Z oo ' 70'0 W -
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ST CROiX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
r
1
Owner/Buyer -
Mailing Address
Property Address 5 t ala �� w �+�u►�cX
(Verification required from Planning Department for new construction)
City /State Parcel Identification Number 117 . 00
LEGAL DESCRIPTION
Property Location '/<, -5�,/L ' /a, Sec. I-s T L N -R _ W, Town of
Subdivision :N , Lot #.
Certified Survey Map # , Volume , Page #
Warranty Deed # , Volume if , Page #
Spec house l9 yes ❑ no Lot lines identifiable L4 yes ❑ no
SYSTEM MAINTENANCE
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance
rnm kfs of pumping out the septic tank every three years or sooner, What you pw 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.
I/we, 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 Zor.i.ng Office within 30
days of the three year expiration date.
L A 'kX ' ftX '� / E l
SI ATURE. F 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 pro C'n describe above, by virtue of a xvarranty deed recorded in Register of Deeds Office.
/8 /99
SIGt4ATURE I F 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
�• V
VOL 1402 0
59
STATE BAR OF WISCONSIN FORM 2 — 1982 7491 KATHLEEN H. WALSH
WARRANTY DEED REGISTER OF DEEDS
DOCUMENT NO. ST. CROIX CO., WI
RECEIVED FOR RECORD
02- 08-1999 11:15 AM
RICHARD 0. STOUT
WARRANTY DEED
EXEMPT N
CERT COPY FEE:
conveys and warrants to M & G, INC. COPY FEE:
TRANSFER FEE: 79.80
RECORDING FEE: 10.00
PAGES: 1
THIS SPACE RESERVED FOR RECORDING DATA
NAME AND RETURN ADDRE S
the following described real estate in St. C roix County, x
State of Wisconsin: 1,3 $.3 y �
Lot 28, Plat of Apple River Bend First ^�
Addition, Town of Star Prairie, St. Croix., 2!/.fl 5y0�
County, Wisconsin.
038 - 1179 - 70 -000
PARCEL IDENTIFICATION NUMBER
This is not homestead property.
(is) (is not)
Exception towarrantieeasements, restrictions, rights -of -way and covenants
of record.
Dated this 8 th day of Februa A.D., 19 99
i hard 0. Stout (SEAL) (SEAL)
(SEAL) (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) State of Wisconsin,
ss.
St. Croix
County.
authenticated this day of 19 Personally came before me this 8th day of
February , 19 9 9 the above named
` Richard 0. Stout
TITLE: MEMBER STATE BAR OF WISCONSIN APE N
(If not,
authorized by §706.06, Wis. Stats.) N� l =j �` !�� :'to me known to be the person who executed the foregoing
- instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY ; �' �'U
Janet P. Stout
1353 Awatukee Tr-.
Hudson Wi. 54016 �
t•'� Ilic, County, Wis.
(Signatures may be authenticated or acknowledged. Both.are not y _ ,.. My commis ion s permanent. (If not, state expiration date:
necessary.) I , 19 .)
t
Names of persons signing in any capacity should by typed or printed below their signatures.
STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc.
WARRANTY DEED Form No. 2 —1982 Milwaukee, Wis.