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HomeMy WebLinkAbout038-1180-00-000 ST. CROIX COUNTY ZONING DEPARTME AS BUILT SANITARY REPORT RECE IVED c0 _ Owner C T Q 5 1,998 i r� Address ST e ROl x City /State _ ' , zc�rmCo IeE �..._ Legal Description: /CT C6 Lot -?/ Block Subdivision/CSM # '/, ld '/, ,, Sec. , T, N- R,(�W, Town o - PIN # /- •3/.13. g9 SEPTIC TANK + DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer - Size ST/PC / Setback from: House L � Well � 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: 2 4yo Width _ „L Length 7Z Number of Trenches Setback from: House _ Well ;q�i_ P/L ,; Vent to fresh air intake ELEVATIONS Description of benchmark L Elevation Description of alternate benchmark D Elevation Building Sewer — ,//gZ.2 ST/HT Inlet /z) 7 Q.3 ST Outlet /,-9 7 j::2 PC Inlet PC Bottom Header/Manifold /,��, s', 2 Top of ST/PC Manhole Cover Distribution Lines Bottom of System Final Grade Date of installatioZ �� ermik num er State plan number Plumber's sign to - License number �� Date 1d / Inspector Complete plot plan a 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 6A i� 42- w'ff�� INDICATE NORTH ARROW Vw f iscqpVo Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page of Bureau of Integrated Services in accordance with s. ILHR_83.09, Wis. Adm. Code ? q Attach 11 1/2 8 than less not p aper Ian site complete on a er x inches i si /7, County p p �.P n must include, but not limited to: vertical and horizontal reference point ), irectionl tip' percent slope, scale or dimensions, north arrow, and location an nce t �d. P rcel LD. # CD r i APPLICANT INFORMATION - Please print all in ati T Q 5 1998 iewed by Date Personal information you provide may be used for secondary purposes ( iv Law, s. 1 W ()FIM — - 1 1 Property Owner at' Govt. Lot 1/4 114,S1 T3 N,R E(or& Property Owner's Mailing Address t W t3rco. S Ll d" Name or CSM 1f/ �P City State Zip Code Phone Number ty ❑ Vill e Z1 Town Nearest Road ❑ city � ❑ 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 1 bed, 9pd1ft _ trench, gpd /ft Absorption area required l�3 bed, n . C�3 trench, n Maximum design loading rate bed, gpd /tt _,S _ trench, gpd /ft Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design /site considerations - Parent material A, a ,&-CZ Flood plain elevation, if applicable n S = Suitable for system I Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for systeml ®S ❑ U ®S ❑ U I WS ❑ U 1 2S ❑ U ❑ S f o U ❑ S Z U SOIL DESCRIPTION REPORT Boren # Horizon Depth Dominant Color Mottles Structure GPD /ft Boring Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench a Ground 3 _ elev. _ ' Depth to limiting factor Remarks: Boring # /4 fee 22 -Z9 Ground A - elev. ln• ; Depth to limiting factor 22$in. Remarks: CST Name ease Print) Signature Telephone No. l Addres l,;, 1 Date CST Number ' a 22 Z2 4�2-11 PROPERTY OWNER � �� _ SOIL DESCRIPTION REPORT Page, 3 PARCEL I.D.# Boring Horizon Depth Dominant Color Mottles Structure 2 g in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh, Consistence Boundary Roots ::... ....... ....:: Bed ,Trench / d s Ground elev. Depth to limiting factor n. Remarks: Boring # Ground elev. tt. Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Boring # 13 Ground elev. ft Depth to limiting factor in. Remarks: Boring # Ground elev. ft. Depth to limiting factor in ' Remarks: SBD -8330 (R. 07/96) k � 3 f 1: 1 cJ Z-or 3� Wisconsin Department of Commerce M Count y PRIVATE SEWAGE SYSTEM Safety and Buildings Division INSPECTION REPORT ST. CROIX GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Personal infor you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 315922 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: M & G INC. STAR PRAIRIE CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 038- 1180 -00 -000 T ANK IN FORMATION VILEVAiION DATA A9800311 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic �� Benchm Dosing A 1, A M /1 Aeration Bldg. Sewer 4 •TL� 10A, 2~ Holding Inlet �,� /0 7,$� TANK SETBACK INFORMATION �n w O nT - St/ Outlet q/ 107.3-q TANK TO P/L WELL BLDG. Airintake ROAD Dt Inlet Septic ��� f r NA Dt Bottom Dosing NA Header/ Man. 10& . 62— Aeration NA Dist. P i p e t7 tjjG X73 Holding Bot. System 3-27' PUMP / SIPHON INFORMATION Final Grade 41P Manufacturer De m c G p�, Z, Model Nu GPM TDH ift Friction m TDH Ft L Forcemain Length Dia. Dist. To Well BSORPTION SYSTEM BED / ENCH Width Length / No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth EN 1 N '7 DIMENSION SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM LE INFORMATION Type I �v� BER Mode ber: Syst OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s} 4 x Hole Size I x Hole Spacing I Vent To Air In ake Length jGL Dia �' Length IL Dia. <- Spacing G < 564 �j� (!� 22Z 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 15.31.18,NE,SW 1144 ( 212TH AVENUE tz� 31 q Y �t t �( 7�i �J .�{ . 'I ,AS U �CG'I uG atc d� 7�a� A0e aq.5 (?A 1%)M 40a,r - � ✓J ww �� 0A Oe,*. Plan revision required? ❑ Yes [vj Itlo Use other side for additional information. 107 �'8 �jt [ : T 7 6 1 SBD -6710 (R.3/97) Date Inspector's Signature Cert. No *19c Safety and nt Division SANITARY PERMIT APPLICATION 201 E. W aB h ll i n g c0t1 Ave. P.O. Box 7969 Department of Commerce In accord with ILHR 83. 05, Wis. Adm. Code Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x 11 inches in size. • See reverse side for instructions for completing this application State 5anitary Permit Number The information you provide may be used by other government agency programs ❑ Check if revision to previous application (Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N Property wner Name Property Location 1/4 1/4, S T , N, R 4 F (ore�p Property O ner's Mailing Ad s of Number Block N ber , 7 City tate �' Zip Code Phone Number Subdivis n N SM Nu ber ( ) a 11. TYPE OF 11011 DING (check one) ❑ State Owned 11 ❑ vlly NearestROad la.ge Public A 1 or 2 Famil Dwelling - No. of bedrooms - Town of l og III. 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. Ig 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 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 []Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 []Seepage Pit 7� 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. /i ch) Elevation , Feet; Feet Capacity VII. TANK in Ca allon Total # of r Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturers Name Concrete Con Steel glass Plastic App New Existing structed Tanks Tanks e tic Tank ❑ ❑ El El El 11 Lift Pump Tank /SiphonChamberl I ❑ 1 ❑ 1 ❑ 1 ❑ 1 ❑ ❑ Vlll. RESPONSIBILITY STATEMENT I, the 4ndersigned, assume responsibility for inst Ilation of the onsite sewage system shown on the attached plans. Plumb is ame Print), Plumbe ' Si o ps) MP /MPRSW No.: Business Phone Number: Plum er's A dress Stree , City, State, Zip Co ): IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater Ea ssue Issuing A Si to (No Stamps) p � Surcharge Fee) Approved E] Owner Given Initial CJ� 1 Ct O Adverse Determination / X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: P a ,rt�.. co � be for- �.eaj� pry � � l�orr I , 361344 (R.1 1/96) V DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber f IvIi - / y � loal 33 al 75 �z I /D.93 I�US/Z /Q7 73 �gr(OC2 \ 73 3 / 9 /t?e8 - 33S DG � ' Lag r d Department Industry SOIL AND SITE EVALUATION REPORT �e rann "u d Human n Relations bons Division of Safety 9 8ullangs in accord with ILHR 83.05, Wis. Adm. Code �' Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but C not limited to vertical and horizontal reference point (SM), direction and % of slope, scale or c LID f. ; dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION t!"DBY` #k DA PROPE4ff OWNER: PROPERTY LOCATION VI'ChARD 5 v 7 GOVT. LOT C v4 SW /4 . l 3/ A! 1 s s T PROPERTY OWNF�R':S MAILING ADDRESS 35"3 /y w,4 T Ali5c TiP . LOT # BLOCK # SUBb. N OR CSM # - - CITY, STATE 3 Pig %V �ENj� &P �S ZIP CODE PHONE NUM ER 0CITY []VILLAGE NEAREST ROAD I1T� Sow Syof[o t/i5)s4�-(o731 5r R PRAIRIE &WY- Cc ( dew ConMtruc&M Use 4-'fiesidential / Number of b6drooms 3 +0 4 (� Addition to existing building (� Replacement (I Public o► commercial describe Code derived daily flow 't av gpd Recommended design loading rate Y k bed, gpoltt trench, gpd/11 Absorption area required MA bed, 1`1 10 Wench, ti ftlmum design baling rate bed, gpd/R trench, gW Recommended Infiltration surface elevation(s) _SE£ }b .3 ft (as referred to site plan benchmark) Additional design I site cons ations Parent material 5CS 11 Flood plain elevat'an, N applicable R S = Suitable for system ❑ U (� MOUND U Q 'S [ t R411Nb U ESSURE (E o U 19 #I FILL LI S TAW_ U = Urlstfltable lor S tem Q U ['3'S t� U ❑ S W SOIL DESCRIPTION REPORT N12 = l3orino # F,1zon Depth Dominant Color Mottles Texture Structure Consistence Roots GPD /ft in. Munsell tau. Sz. ConL Color Gr. Sz. Sh. Bed 0- 1 1 0 KO, 313 r-- y'PA is /,m 2 /hfv-2 C5 3 .7 .8 z 2.5 /o Y,4e � i /s /.►� ,e cis �s 3 f 7 .8 Ground 3 s- q /o elev. /o8. y it. Depth to limiting factor n Remarks: goring !I / D -// 1011 3/3 15 1441 444 ofie ...Z.... 2__ /- /� /o Y/z 3/� /S /,w, y/f d-5 6's z Ground 3 - 90 /o �� / S / s elev. /ol. 5 . Depth to limiting factor Remarks: T Name: — Please Print Ro t R r ZI L ( 3 R i'C t-. -r- Phone: 7 16 -3 Address: V Signature: Ulbricht & Associates Date: CST Number: Private Sswage Consultants 855 O'Nelt Rd. /( Hudson, WIS. 54018 PROPERLY OWNER R +?- SYn y T r SOIL DESCRIPTION REPORT p Z of 3 ', PARCEL I.D. ii* a r Y /f / 11 Ep— 8&vp Boring # [Horizon Depth Dominant Color Mottles Texture Structure Consistence Bw1fty Roots Gpb /fi In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. - Bed Iliench o - 2 10M 3/3 or /,$" fe ,, vf' w Z f . .9 Ground 3 Depth to Imitlng factor Remarks: Boring # /o /OM 3Z3 �S /.wr R � S 3-iC 7 • $ loylle 3 /9 1/ Ground elev. , 1(Q_ b It. Depth to Imltlng factor f► Remarks: Boring # ©// 10ri2 313 / 7 .....::.....:... Z /- l� o oe 3 /s /.�,, cs z- - F � £3 Ground /4 944 � elev.� ii /.� ►t. Depth to Imitlng factor n Remarks: a ks. Boring # Ground elev. It. Depth to < Inviting factor 1 Remarks: � coh eoen•o nd rnn� i wo . L or L. ?/' O zG g' 41 o f SvRv& !(ole 'S • �i • �� Xp hr N6 LOT 130 13 X30 CvlfJ� r � 3 Z- O 31 � / 7 Q 3 112 . ,YO ' B y ,/p ' [3 �o� 'mss► 1 33 - 13V-133 Y4, 7; R F, a� SCALE: 1 3 0 10 7. 4'0 4014J 71��Aj U L, 107,0 ' St1 �rG ES TE1O /Evrrrio�v S r-- P� . 3 a f 3— ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM n OwnerBuyer Mailing Address 13LO Aug q kec 7f iL Property Address JHq c 1, 4 AU F_ (Verification required from Planning Department for new construction) City/State 12eio R�L tlmarjn Parcel Identification Number LE GAL DESCRIPTION Property Location I V C `14, _ J _ Y4, Sec. _LS , T _31 _ N -R_/,�_W, Town of Subdivision le V. iy_ 0 , Lot # &/ _ . Certified Survey Map # , Volume , Page # / Warranty Deed # , Volume 1.3' , Page # l Spec house X yes 0 no Tot lines identifiable q yes 0 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 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 /x•e, 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. �m AA� � �, r `7 / / / SIG ATURE 04 APPLICANT DATE: OWNF,R 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. 7//V/71 GNA 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 O'. 16 n9 :33 F41 1 715 241 3622 XULUTEAN I REAL YY 9 41 583071 STATE BAR OF WISCONSIN FORM 2 - 1982 WARRANTY DEED 340cAcF446 l! RICHARD T,' CRO X CO., W1 conveys and warrants to M 8 G INC. JUL 93 A TA SPACE RESERVED FOR REClEIRLING DATA INA60 AWn RETURN ADDRESS the (ok'al dell mial estate in Col Starr or Wisconsin: ' P / A A474-, Lot 31, Plat of Apple River Band FirSt hpj'qru104 7 . Addition, Town C Star Prairie, St. Croix County, Wisconsin. 'Dix, .� 03 - 1180 - 00 - 600 �� PARCEL IDENTIFICATION Will �1 ICI J VSFE RA FEE i i 1! na is not homestead pmnerry if Eseerl Lo vllarrarlr;es: easements, restrictions, rights -of -way and covenants of record, it any. ii Dated this — day of July AD, 19 Richard 0. Stout (SFAL) (SEAL) (SEAL) AIJTIIENTICAT10N ACKNOWLEDGMENT Richard 0. Stout State of Wisconsin. ii St. Croix County I th July if a.tse'lmraike this duty Personally came berom me this 15th day of July 19— the c naw.ce- Stout Mary B". Cahala jl XXXX (Ir not Nn-hAry Pu C-- 11 M 111halized by 9706.06. Wui. ;tant, to me know. to be the er"r h. e xecuted the fore in y commission expi as 06/18/00 p g ins[rument and a&r.owltdAt the same. THIS INSTRUMF14T WAS DRAI TFD BY 'l P. Stout 353 Awatukee T:,. W;L . S4016 Notary Public,­­ County. wi-5 (Signature may awhCrILtil or acknowledged. both arr. not. My commission is permanent (if not, state expiration date: WARPLANTY DEED STATL 6AR or 'Al ~ L W,BC4994 50- LD. IT Fall Nell 2 - 1962 Wwol wl APPLE R1 BEND -[ �bY V/1 t !OCATEO IN F31RTOF TF!E NWI 14 OF ]VIE SWI /�1, PART OF [VIE SbVV4 r�. ( _E `- 1 NEI /4 OF THE SWI /R AND IN PAR1 OF T1!E NWI /n OF THE SF/ F - At 1 4 "I `F I!OIV I " TU I (it I tit j[ti'r Or y11 ,1V,Wf, E .u, 1 , T31N, RIFJW, TOWN OF STAR PRAIRIE, ST CROIX COUNTY, WISCONSIN Yi / LOT 27 LOT 26 LOT 39 9i.9D S� - 05..50 F I a r K f.0 15w3 — __ LOT 25 0 J j LOT 28 90.0+2 SO. EV -' \- LOT 38 2 K E._ x].r � �' �� 89. F66 SO. IT Q ,tl �' S L a� s° 11 nee)i ]i E ]� r.+6' _ ;; ,Hl 4/ =. 'b 2.J2 $ J ti ' � LOT 24 0 - 9.JL6 S. E•.2r ' � � 9 g +C LOT 29, 2/ tl5 aC :1 221 E 2y E.i E]M 1 ; - ri J. 9 m LOT 23 0 l o T 1 4 LOT 37 9BB 1, ]e -w ]]9.9. ' ti • � � '0 it ter +c. , y]onc 'f,I`r.M m LOT 30 1 O I •I E6. ]B1 94.E , ' ` t 29 - R �' 22 2 C t - O I !9 •yu �vu.+ _CUn iv ]F(.Y.n ` LOT 36 N35 3� n r F-1 94 gq ac i a ,].9..- _ LOT 31 I I • I 'S. ]6r > 1 `\ � \ _: E - 7 1 —.. :E _ 1, P a,E..f.v . i 3 N � - `_ _ - _- _ -_•a. . - � .c I ` w lVl O) aC SSS.06' \ 9 5E - r- LOT 35 � n 7 I 191 nC LOT, 1_I z 4).J06 ]J ct 1 a , •, � J \ .�_ .v ..at,a ':f (Nato -'. a E 2 LOT 1 ,1 LOT 34 E.L i I - � ! w �, ST. CROIX COUNTY WISCONSIN �•,� ZONING OFFICE r r r a N N ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016 -7710 (715) 386 -4680 October 8, 1998 REMAX Realty Attn: Mike Germain 103 Main Somerset, WI 54025 RE: Septic Inspection for M & G Inc. located at 1144 212th Avenue, Lot 31 of Apple River Bend, Town of Star Prairie, St. Croix County, Wisconsin Dear Mike: A septic inspection of the above referenced property was conducted on September 29, 1998. This property is located in the NEY4 of the SWA of Section 15, T31 N -R18W, Lot 31 of Apple River Bend, Town of Star Prairie, St. Croix County, Wisconsin. At the time of the inspection, this septic system was found to be code compliant for a three (3) bedroom home. If you have any questions regarding this, please contact our office at (715) 386 -4680. Si rely, od Eslinger Assistant Zoning Administrator /sm