HomeMy WebLinkAbout038-1076-60-000 r
ST. CROIX COUNTY ZONING DEPARTMENT
AS BUILT SANITARY REPORT
Owner
Property Address A '3 2 26 t�•c
City /State .ta `tee,
i
Legal Description: f
Lot Block Subdivision/CSM #
Se - /:L, T 3 N -R ) b W, Town U PIN # fir Aar 4
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION:
Tank manufacturer Size ST/PC / Setback from: House Well `-' P/L ; °
Pump manufacturer rl 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: AJ Width Length Number of Trenches
Setback from: House Well P/L Vent to fresh air intake 7/0
ELEVATIONS
Description of benchmark Elevation
Description of alternate benchmazk Elevation
Building Sewer 10l. 'Y? ST/HT Inlet 1 ST Outlet /O/ ° Z— PC Inlet
PC Bottom Header/Manifold %00, to a' Top of ST/PC Manhole Cover /03. 92
Distribution Lines ( ) /00-5 () ( )
Bottom of System () c79
Final Grade O %G 3,
Date of installation 5'/N/5'9 Permit number State plan number,?
Plumber's signature License number 22/V71 Date /55'
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
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INDICATE NORTH ARROW
Wisconsin Department of Commerce
Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count y
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: IX
Personal in formation you provice may be used for secondary purposes [Privacy w [Privacy La s.15.04 (1)(m)). 338859
Perr> t G E Na Villa e kRTY ❑ City STAR a IRIE State Plan ID No.:
CST BM Elev.; Insp. BM Elev.: BAA�scription: Parcel Tax No.:
, � on i 038- 1076 -60 -000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Benchmark .
Dosing /' ,l/t^, rI Z�}
Aerati n Bldg. Sewer
Holding d Ho Inlet /d
TANK SETBACK INFORMATION t/ Outlet
TANKTO P/L WELL BLDG. ntto Air Intake ROAD Dt Inlet
NA Dt Bottom
Dosing NA Header /Man. 3`/ J >p„ 6
Aeration NA Dist. Pipe
Holding Bot. System 9C 3Z
PUMP / SIPHON INFORMATION Final Grade S Ia3�8�-
Manufacturer emand (n,i,,,.1 ., 5- $3 1 3- 2/5
Model Num GPM
TDH Lift Friction S TDH Ft
Forcemai nj Length Dia, Dist. To Well
SOIL ABSORPTION SYSTEM
/ TRENCH Width Length 7 No. Of Trenches PIT No. Of Pits Inside Dia. Liquid De th
DIMENSIONS DIMEN I N
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING facturer:
SETBACK Nu r:
INFORMATION Type CHAMBER Mode
S s / �/ OR UNIT
DISTRIBUTION SYSTEM
Header / Man fold Distribution Pi e(s) fl, Hole Size x Hole Spacing Vent Air Intake
Length 10 } Dia- Length ��' Dia. Spacing �®~ ��'� "` Z Woo
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.)
L TION• STAR PR
AR 18.31.18.313B,NE,NW 843 220TH AVENUE
Plan revision required? ❑ Yes E�
Use other side for additional information. �� Fle 5
SBD -6710 (R.3/97) Date Inspector's Signa re Cert. No
SANITARY PERMIT APPLICATION Safety and Buildings Division
201 W. Washington Avenue
Vi sc onsin 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
than 8112 x 11 inches in size. Z7
• See reverse side for instructions for completing this application State sanitary Permit Number
you provide may be used for seconds 133 � �� `��
Personal information
Y p Y 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
�''�
Propert y caner Name Property Location
v w er" 1� 1/4 Kf/ 1/4, S j r T ?I , N, R/r E (or)40
Property Owner's"Mailing AdhAess Lot Number Block Number
City, State Zip Code Phone Number Subdivision Name or CSIVI Number
*w W .L _S ( 7/r 12`{G- GGa
II. TYPE OF BUILDING: (check one) ❑ State Owned it Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms Iow OF a 4v
III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo 6 3 ? - _/6 7
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 online B, if applicable)
A) 1. ig New 2 ❑ Replacement 3 ❑ Replacement of 4 ❑ Reconnection of 5 [3 Repair of an
------ -------- ________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
114!9.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.) (Min. /inch) p Elevation
�� 1 2WO /.ZO • f —� T 9 �5� feet /03. vJV' Feet
Cap acity
VII. TANK in Ca gallo S Total # of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturers Name Concrete Con Steel glass Plastic App
New Exist in structed
Tanks Tanks
It or HoldingTank /,Vp / ® ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ El El El El 1:1
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sews ne 5y5tem shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: (No Stamps) /MPRS o.: Business Phone Number:
nn ; s .� 4 r -.2Lr- 40 3".
Plumber's Address (Street, Cit , State, Zip Code):
D z /yo M S7 1#74/ V wa
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groun:i I Issuing Age gnature (No Stamps)
S charge Fee)
Approved ❑ Owner Given Initial oo g /
Adverse Determination R� / / op
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
,Q1�] DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
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ffts1 Alt Ittlele AM C►e4tootloe Pipe
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To fifto amoll4 VeM �W
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•re 1 Apnple
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SOIL 0
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Iti� Ai4R�Ert �'!' _'`oR M FJµ F1 j1 O STRAW
(_f�/ OF Eri • L 01' %t •t AG. 6RCGA,T[
D13T'Rl!5U - r17W PIPC TO eC Al 1,¢Ati'T � tNGti+fS *CLOw GR�GII,JA{� Gkl►Ot
AVk AT t I"HIES 9UT AIO MORC TwgIJ 42 I1d(,ME3 Df.lpw i'IgiAL GRADE
MnrxiM V Apr4 OF EXCAVAT100 FAOM OWwou 60 N � It. L ec �� suc'mcs
NYNiaWM OEtr�i of LtACAVATION FROM 01K 161 1 1AIAL 6R4vE '- L BE .. _ ir3cWCa
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LIC CWSE III UMBE R:
004 E
'Wisconsin't)epartment of Commerce --SOIL AND SITE EVALUATION
Division of Safety and Buildings , , Page of
Bureau of Integrated Services < 'e),� - aeeordance with s. ILHR 83.09, Wis. Adm. Code
Attach complete site plan on paper no lesg..4han 8 °1 {1rF es in size. `,Plan must Coun
include, but not limited to: vertical an zontal refe point (BM), direction and
;L� , ��
percent slope, scale or dimensions, oitfilarrow and location,�rng_distance to nearest road. Parcel I.D. #
APPLICANT INFORMATION Pl se pri�6pWnform4i Re by Date
Personal information you provide may be use fof s0"-onrFdo"RWs Marro s. 15.04 (1) (m)).
Property Owner "7 ; Property Location
' I Govt. Lot 114 l 1 /4,S T ,N,R E (or)
Property Owner's Mailing Address Lot # Block Subd. Name or CSM#
City Stat Zip Code Phone Number -1 ® Town Nearest Road
❑ City , ❑ Village
J � v
New Construction Use: JZ Residential / Number of bedrooms Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow dX — gpd Recommended design loading rate 5' bed, gpd /f trench, gpd /ft
Absorption area required 4 M bed, ft 2 ' Z,�26 . _ trench, ft Maximum design loading rate < bed, gpd /ft __ trench, gpd /ft
Recommended infiltration surface elevation(s) ! X5 ft (as referred to site plan benchmark)
Additional design /site considerations
Parent materia 49 J4 1T oQq d Flood plain elevation, if applicable J1 it
S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
U= Unsuitable for system JAI S❑ U Z S ❑ U JZ S❑ U Fx S❑ U El S M U ❑ S u
SOIL DESCRIPTION REPORT
Boring Horizon Depth Dominant Color Mottles Structure GPD /ft
g Texture Consistence Boundary Roots
/ in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
l
Ground
elev.
Depth to
limiting
factor
144
Remarks:
Boring #
a j s
Ground —
elev.
ft.
Depth to
limiting
factor
2W in. Remarks:
CST Name (Ple a Pri l ) Signature Telephone No.
Address _ Date CST Number
c
SOIL DESCRIPTION REPORT "
PROPERTY OWNER — Page of
PARCEL I.D.#
Boris # Horizon Depth Dominant Color Mottles Structure 2
Boring Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
,
LIA r 'G
Ground
elev. i/
L2,r ft. — —
J /
Depth to
limiting
factor
Remarks:
Boring #
to
F� S
Ground
elev.
Depth to
limiting
factor
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 # ;
3 _ a ,
Ground _�
elev.
Depth to
limiting �a $
factor
�in. Remarks:
Boring #
13
Ground
elev.
ft. '
Depth to
limiting
factor
in. Remarks:
SBD -8330 (R. 07/96)
90
3�
y,
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer
Mailing Address Are- fie.W
Property Address A
(Verification required from Planning Department for new construction)
City /State 54-AY Pry Sri e- Parcel Identification Number (r3$'- /c> >( - (o
LEGAL DESCRIPTION
Property Location �- '/4, SW '/4, Sec. %,F , T ..?/ N -RAW, Town of .S'74.-° A_111.1-
Subdivision -- - , Lot #
Certified Survey Map # , Volume , Page # -
Warranty Deed # �Z04 - 13 9 , Volume _71q , Page # _
Spec house ❑ yes 11Y 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
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.
!/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 Zoning Office within 30
days of of the three year expiration date.
SIGNA OF AYOLIdANT DATE
OWNER CERTIFICATION
I (we) certify that all statements on this foram 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.
/ /d
SIG'NATXRRE OF AP961CANT 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
DOCUMENT NO. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA
STATE BAR OF WIS CONSIN FORM 2-1982
10IIAGE4 I'd
MUSTERS OPFICE
James L. Bell and Virginia Bell, husband ST. CROIX CO, WIS.
i e -
.... - ------------- ----------------------- 11 ........ ---------------------
---- - - -- --- - i = 28th
..a..n......w............. Roc'd. for Re
Aug. ..........•.................................................. Aug . this 6r
------------------------------------------------------------------------------------------------------------------ day of A. Mgt!
conveys and warrants t
..q4.r:tin --- 13 Ar g_e r .. an.d..Ann.ette .............
--- jo-in.t ... tenants........
1 --------------------------------- ----------------------------------------------------------------- * •--------- - - - -•-
................................................................... ......................................
..................................................................................... ........................... RETURN TO
Ii --------- -------------------------------------------------------------------------------------------------------
- --......................... ...............................
...... .............................................
the following described real estate in ....... S.t--..Criaix .......... .........County,
State of Wisconsin:
038 074 - 4a -
Tax Parcel No: ----------------------------
The North 1100 feet of the West 200 feet of the North 100 feet of
the East Half of the East Half of the Northi7est Quarter (Ej of Ef
of NWW of Section Eighteen (18), Township Thirty-one (31) North,
Range Eighteen (18) West.
This warranty Deed is given in partial satisfaction of that Land
Contract between Grantor and Grantee dated March 12, 1982, and
recorded in the St. Croix County Register of deeds office on March 16,
1982, in Volume 644 of Records on Page 116 as Document No. 376620'.
A
TRANSFA N
This ------- is not
.- ...... homestead property.
(is not)
Exception to warranties: