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HomeMy WebLinkAbout038-1088-90-000 ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT Owner _/ A R R V Property Address City /Stat Legal Description: Lot Block Subdivision/CSM # S- t /4 W t /4, Sec. J j T, �N -RAW, Town of 5 A � /Qc= PIN # rJ 38 - /dB8 -3;,'0 [.� SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer 4Wd,&2a ( Size ST/PC /-0&/,04Q Setback from: House .2-6" Well Y, P/L Jam' Pump manufacturer 2DELL &2 Model f'c4 Alarm location &2a s DING TANKS ONLY) Setbacks: e viz Vent to fresh air intake Water Line Meter location ocation SOIL ABSORPTION SYSTEM Type of system: % jfg- cA— Aj Width ` _ Length Number of Trenches _ Setback from: House 4 �> I Well 160 0- P/L Vent to fresh air intake ELEVATIONS Description of benchmark ,75 P P VG 4D , ,eo ,6-7 Elevation 4D• O Description of alternate benchmark a22Z of 2j /Q/A apt.- &zw5,6 Elevation /03.Y 2 Building Sewer ST/HT Inlet ST Outlet Z V-2 PC Inlet PC Bottom ?-3 Header/Manifold Top of ST/PC Manhole Cover Distribution Lines O 9Z 2f O 7. 2F ( ) Bottom of System () 6 . V 5 () f - y 5 ( ) Final Grade O ADD" 0 0- G ( ) Date of installation / / Permit number State plan number A/ A Plumber's signature - License number ,22/ 7 Date / Inspector �,.t�. Complete plot plan or y 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 800 6-& P.C. /OOG Gf S;7; �uS G 0 s INF/ c rRA-702S'. J INDICATE NORTH ARROW • Wisconsin Department of Commerce Safety and Buildings Division PRIVATE SEWAGE SYSTEM County: INSPECTION REPORT St. Croix GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)1. 353224 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: SIo ar Larry & Peggy I Town of Star Prairie — CST BM Elev.:- ( Insp. BM Elev.: B Description: Parcel Tax No.: Z P - CSi r,ow _ 038 - 1088 -90 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic l ` S ? 0rD Benchmark 3 • I N Ip3•l Dosing DU Alt. BM tl k; 0 1 q 4.3 !' Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake q oss Septic D r b r ..- NA Dt Bottom I b• of 3 • 9 Dosing ! ` �� ` �' 3 NA Header/ Man. w S r3 9 7.9 Aeration NA Dist. Pipe W . 6 8 Holding Bot. System (O' Its– �: �S� PUMP/ SIPHON INFORMATION Final Grade Q p ' Manufacturer D d St cover It Model Number'�� �1 TDH Lift q,`t� Friction 14. �3 Syst Loss m ead �• Forcemain Length Dia. 2 " Dist. To We SOIL AB TION SYSTEM `T,35 -} 8 © " RENCH Width Length i N f renches PIT No. Of ins Inside Dia Liquid Depth DIMENSIONS ' DIMENSION SYSTEM TO P/ L BLDG WELL LAKE/ STREAM LEACHING M' SETBACK INFORMATION Type O f CHAMBER Mod Num e System: Cam! + > b� OR UNIT ac • FIJI DISTRIBUTION SYSTEM 5 7 y &T � �, ' Header/ nifold u Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake LengthDia Length %> 118 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 I ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: 1 ( /a 91 Inspection #2: Location: 2094 Cook Drive, omerset, WI (SE1 /4, NW1 /4, Section 21 T31N -R18W) - 21.31.18.363G 1.) Alt BM Description = D Caxl 2.) Bldg sewer length= - amount of cover = Il `3 91 Plan revision required? ❑ Yes Pq No Use other side for additional information. I+ SBD -6710 (R.3197) Date Inspector's Signature Cert. No. Safety and Buildings Division Visetinsin SANITARY PERMIT APPLICATION 201 Box Washington Avenue Department of Commerce In accord with Comm 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. 9 CApt • See reverse side for instructions for completing this application State Sanitary Permit Number 35 274 [I Personal information you provide may be used for secondary purposes Check it revision to previous a piication [Privacy Law, s. 15.04 (1) (m)). State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Owner Name Property Location L — !e C-1 /4 w v4, S T 3 , N, R 1 E (or Property Owner's Mailing Address Lot Number Block Number Q CIA, State I Zip Code Phone Number Subdivision Name or CSM Number 1-5301 7Wd II. TYPE OF BUILDING* (check one) ❑ State Owned ❑ Cit Nearest Road Public C 1 or 2 Family Dwelling - No. of bedrooms O village ..�_ .Town OF ,k Ill. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1. '? I� IQ . 3 b-'�P G 1 ❑ Apartment/ Condo 103 ,P — /0 0 0 470 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, ❑ 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 _ r 43 ❑ Vault Privy 14 E] System -In -Fill ��> X 5� 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 � S r 8 Feet Feet Cap acity VII TANK in Ca gallo s Total # of Prefab. Site Fiber- Plastic Exper. INFORMATION Gallons Tanks Manufacturer Name Concrete Con Steel glass App. New Existin strutted Tanks Tanks Septic Tank or Holding Tank I WO Q4V ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber 1960 1 1 A " I dj6 I ❑ 1 ❑ 1 ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plu er Signature: (No Stamps M No.: Business Phone Number: h9v 1.5—S — e 4: Plumber's Address (Street, City, State, Zip Code): 6 , - oz s IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ❑ Surcharge Fee) Eess Issuing gent Signature (No Stamps) e WApproved Owner Given initial . Adverse Determination 4j9NDITIONS OF r RO�VAL / REAS S F R DIS RPROVA� (� v� �l�j J� SBD -6398 (R. 4/99) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber } i I i I i -G ,a X02 - - i Sy' E I "y'Gw -Bo© GG oc ; I I t Z - — - - -- - -- - �xc��S , k ; D&uc _ j 1 f 'Wisconsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page of Bureau of Integrated Services in accordance with s. 1,1. TFj$ W, is. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan mu ounty include, but not limited to: vertical and horizontal reference point (BM),,birection anc ery / percent slope, scale or dimensions, north arrow, and location and distance to nearest road. " `' Parcel I.D. # APPLICANT INFORMATION - Please print all information, Mv Wed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) 1 !/ �S Property Owner �i ` Property Location" ,,/ l &n / 3 D Cv►o" Govt. L ©t, > / ,0/4,S 21 T 31 , N , R Property Owner's Mailing Address //�� Lot # ? #' Subd. Name or CSM# �d' Coo i'Jrl't/e City State Zip Code Phone Number ty El villa e � Town Nearest Road ❑ city e -P S?/v� s' (�/S�) a y6 - �y.To ❑ New Construction Use: gResidential / Number of bedrooms Addition to existing building K Replacement �� [__1 Public or commercial - Describe: Code derived daily flow T,-G7 and Recommended design loading rate 1 bed, gpd /ft2 4 trench, gpd/ft Absorption area required . bed, ft � ft2 Maximum design loading rate bed, gpd /ft trench, gpd /ft Recommended infiltration surface elevation(s) / ft (as referred to site plan benchmark) Additional design /site considerations Parent material Flood plain elevation, if applicable A/* ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system ®S ❑ U Xf S ❑ U ®'S ❑ U Si S ❑ U 0 YU ❑ s ®'() SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench D � D ee.�l�..� "--- -'_' � �-F' �� Zvi �' � �' • ,s' Ground 3 �_ 0 d C OS ® C S `- • 7 levpt��t •— / �y Depth to limiting 36 •`�� Z ; factor `'Yin. Remarks: Boring # 0'1/ -0 Nve V11 Ground 7' y 10 er elle l vim' - �"• Depth to limiting factor in. Remarks: CST Na a (Please Print) Signature Telephone No. L" Lon S Address Date CST Number Ili 11 & 44 ®O,t - a.? �d SOIL DESCRIPTION REPORT PROPERTY OWNER Page of PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Ground elev ---- - Depth to Z limiting � 5 Y 4 factor 'rM in. Remarks: Boring # Ground elev. ft. 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 # Ground elev. ft. Depth to limiting factor in. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBD -8330 (R. 07/96) : I I I : I I � , 1 -1 i 1 Oil l - b i i i I I Q` I I f i i I i i : I I 7,_. _ c r Z 7 d / I ._ _. �..tl►,' % J�✓ �,'n�e i,7CJ6 [.t' 6 e�✓ 6/'t�' 4 c' s-yQ PAGE OF ---- PUMP CHAMBER CROSS SECTIOW AND SPECIFiCATIOWS V T CAP 4"C,I. VENT PIPE WCATHER PROOF APPROVED L.00KIM& JtIMMOM BOX MANHOLE COVER �7 pol vaart nnnx, It I MILJ. I 41hio 1W UK F - RLS'H I AIR INTAKE I GRADE i 4 Aim. J � B. Alm COWDUIT �" - -- 10 "MIN. PROVIDE IMLET AIRTIGHT $[At. I 1 I APPROVED JOiN I APPROVED JOIN T A 1 I I W /C.T. PIPE W /C.z. PIPE I II EXTEUDINb 3' EXTENDILIG 3' ( ONTO SOLID WIL OUTO 50WO *OI S ij 10 I ( OW C I LLEV. FL PUMP ---�- __J r OFF D COUCKETE. BLOCK I R15ER EXIT PLRMITTED ONLY IF TAWK MANUFACTURCR HAS SUCH APPROVAL. EppIN` SEPTIC SPECIFICATIOKIS f L� 0056 /�S NUMBER OF DOSES: � .._1- --- PER DAU TA►� K MANUFACTURER:...LAIL _ TAWK 51ZE: - --&Q- - GALLOWS DOSE VOLUME ALCM MAmUFACTURER: / ,� INCLUDINV DACK /LOW: �---- GAttONS MODEL WUMBER: CAPACITIES A= 17 - INCHES OIL ?71y WALLOWS SWITCH TUPIL: Z IN CHES OR ..Z. G+ LLOIJS PUMP MAID UFACTURCR: ZdELc.4 f2 G• CO WCHES OR 1 i l GALLOIJS MODEL. MUMOCR: 9B D / 1- INCHES OR 16.Z GALLOIJG SWITCH TUPE: aGj NOrE: PUMP A ALARM ARE TO OC MIIJIMUM DISCHARGE RATE... T GPM INSTALLED Oki SEPARATI: CIRCUITS VERTICAL. DIFFERENCE OETWEEN PUMP OFF ALID..DISTRIBUTIOU PIPE.. L � - FEET t MINIMUM NETWORK SUPPLY PKE$SURE .. .. �-5- FEET ♦ FEET OF FORCE MAIN X � a2L F Yuorr.FKICTIOU FACTOR.. FEET -- TOTAL OtiWAMIC HLAD = ga.Z& FEET /NSiOF 46A• 1, IAITERLIAL. DIMLI.JSIOW� OF TAWK: QTR'-- -f=-•- ;WIDTH ---- riL.IQUIO DEPTH - dg,2 /7Y1 SIGtJED: � L. iCElaSE IJUM9l =R: - DATE:.LL_1Z1/ - fo /a/ Dynamic Nead /Capoe! /y SEWAGEMASTE PUMPS GRINDER PUMPS 0 mom No M No No 11 N mom I N ONEu AGRICULTURE PUMPS 0 M EN SEWAGE & DEWATERING PUMPS Emil mite 1l,0. Ain .,�5_WIN, Sig , mom EZ IBM owl M ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer _� R AA(4 Mailing Address oo X Property Address c5O 12 S re— (Verification required from Planning Department for new construction) City/State Parcel Identification Number O 1? IMF 00 —OUd LEGAL DESCRIPTION Property Location 5�e '/4, A W_ '/4, Sec. T 3 / N -R_,�S _W, Town of 57 Subdi vision Lot # Certified Survey Map # , Volume , Page # Warranty Deed # 5) ,8 7YL , Volume — 10 &5� , Page # Spec house ❑ yes J9 no Lot lines identifiable 9 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 masterplumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal system e. is is 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. Si0N M,QP APPLIC SI w ` ` A� OWNER CERTIFICATION e I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am owner (s) ) the owne ( s ) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. 7" � 11 . 1 - 12 ./ qq OPUC * * * * ** 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 ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT Tnil 11'I'TT,TZA'T'TON (IF AN RXIST'TN(. r.RPT'T(' 'DANK This is to certify that I have inspected the septic tank presently serving the 4 A/! residence located at: 1/4, _ 1/4, Sec. �_ , T_3j N R -11d_ W, Town of Sad P - MA &e- Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced Did flow back occur from absorption system? Yes No (if no, skip next line) Approximate volume or length of time: gallons minutes Capacity: /000 Construction: Prefab Concrete k' Steel Other Manufacurer (if known): Age f Tank ( if known) : o 2O�riCs. �Qdf/AOz l/ (S gnature) (Name) Please Print (Title) (License Number) //- /0 (Date) Form to be completed by licensed plumber (x.145.06, Wisconsin Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative Code) Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank to the best of my knowledge will conform to the requirements of ILHR -83, Wis. Adm. Code (except for Inspection ope ��//7-7- ing over outlet baffle). Name /V.40rN � S ignature `' P MPR z- zz 5/88 r -• THIS srAu rsssnvso ro" Issco "orna DATA DpcuMENT No. WARRANTY DEEC STATE BAR OF WISCONSIN FORM 2-1982 518356 2 --- ---- -- Larry E. DuBois and Jan - ice M.. DuBoi -s, -, husband t�ec•drtxRo.yaf and...wi f e t _ ..._._....... ......... . .. . JUN 2 8 199' 12:1 P. , . . - • C.... t 5 � O ,•i conve s and warrants to _- ------ Larry -. Slogar. and. Peggy..- t -;,+ ,_..✓ -.��_ S .ogar,._husband..and_ wife,.- - 4 ` I_ ...................... .... .. _._.... -.._ j� �i i j. i .. ...... . . .. .... .. ........ .. ..... .. . . .. .. - -.... - -. -. ... - - - - - -• - -- -- i - - -- St. Croix -_ , - - --�, the following described real estate in ......... . .. . . __-- -_ - -_- County, ` g d - -- ._ —_ - = - - -- - - - -- i State of Wisconsin: Tax Parcel No- ------------------------------ ! I 'I 1) West 1032.5 feet of East 1866.5 feet of North 208.5 feet of the S1 /2 of NW1 /4 of Section 21; Township 31 North, Range 18 West y EXCEPT Ez,st 178.49 feet thereof and EXCEPT part to Gary L. and 1. Nancy Jean Cook in Vol. "635 ", page 434. 2) Part of the S1 /2 of NW1 /4 of Section 21, Township 31 North, I1 Range 18 West described as follows: Commencing at the NW corner ;! of said Section 21; thence S00 "W along the West line of the NW1 /4, 1316.0 feet to the NW corner of the SW1 /4 of NW1 /4 of said ! x Section 21; thence S89 along the North line of the SW1 /4 of NW1 /4, 1206.78 feet; thence SO1°24 208.5 feet to the point of beginning; thence S01 0 24 1 58 "W 290.58 feet; thence �I S89 0 17 1 52 "E 436.4 feet; thence N01 290.58 feet; thence N89 0 17 1 52 "W 436.4 feet to the point of beginning. L F� I This ... . ....... . .......... homestead proirerty. (is) (IiXii��X Exception to Warranties: Easements, restrictions and rights -of -way !` of record, if any. II Dated this -. _._-----...i"..... day o , 19. ` _ June 119-94. �I I L \�!t'���Y d I� (SEAL) �., ( ----- . - - - -- arry - E., . Du . o c� ....... .. .........(SEAL) _.. 1w \- de _(SEAL► nice M. DuBois .. ...... ............ -- -- ------- - - - - -- AUTHBNTICATION ACKNOWLEDGMENT Signature(s) . - Larry E . DuBois STATE OF WISCONSIN . ...................... DuBois j as. -- -�a.•_�.---...--- -•- - -- --• - ---...._--•-- -• County authenticated this ...'..day of......Jun _- _ -__._. 19. 94 Parsowrhy .arnc before -nc th r - - - - . - _ -daY of - --- --- ------- --- ----- --- -- - - - -- 19 ........ the above named .......................... .1 taxvw.- ...................... a Kristina 0gI and - _••- •_ ________ ____ _ __ TITLE: MEMBER STATE BAR OF WISCONSIN ................. (If not.......... ............................................. --- -- --- •- - - - - - - ._.- ................... - ---• ............... ------­-- by j 706.06, Wis. Stats.) to me known to be the person ------------ who executed the foregoing instrument and acknowledge the same. j THIS INSTRUMENT WAS DRAFTED BY - ••••- •--- •Kristina Ogland - -- _. . -- - - ._....---- -------- . ...... . . . . .. __.... -- -- - - - -- ..... . ----• .... ..........•_.... Attorney ... at _..-... Law • - w.. .•-- •--......••- _..- ........... Notary Public - --- -- -- --- -- . .. Count., Wis. I (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration are not necessary.) date: ..... - -- --- - - -- - - ---- --- --- ------ - -• 19 ....... .) ;I j ,i �Namd of Dersone sitaiaQ iq asp Capacity should be typed or printed below their signatur --= _ ----_— r WARRANTY DEED STATE OF WISCONSIN Wisconsin Legal Blank Co.. Inc li FORM Alp. 2 — 1992 Milwaukee. Wisconsin