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HomeMy WebLinkAbout038-1183-60-000 Wisconsin Department of Commerce Safety and-Buildings Division PRIVATE SEWAGE SYSTEM Count y INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit IX Personal information you provice may be used for secondary purposes [Privacy Law s.15.04 (1)(m)]. 3445444 4 Perm H I r' Nam El e City ❑ Villa Town of: State Plan ID No.: HE1�I��G, J6HN STAR � IRIE �--� CST BM Elev.; Insp. BM Elev.: BM Description: I Parcel Tax No.: / _¢ 038- 1183 -60 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic (N (�,,� - Benchmark Y. ( 00 ''D f Dosing All &A4 0. 1 2 0 10 3-3 3 Aerati n Bldg. Sewer , g 2 • Z Holding St/ Ht Inlet ?, Q1J �, 4.3 TANK SETBACK INFORMATION St / Ht Outlet 1 S_ TANK TO P/ L WELL BLDG. Vent to ROAD D Air Intake Septic �(05� NA at Bottom Dosing NA Header /Man. t 30 , (3 `� / ,J Aeration NA Dist. Pipe s I 'f2. , t t Holding Bot. System 9. 3° U., Z PUMP/ SIPHON INFORMATION Final Grade x;60 , g3 Manufacturer errand j t3 , 3p Mode ber GPM TDH I Lift S stem TDH Ft Force Length Dia. Dist. To we SOIL RPTION SYSTEM NCH Width Len th / N .O Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMEN i N DIMENSION SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK CHAMBER INFORMATION Type Of r model Number: System: S6 3 OR UNIT DISTRIBUTION SYSTEM Header / Manifold f , Distribution Pipe(s)t 4 x Hole Size x Hole Spacing Vent To Air Intake Length �A•L Dia- `'t Length Dia. Spacing >9a SOIL 68W E k 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 El Yes E] No E] Yes E] No COMMENTS (Include code discrepancies, persons present, etc.) tt LOCATION: STAR PRAIRIE 21.31.19.923,SE,NW 2097 COOK DRIVE f w r 2 , II Z �� A S y�w•er �- C� - .2 Plan revision required? ❑ Yes No Use other side for additional infor ation. 5- 1 4 o F 7 Fi 5 W SBD -6710 (8.3/97) Date Inspector's Signature Cert. No. ST. CROIX COUNTY ZONING DEPARTMEN AS BUILT SANITARY REPORT - ` '; Owner Property Address r. Ad r City /State Legal Description: Lot Block Subdivision/CSM # , 3'Gl ' /4, ' /a, Sec. al ,TAN -RAW, Town of 5 'P # yy� rr. e SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION Tank manufacturer • Size ST/PC/ / °'/ _ Setback from: ou 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: .v Width S Length i e /-I Number of Trenches ,�Z_ Setback from: House . :k Well o' =r P/L 3- -r-- Vent to fresh air intake ELEVATIONS Description of benchmark a ': j'e Elevation Description of alternate benchmark 1-5a,pd r,' e i �.J Elevation Building Sewer ST/HT Inlet T 7- ST Outlet :i 7 PC Inlet PC Bottom Header/Manifold Top of ST/PC Manhole Cover 3d Distribution Lines () ll () ( ) Bottom of System () () ( ) Final Grade Date of installation /a l f7 Permit number 3q 4 ( - State plan number Plumber's signature 4 jl - �/1/ License number DQT MD Date f 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 Loa ij- y Q a� i5 � O e � � INDICATE NORTH ARROW Safety and Buildings Division SANITARY PERMIT APPLICATION 2 1 Washington Avenue Visconsin Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Box I P 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. -Vrrc 1/,x' • See reverse side for instructions for completing this application State Sani Number Personal information you provide may be used for secondary purposes ❑ Chick it 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 -- Property Owner Name Property Location ,/ f -y 1 / 4 1 /4 , S a/ T 3 , N, R/S E ( o r t=�`" Property Owner's Mailing Address Lot Number Block Number 94 C;Pw cc City, State Zip Code Phone Number Subdivision Name or CSM Number II. TYPE BUILDING: (check one) C] State Owned ,� t la Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms ❑ v i lge Town OF 42 III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo B F— 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, 5LNew 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 JR Seepage Trench 22 ❑ In- Ground Pressure 42 ❑Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill 5x57 r C 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 �, o 3 7Q Ater Feet 9X D Feet Capacit VII TANK in Ca allo s g Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existing structed Tanks Tanks Septic Tank or Holding Tank Y ZM h ( e ❑ ❑ ❑ 1 ❑ ❑ Lift Pump Tank /Siphon Chamber I 1 ❑ 1 ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite se ge system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: o tamps) MP/ PRSW No.: Business Phone Number: I ll, a 1W s A, t1,0-e,V o 17e 5 - 3ac Plumber's Address (Street, City, - State, Zip Code): IX. COUNTY/ DEPARTME USE ONLY ❑ Disapproved San' ary Permit Fee (Includes Groundwater D ate Issued Issuing Agent Signature (No Stamps) /Approved ❑ Surcharge Fee) Owner Given Initial �' 1 1/7Ig ar Adverse Determination IF X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.11197) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber u 71/ s 3 !o s um s� h ' �c a Wisconiiiiij Department of Commerce SOIL AND SITE EVALUATION DiAsion offafety and Buildings -- Page of S� Bureau of Integrated Services in accor nce with s: ICH13 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 X11`in6hes i r lan must County include, but not limited to: vertical and horizontal refe�ence`point (BM and percent slope, scale or dimensions, north arrow, and of anon and distance to nearest rpa�f'' parcel I.D. # � APPLICANT INFORMATION - Please pri�� inforrlhAlffi Rp'X U' Reviewed by Date Personal information you provide may be used for secondary p rpo (F 15. 04(l) Property ner ocation IG . of 114 t /4,S T N,R je F(ore1l Property Owners Mailing Address Lot # Block# I Subd. Name or SM# - z I zzl�ed �j � z"j Statq Zip Code Phone Number ❑ City [:1 Villa a (� Town Nearest Road 1 ( I Jam J .III IN New Construction Use: JZ Residential / Number of bedrooms Addition to existing building Replacement ❑ Public or commercial - Describe: Code derived daily flow gpd Recommended design loading rate bad, gpd/ft trench, gpd/ft Absorption area required bed, ft2 5:2�;3 _ trench, ft 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 ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = unsuitable for system Egs ❑ u E�S ❑ u C� S El I M S ❑ u I ' EIS Eq u EIS CJ u SOIL DESCRIPTION REPORT Horizon Depth Dominant Color Mottles Structure GPD /tt g in. Munsell Ou. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed , Trench o ......... ° h r s / Ground 3 Z ell e � lev. ` 'a Li ^ , Depth to limiting factor Remarks: Boring # / t Jf 3 - z Ground elev. Depth to limiting factor ? in. Remarks: CST Name ease Pr' t) � ZS ignat Telephone No. Address Date CST Number I Gob _ -AM�, � V • • � � �i7��'T.S7S1�d� � • 1 c • r Dorrdnant Color • C C olor ® ® ® ®® - • r • •. •• :. • M,AM © MA �i : --�9N� r /,�>itJTZ S.�'�i' �11GJ �x 'S�'�J' 7'31/ ✓�°�cQ� ��G� �af',.� ..11 s� 9�7 d �5 -- ' 18� /o! ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer John N- Heintz / P. C. Collova Builders, Inc. Mailing Address 9 05 County Road H, New Richmond, WI 54017 Property Address 2097 Cook Drive, Somerset, WI 54025 (Verification required from Planning Department for new construction) City/State S t a r Prairie, W1 Parcel Identification Number O 3? LEGAL DESCRIPTION Property Location SE %,, NW 1 /,, See. 21 , ' r 31 N -R 18 W, Town of Star Prairie. Subdivision Circle C L # 6 Certified Survey Map # . Volume . Page # Warranty Deed # 5 5 0 5 21 Volume 1202 . Page # 234 Spec house ® yes O no Lot lines identifiable (9 yes O 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, restrictedplumberor 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 Commence 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. X Y ATURE OF APPLI 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 property described above, by virtue of a warranty deed recorded in Register of Deeds Office. . ° X &/7-3/4 NATURE OF AP PL 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 State liar of Wisconsin Form 2 — 1982 j0 J WARRANTY DEED DOCUMENT NO. F��G.�TE� c�� L., rIC VOL PAGE ST. r1nc,xCo.,W1 a f ...:': r Pa%^M i James Barnett, a married man •0 CT 7 1196 at 10:00 A. M ;. a. Deaft John N. Heintz and Patricia J. f d com�cys and warrants t° _ -- - - - -- - --.._._..----- . -- -- - - -- -__ _ -- - - - - - - -- '' ;. Heintz, husband_ and wif as survi vorship marital property -- .. - - - -- - - - - - -- - -- - - -- THIS SPACE nESERVED FOR RECORDING DATA NAME AND RETURN ADDRESS . --------- ___. -- ----- _ -__ -- -� REINSTRA & VAN DYK, S.C. 201 South Knowles Avenue ! the following described real estate in St. Croix New Richmond, Wisconsin 54017 Countv. State of Wisconsin: 038 - 1088. -30; 038 - 1088- 80; (Parcel Identification Number) 038 1089 - 30 and 038 - 1089 -30 -110 SEE ATTACHED SHEET IRAN §FFR is This --is homestead property. (is) (is not) j Exception to warranties: Subject to all easements, restrictions and covenants of record. Dated this 2 nd __ ------ __ —._. day of __— ____.- -- October 19 96 5 � _._. (SEAL) _ _— ... (SEAL) James Barnett -- - - - -- (SEAL) --- -.._.. _.... - - - (SEAL) AUTIIENTICATION ACKNOWLEDGMENT Signature(s) James Barnett STATE OF WISCONSIN ss. _. ... .. ...._ COuntY. authcn it Ic I this 2nd ll.1% of October 19 96 Personally came before me this day: of .19 the abo%e named Hendrik W. Van Dyk IIII.f: NIEKIIIFR( STAI'l: IIAR OF WISCONSIN III not. aulhorired bY §706.06, \Vis. Slats.) to me known to he the person who executed the foregoing instrument and arknowledgc the same. Ili! ; I1 WAS I)IIAI IED BY REINSTRA & VAN DYK, S.C. 201 South Knowles Avenue New Richmond, Wisconsin 54017 Notary Public Cott" (Sigimlurc• may he authenticaled or acknowledged. Boll) are not My commission is permanent. (If nut. state exp: ncrc.sarc.l n•r• • „ I I ••rr. •rronn m run r:q arih h ndJ M Icprd nr I rintrd hclua Ihcir sit nalun�. 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