HomeMy WebLinkAbout038-1167-10-000 ST. CROIX COUNTY ZONING DEPARTMENT �
AS BUILT SANITARY REPORT ; � ,{, ' s
Owner
Property Addr ss
City /State
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Legal Description: Qt -
Lot Block Subdivision/CSM # -
1 /a A6�2_ ' /a, Sec T, f N -RAW, Town of PIN #
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION:
Tank manufacturer /,o fps' Size ST/PC / / _ _ Setback from: Hous X Well ),k- P/L kf
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: I-f a Width - ength S` _ Number of Trenches
Setback from: House A�P- l Well _ / P/L Vent to fresh air intake
ELEVATIONS
Description of benchmark Elevatio
Description of alternate benchmark Elevation , ,
Building Sewer _/ /. /i ST/HT Inlet 99- ST Outlet „9-1 PC Inlet
PC Bottom Header/Manifold 97-1 Top of ST/PC Manhole Cover /,�7
Distribution Lines () 9191 () ( )
Bottom of System ezf () ( )
Final Grade O 4e �2 z O ( )
Date of installation Q ' 19912 Permit number 33,?5�4, State plan number
Plumber's signature License number �,�� f Date
Inspector
Complete plot plan �
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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
j"'t I
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Hg usK
INDICATE NORTH ARROW
(4A, b Cam
Wisconsin Department i Commerce PRIVATE SEWAGE SYSTEM y:
Count
Safety and Buildings Division INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: ST __ (7 RC IX
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 338816
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
ROESER, RONALD STAR PRAIRIE
CST BM Elev. :- Insp. BM Elev.: BM Description: Parcel Tax No.:
(70 038- 1167 -10 -000
TANK INFORMATION LEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic G ) Benchmark V. 3,ili- f 3 0�
Dosing Wii,
Aeration Bldg. Sewer �?, 2C p .
Holding S / 1+1:- IrrFet
`�.� qq. 2i
TANK SETBACK INFORMATION Q /slit a tle 9; Sj' 18.9 3
TANK TO P/ L WELL BLDG. Ventto ROAD 49t 1 mlet
Air Intake
Septic ,>b D t > NA -94 96061121111 —
Dosi ng NA Header /Man. ! q? 33
Aerat
7T — T — ZiAlk
ion NA Dist. Pipe "` �� � ��� q�. .. r � rs 5
H Ing Bot. System Aa.3/ 96106
PUMP / SIPHON INFORMATION Final Grade 9', le qg,Q?-
Manufacturer Demand 7. 1 o . 2'
Model Number GPM
TDH Lift F ' lon Syestem TDH Ft
Forcemain Length Dia. FFii Dist. To well
SO L ABSORPTION SYSTEM
ED 1'R'Emell Width f I Length t No. PIT No. Of Pits Inside Dia. Liquid Depth
EN I N 2 �i DIMENSION
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK CHAMBER
INFORMATION Type O � t � i Model Number:
System: c ow 5.2 1 >/Cm OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold „ Distribution Pipe(s) a x Hole Size x Hole Spacing Vent To Air Intake
�^- �t — �(
Length � Dia- Length J Z Dia. T 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 ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) 3 `� r �"^^ � ��✓
101
LOCATION: STAR PRAIRIE 28.31.18.802,SE,NW 1963 104TH STREET
LT W , 8 M -7 � �
Plan revision required? ❑ Yes [X No
Use other side for additional information. [ a' 1 0 3 1 00 F * Z
SBD -6710 (R.3/97) Date Inspector's Signature Cert No.
Safety and Buildings Division
SANITARY PERMIT APPLICATION 201 W. Washington Avenue
Visconsin In a P O Box 7302
Department of Commerce accord with ILHR $3.05, Wis. Adm. Code
Madison, WI 53707 -7302
• Attach complete plans (to the county copy only) for the system, on paper not less Count
than 81/2 x 11 inches in size. 1 e�2
• See reverse side for instructions for completing this application State Sanitary Permit Number
Personal information you provide may be used for secondary purposes ❑Check if revision to previous placation
(Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION
Prop" Owner Name Property Location
1/4 1 /4,S , _ T , N, R (or
Property Owner's Mailin Address Lot Number Block Numb
City ate Zip Code Phone Number Subdivision ame or M Number
° ( U e,4 E
11 . TYPEW BUILDING: (check one) ❑ State Owned i- I NearestRo d
El Public 1 or 2 Family Dwelling - No. of bedrooms �� 5 Town o ,✓
III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 2 18� pO 2
1 E] Apartment/ Condo — a
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/ Bar/ Dining
4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station /Car Wash
5 ❑ Hotel/ Motel 9 ❑ Office/Factory 13 ❑ Other: specify
IV. TYPE OF PERMIT (Check only one box on line A. Check box on line B, if applicable)
A) 1. Eg New 2 ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an
- _____ System________ System____ _________TankOnly______________ Existing System_________ Exis -- - System
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non - Pressurized Distribution Pressurized Distribution Experimental Other
11$f Seepage Bed 21 ❑ Mound 30 []Specify Type 41 []Holding Tank
12 ❑ Seepage Trench 22 ❑ In- Ground Pressure / 42 ❑ Pit Privy
13 E] Seepage Pit �C: - x SS 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
Require (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft_) (Min .A ch) Elevation
TA Feet q9 9 Feet
' Capacit y
VII. TANK in g allons Total # of Prefab. Site Fiber- Exper.
INFORMATION New Existin Gallons Tanks Manufacturer s Name Concrete st on- Steel glass Plastic App
Tank Tanks
Septic Tank or Holding Tank — S' ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ 1 ❑ 1 ❑ I ❑ 1 ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the yndersigned, assume responsibility for instal tion of th onsite sewage system shown on the attached plans.
Plum r' lame: ri Plum berj(Si9P0fy C Si ) MP /MPRSW No.: Business Phone Number:
3 /
PI umber's Address et, Ci y, State, Zip de):
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IX COUNTY/ DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued ssuin Age Signature (No Stamps)
�W Approved []Owner Given Initial / Surcharge Fee)
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD- 6398 R.I i�97 DISTRIBUTION: Original to County, One copy To: Safety 8 Buildings Division, Owner, Plumber
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Wisconsin Department of Commerce SOIL AND SITE EVALUATION j
Division of Safety and Buildings Page - �— of
Bureau of Integrated Services in accordance with Comm 83.09, Wis. Adm. Code
Attach complete site plan on paper not less than 8 1J2 x 11 inches in sizQ �I�rt ttlut. ° ' ' County
7 "
include, but not limited to: vertical and horizontal reference point (BM ',�ii;@6or and
percent slope, scale or dimensions, north arrow, and location and d' 80�t nelaresdoad. P2 el .D. #
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APPLICANT INFORMATION - Please print all info • rnaliiont, t , Revi ed by Date
Personal information you provide may be used for secondary purposes (Pri y ' w, s. 15.04 (1) / x f C
Props Owner ovation !� J
t .. xQ 6
��` ". it9wt;ko;:a04 1/4 l 1/4,S T� N,R E (ot�V
Property Owner's Mailinb Address ' Lot # Block [ Subd Name or CSM#
City fate Zip Code Phone Number Ci ty ❑ Vj ge Town Nearest Road
❑ Ci
( JAI) _ _ 2
® New Construction Use: t4 Residential / Number of bedrooms Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow - gpd Recommended design loading rate �7 bed, gpd/ft2 _ trench, gpdht
Absorption area required l 5' bed, ft -L trench, ft 2 Maximum design loading rate 7 bed, gpd/ft gpd/ft
Recommended infiltration surface elevation(s) S ft (as referred to site plan benchmark)
Additional design /site c nsiderations ' ✓ --'T'
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 ® S ❑ U E1 S ❑ U [ES ❑ U I ®S ❑ U I ❑ S �K U [:Is U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Structure GPD /ft
in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots
Bed ,Trench
'c
Ground
elev.
=ft.
Depth to
limiting
factor
in.
Remarks:
Boring #
Ground —
elev.
Depth to
limiting
factor
,�>,/QLin. Remarks:
CST Name ease P 'nt) Signature Telephone No.
ILA
Address ate CST Number
J r L
I
SOIL DESCRIPTION REPORT
PROPERTY OWNER Page of
PARCEL I.D.# f1'3 AD _
Boris # Horizon Depth Dominant Color Mottles Structure 2
Boring Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. / Sh. Bed , Trench
6
Ground - -16 J
elev
Depth to
limiting
factor
Rem \b
arks:
Boring #
-
Ground 9 —
elev.
ft.
Depth to
limiting
factor
}_in.
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /fie
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Boring # �-
S �
Ground — — 8
elev.
/
Depth to
limiting �� a
fMUMr
Remarks:
Boring #
i
Ground
elev.
ft. '
Depth to
limiting
factor
' Remarks:
SBD -8330 (R.9/98)
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OCT -09 -98 10:02 PM BELISLE EXCAVATING ?132473038+ P.01
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer Xon R6 ener
Mailing Address /S UP kt , L, P.a.
Property Address
(verification required from Planning Department for new construction)
Citylstate JF Parcel Identification Number Q? ///7-. j4 -
LEGAL DESCRIPTION
Property Location � ''h, ,d/ L '/., Sec. �_ , T —Zj - R-Ly W. Town of _54 •
Subdivision 8d ►'l feAlez , Lot #
CertiCed Survey Map # , Volume Page #
Warranty Deed # 55 31 p- , Volume _ . Page #
Spec house ❑ yes x Lot lines identiftablexyes 0 no
SYS M MAINTENANCE
Improper use and maintenance of your septic system could result in its premature failure to handle wastes, Proper ntsintenmace
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 tivtetion 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, restrictedplumber or it licensed pumper verifying that (t) the on -site wastewsterdisposal system
is in proper operating condition and/or (2) after inspection and ptttiping (if necessary), the septic tank is less than 1/3 lull 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 Deparment of Commerce and the depwtr►ent of Natural ResourcM State of Wisconsin. CeIcstion
stating that your septic system has been maintained must be compacted and returned to the St. Croix County Zoning Office within 30
days of the three year expiration date.
G
SIONATI,W F APPLIC 'T 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 ownst(s) of
the roperty described above, by virtue of a warranty deed recorded in Register of Deeds Office.
3 /l lq
_J/j W1 SIONA OP A LICANT 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
it copy of the certified survey map if reference is made in the warranty deed
I
,�rJ►A STATZ MR OF WISCONiW POEM 2 -1994
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AUT?tLN�ii Ait� T+1 ACKNOWLEDGMENT�
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