HomeMy WebLinkAbout040-1234-90-000
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ST. CROIX COUNTY ZONING DEPARTMEN ~p
AS BUILT SANITARY REPORT
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Owner
Property Address < r • " I
City/State 3-GF~ 1, a~~~
sT cPvlx
CCUNTY
Legal Description: ZONINGOFTICE
;
Lot -F 1'~`Block Subdivis-on/CSM #
'/a /f~ 2 '/4, Sec. N;-Rji-VOW, Town of PIN #
SEPTIC TANK DOSE CHA ER HOLDING TANK INFORMATION:
Tank manufacturer Size ST/PGI~/ Setback from: House WellA o 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: ~vG Width Length Number of Trenches
Setback from: House ~ 7 Well ~0 Vent to fresh air intake r~2
Cyr`//
ELEVATIONS:
Description of benchmark ,2,r 77o Elevation
Description of alternate benchmark t Elevation
Building Sewer -Gf ST/HT Inlet f -40c ST Outlet ,95 . PC Inlet
PC Bottom Header/Manifold Top of ST/PC Manhole Cover
Distribution Lines
tt Q
Bottom of System O~ f O l O 7v'~
o6p
Final Grade ( )
I
~VState plan number
Date of installation / / ermit number ~
Plumber's signature License number i,- 3'02-7 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
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INDICATE NORTH ARROW
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Wisconsiri, Department of Commerce
PRIVATE SEWAGE SYSTEM County:
Safety and Buildings Division INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: ST. CR IX
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)J. 338896
Permit Holder's Name: ❑ City ❑ Village N Town of: State Plan ID No.:
HOLLAND, DAVID TROY
CST BM Elev--- Insp. BM Elev.: BM Description: Parcel Tax No.:
O ~ 5 040-1234-90
=
TANK INFORMATION ELEVATION DATA A9900108
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic S Z ~O Benchmark 1,23 1003 ~O G
Do ing BM d, 5 9 61_
Aeration Bldg. Sewer j; Q FZ
Holding t Ht Inlet 0 7-71 TANK SETBACK INFORMATION &Ht Outlet qf,~al
TANK TO P/ L WELL BLDG. V t ke ROAD D et
Septic i N NA Dt M
Do n Header / Man. O
Aeration NA Dist. Pipe S/ - -s i-
3
Holding--- Bot. System f I 1b. Z1.
Z
PUMP/ SIPHON INFORMATION Final Grade C Z
anufacturer and A-Lz
04
Model u GP
TDH Li Friction S stem TDH
F cemain Length Dia. Dist-To Well
SOIL AB RPTION SYSTEM
17,' f s
BED / Width Len th No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS S r l DIMENSIONS
SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: Y
INFORMATION Type O CHAMBER Mo el Num er:
System: v p OR UNIT
DISTRIBUTION SYSTEM
Header /Manifold Distribution Pipe(s) r x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length ~.S Dia. -AM Spacing N~ A Q
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.)
LOCATIONZ TROY 3.28.19,NE,NW 551 GILBERT ROAD
~ bp el ter- ~ sy sfti•. W,,5 ski 4ee/ -/a tic E. s f &,V st Trenc4 4v sie-v/,
w~11 Wf 4 41"41 lie's eve, BI lag
Plan revision required? ❑ Yes ❑ No
Use other side for additional information. q rr`
SBD-6710 (R.3/97) Date Inspector nature Cert No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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Safety and Buildings Division
SANITARY PERMIT APPLICATION 201 W. Washington Avenue
Wisconsin P O Box 7302
Department of Commerce In accord with ILHR 33.05, Wis. Adm. Code Madison, WI 53707-7302
• Attach complete plans (to the county copy only) for the system, on paper not less County fJ
than 81/2 x 11 inches in size.
• See reverse side for instructions for completing this application State Sanitary Permit Number//
Personal information you provide may be used for seconds ~ b
Y Y ry purposes ❑ 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 Owner Nam Property Location
/4t. t! 114A1,Jl14, S 3 T,2 if , N, R I E (or
Propert Owner's Mailing Address Lot Number Bk r,Number
7 4. yJ
42 Ci , Stat Zi Code Phone Number Subdivision ame or CSM Number
BEd 16 (1 ) Q/
11. TYPE F BUILDING: (check one) ❑ State Owned o it Nearest Road
Public J?L1 or 2 Family Dwelling -No. of bedrooms ❑ vtl~ag of /`G7
111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) J. 1 ❑ Apartment/ Condo -12 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.ew 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
Syrstem-_______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 410 Holding Tank
12~gSeepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 31' 6 5 . 43 C] Vault P 'vy
14 E] System-In-FiII .e 3 x /
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
X/ Re uired (sq. ft.) Pro osed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevati n
6/3 32 Feet ~ Feet
VII. TANK Capacity gallons Total # of Prefab. Site Fiber- Exper.
INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existin strutted
Tanks Tanks
eptic Tank ~ldiag Farrlr~ ,x 7z -W 7 ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print)Plumb ignature: (N amps) MP/MPRSW No.: Business Phone Number:
r e2dJ Z Z
PI m tier's Address (Street, City, /state, Zip Code):
IX. OUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing ent Signature (No Stamps)
A roved Surcharge fee)
pp ❑ Owner Given initial ~oo(
Adverse Determination I00
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD- 6398 (R.11/97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
I~
INSTRUCTIONS ,
1. A sanitary permit is valid for two (2) years.
•2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD-6399) to be submitted to the
county prior to installation
5. Onse sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever
necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of
i
Wisconsin, Safety and Buildings Division, 608-266-3151.
To be complete and accurate this sanitary permit application must include:
1. Property owner's name and_ mailing address. Provide the legal description and parcel tax number(s) of where the
system is to be installed.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is public, check all appropriate boxes that apply.
IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested for numbers 1 through 7.
VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and
manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and
holding tanks for this system. Check experimental approval only if tanks received experimental product approval from
DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.),
address and phone number. Plumber must sign application form.
IX. County / Department Use Only.>
X. County/ Department Use Only.
Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must
include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic
tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon
tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served;
B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume;
elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section
of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information.
i
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
PLOT PLAN
PROJECT David Holland ADDRESS 227 Elm St. Hudson Wi 54016
NE 1/4 NW 1/4s 3 /T 28 N/R 19 W TOWN Troy COUNTY ST. CROIX
MPRS Byron Bird Jr. 220527 DATE4/29/99 BEDROOM 4
CONVENTIONAL X04C IN-GROUN PRESSURE CO VENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1200 Gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .8 ABSORPTION AREA 763 # of chambers 24
BENCHMARK V.R.P. Top of 1" Steel Pipe ASSUME ELEVATION 100'
❑ BOREHOLE O WELL *H.R.P. Same as Benchmark
Vent
SYSTEM ELEVATION 95.32
Sidewinder High
Capacity Leaching
Chamber with 31.8
ft^2 per chamb
er
ALong
34 Grade at System Elevation
Tower
Road
Vents
B-4 B-1
56'
1°Io 8'
Slope B-3 2-3'X 77'
Trenches with 6'
Spacing
80' 53'
B-5 -2
S'
Property 28' 10'
Line 40' 21' S.M.
T
22'
10
380' Pro 4
Garage Bedroom
House
325' Property Line
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3
,J atr and.Human Relations
Ur~ision of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but St. Croix
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road. P.,, , .',spending
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION.. p BY DATE
PROPERTY OWNER: PRO LOCATION
Richard Stout GO t.;E3+f NE 1/4 SW 1/4,S 3~•-'T 28 N,R 19 W
PROPERTY OWNER':S MAILING ADDRESS LOT " : BLOCk # 9011D. NA,% OR
1353 Awatukee Trl. 38 na untr
CITY, STATE ZIP CODE PHONE NUMBER ❑CI VILLAGE,, EAREST ROAD
Hudson, WI. 54016 (715 549-6731 T Tower Rd.
[x] New Construction Use [ Residential / Number of bedrooms R _AdditrbrOcr existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow 450 gpd Recommended design loading rate .7 bed, gpd/0 .8 trench, gpd/ft2
Absorption area required 643 bed, ft2 563 trench, ft2 Maximum design loading rate • 7 bed, gpd1ft2 - 8 trench, gpd/ft2
Recommended infiltration surface elevation(s) 95.32 ft (as referred to site plan benchmark)
Additional design / site considerations na
Parent material outwash Flood plain elevation, if applicable na ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U=Unsuitable fors stem RIS ❑U ®S ❑U ®S ❑U ®S ❑U ®S ❑U ❑S ZU
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench
i-4
wv 1 1 0-9 10 r2 2 none 1 2msbk mfr gw if .5 .6
4}}
~=`J" 2 9-20 10yr4/4 none sicl lfsbk mfr gw if .2 .3
Ground 3 20-38 7.5 r4/4 none sl 2csbk mvfr na .5 .6
elev.
98.57 ft. 4 38-82 7.5 r4/6 none s osg mvfr na na .7 .8
Depth to
limiting
factor ab
Remarks:
Boring #
1 0;'-10 10 r2/2 none 1 2msbk mfr if . 5 ` .6
.2.3
.3
2 2 10-21 10yr4/4 none sicl lfsbk mfr gw if
Ift
Ground 3 21-36 10yr4/6 none sl 2mgr. mvfr gw na .5.6
elev. 4 36-85 7.5yr4/6 none s osg ml na na .7:1.8
99.33 ft.
Depth to
limiting
factor
+85"
a
Remarks:
CST Name:-Please Print Gary L. Steel Phone: 715-246-6200
Address: 15,54 200th. e., New Richmond, WI. 54017 m02298
Signature: Date: CST Number:
r ~
PROPERTyOWNER Richard Stout SOIL DESCRIPTION REPORT Page 2 of 3
PARCEL I.D. # Fending Lot #38
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench
1 0-14 10 r2/2 none 1 2msbk mfr lf. .5 .6
3
2 14-23 10yr4/4 none sicl lfsbk mfr gw if .2 .3
Ground 3 23-38 7.5 r4/4 none s1 2c r mfr cfw na .5 .6
elev.
99.Q6 4 38-84 7.5 r4 6 none s os mfr na na .7 .8
Depth to
limiting
factor S 'S
+84"
9Y o. ~
Remarks:
Boring #
1 0-15 10yr2/2 none 1 2msbk mfr if
.5 .6
4 2 15-24 10 r4/4 none sici lfsbk mfr C1w if .2 .3
Ground 3 24-34 7.5 r4/4 none sl 2c r mvfr na .5 .6
elev.
98.32ft 4 34-82 7.5 r4 6 none s os ml na na .7 .8
.
Depth to
limiting
factor
+82"
Remarks:
Boring #
•`.4 h 1 0-10 10yr2/2 none 1 2msbk mfr if .5 .6
2 10-24 10yr4/4 none sicl lfsbk mfr if .2 .3
3 24-35 7.5yr4/4 none sl lcsbk mvfr 9w na .4 .5
Ground
j elev. 4 135-84 7.5 r4/6 none s os ml na na .7 .8
98.56 ft.
Depth to
limiting
factor
+84"
i
Remarks:
Boring #
I
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(R.05/92)
STEEL'S SOIL SERVICE
Gary L. Steel 1554 200th Ave.
CSTM2298 Richar Stout New Richmond, WI 54017
MPRSW-3254 4Sw4 S3-T28N-R19W (715) 246-6200
town of Troy
lot #38-Country Wood
N
1"=40'
BM.= top of 1" el pipe el. 100'
3
Z
Zi, zzv1C Y"
325'
Gary L. Steel
4-23-96
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer Qavi d 0, oLv-4 Sa,i M . 40 ! 0'nA
Mailing Address a s 1. nom, T P u d s o h SK o t 6
55.1 `
Property Address - +vfi oh , C
(Verification required from Planning De artment for new construction)
City/State Rt3Loh., 01: Parcel Identification Number OY 0 - I a3 'q - ~0 - 000
LEGAL DESCRIPTION 366
Property Location L '/4, Sec. , T4X N-RZW, Town of firpu
Subdivision Co,o n t,, horse` , Lot # 38
Certified Survey Map # Volume , Page #
Warranty Deed # Volume Page #
Spec house ❑ yes ;Z no Lot lines identifiable X 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.
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 a three ear xpiration date.
q
ATURE APPLICANT DATE l
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 prqerty ri ed ove, by virtue of a warranty deed recorded in Register of Deeds Office.
SIGNATUICE 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
;r31E BAR t+t A1,( ~+ti,t` t t:,1 1gH2 ti CIA 4<30 28
N%ARR.kNI1' 1)1 F1, 144M+ EEN H. WALSH
RFG"SIFR OF DEF":"
DO-~UMEN'Nv "ROIX CO., WI
4E E'VED FOR KL391)
RICHARD Q- S_TQUT
01-n~-19y9 9:90 Alf
,iARRwtiiY DEED
CEk! COPY FEE:
wmctisanu D~ HQLIPND and JAN M. `:UPY FEE:
HDLLANND,_huslaarid and wife 'R'WJER FEE: 107.70
KC04D.NG FEE: 10.00
:he G.II.wng d1 rx•u !t-al c>tati i; St . CLO1 K
,;.ttr A 'Ah.onsrn
Lot 38, Flat of Countrv Wood First Addition,
Town of Troy, St.. Croix Co., WI.
740-1234-90-000
.'ase:Tltrllts, 1- StrJ.': 15, _ 3'y and :OVena 1
is
of record.
10th December
_ chard Stout
1~[IIFVCI(:AIII)\ 1( nti'l~\~i f I)(Att ~r
L :3 1.X
_ 317th
.:°ce..,te 9.3
..t
Janet P. Stout C~.._
IJ53 Awatukee Tr.
IIUdSOIL, Wi. 54016
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8, 39 9 40 REQUIRE A 21" DIAMETER
T WHEN CONTRUCTING DRIVES
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L ) I
- . ~ - 38
2
~a~? y
Nd, 2.71 AC.
o
118,002 SO. FT.
\9 A& Z 39 ~N-
.ol - yN 2.19 AC.
a'o 95,519 SO. FT. 40 317.81'
0 192.81'
2,66 AC. »
S87 38 55 E
115,884 SQ. FT. 125.00,
\-MATCH L IN
E
ry X00 SEE SHEET 1
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a!V 1 LJ
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140 ti ON
N
W
W
0 to N
39 Al W 0
A uw " m
'f', SOS jr N z
Z a
0 2 N U. W
43w 0m
m o
N 4w
2.01 AC. ~s J ?
87,760 SQ. FT. ^C) N
,~.~5 03 W (O M