HomeMy WebLinkAbout040-1236-60-000 ST. CROIX COUNTY ZONING DEPARTME - 7 —,,, `
AS BUILT SANITARY REPORT �-�
Owner
0 t
Property Address
City /State ' s 1,9
C OON
Legal Description: \� OIy;NG OFfic
Lot Block Subdivision/CSM #
'/4 s ,L ' /4, Sec. , T-2 N -RAW, Town of
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION:
Tank manufacturer Size ST/PC Setback from: House 7 Well _:Lj 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: X o Width �— Length _ Number of Trenches
Setback from: House :: �n Well 1,- P/L Vent to fresh air intake y ��
ELEVATIONS
Description of benchmark - Elevation -—
Description of alternate benchmark ' Elevation 2L
-
Building Sewer ST/HT Inlet - 9Z,.6 I - ST Outlet PC Inlet
PC Bottom Header/Manifold OZT7 Top of ST/PC Manhole Cover 97.
Distribution Lines () 9�/, 9 S
Bottom of System
Final Grade () ,9C., 19 ( ) ( )
Date of installation / Per it �nuber State plan number
Plumber's signature License number Date
Inspector
Complete plot plan �
I 1
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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s '
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INDIC TE NORTH ARROW
1
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
j8
Br a�
INDICITE NORTH ARROW
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 La s.15.04 (1)(m)]. 33891 4
Per El TODD El City,., Town of: State Plan ID No.:
CST BBM UUrrall{{ Insp. BM Elev.: BM Description: 11'1KZ Parcel Tax No.:
d0
160 040 - 1236 -60 -000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV.
Septic dd Benchmark , y q loz.q 166
M Bldg. Sewer 3- , / Ht Inlet G, y 9` o 3
TANK SETBACK INFORMATION Ht Outlet
to
TANK TO P/ L WELL BLDG. Ve ROAD D�'hi gW-
Septic f S'O� l NA Dram
Dosi Header /Man. 32
Aeration NA Dist. Pipe y 9y QJ'
Holding Bot. System
. y`/
PUMP / SIPHON INFORMATION Final Grade ( Zr
nufacturer mand 0 p p 17 Z/ Model Number G
T Friction S stem TDH F
L oss
rcemain Length Dia. Dist. II
SOIL ABSORPTION SYSTEM
E TRENCH Wid h r Le gt r No. Of Trench? P T No. Of Pits Inside Dia. Liquid Depth
EN I N / DIME
SYSTEM TO P / L BLDG WELL LAKE/STREAM anufacturer:
IN
SETBACK CHA
INFORMATION TypeO odelNumber:
System: ,) �ig r -� s� — OR UNIT
DISTRIBUTION SYSTEM
Header /Manifold Distribution Pipe(s) �j x Hole Size x Hole Spacing Vent To Air Intake
Length 1 3 ' Dia. Length -&S Dia. / Spacing Z7Z Z Z 7 V
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.)
LOCATION: TROY 3.28.19.1192,SE,SW 538 GILBERT RD – COUNTRYWOOD LOT 55
(3) u�rt � �tf� �r� 0
Plan revision required? ❑ Yes ❑ No
Use other side for additional information. 1 /s 4 Id
SBD -6710 (R.3/97) Date Inspector's ature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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Safety and Buildings Division
20
1 W. Washi Avenue
*sconsin SANITARY PERMIT APPLICATION g
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 8 1/2 x 11 inches in size.
• See reverse side for instructions for completing this application State sanitary Permit Number
3 /
Personal information you provide may be used for secondary purposes ❑ check 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 —��
Pro er Name Property Location
1 S 7j 1 T , N, Rjg E (orb
Property O ner's Maili A ess Lot Number Block Number
City, S e Zip Cod Phone Number Subdivision me or SM Nu er
( )
P BUILDING: (check one) ❑ State Owned 11 It tNeares:R ad
p vllfage
Public EZ 1 or 2 Family Dwelling - No. of bedrooms srTown OF Z
III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(
1 ❑ Apartment/ Condo —
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. j. New 2. Q Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5, ❑ Repair of an
_System System Tank Only______________ Existing System ________ Exlsttng 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 L� Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In- Ground Pressure r r I 42 ❑ Pit Privy
b7
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. nch) Elevation
X10 il Feet Feet
acct
VII. TANK in '-Capacity Total # Of Prefab. Site Fiber- Exper_
INFORMATION g Gallons Tanks Manufacturers Name Concrete Co steel glass Plastic App
New Existin structed
Tanks Tanks
tic an — ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for ins Ilation of the onsite sewage system shown on the attached plans.
Plumbe , Na e: rin Plumb , n N` ps MP /MPRSW No -: Business Phone Number:
12, 2 / — - Z
Plu ber' Address (Street, ty, Stat
c
IX. COUNTY / DEPARTMENT USE ONLY
[I Disapproved Sanitary Permit Fee (includes Groundwater F /o sue I s Issuing A nt ign ture (No Stamps)
Surcharge Fee)
A Owner Given Initial bo Cpp roved °a S l oa
Adverse Determination �
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD- 6398 (R.11/97) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
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. Onsite 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
Wisconsin, Safety and Buildings Division, 608 - 266 -3151.
To be complete and accurate this sanitary permit application must include:
I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to be installed.
11. 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 81/2 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.
----------------------------------------------------------------------------------------------------
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.
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Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page 1 of 3
LaLv)r and Human Relations
Division 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 inrinde but r t. Croix
not limited to vertical and horizontal reference point (BM), direction and % of slope, sage or
r PARE bJ.D. #
dimensioned, north arrow, and location and distance to nearest road. f pending
pY DATE
APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION - , - REV EWED'; -\
PROPERTY OWNER: PRO�FRTY LOCATION i
Richard Stout G01IT. LOT SE 1/4 SW 14,S 3 8 N,R 19 for) W
PROPERTY OWNER':S MAILING ADDRESS LOT # ,. BLOCK # SUDP, NAME O #
1353 Awatukee Trl. nal ; CE t
CITY, STATE ZIP CODE PHONE NUMBER [ VI�LAGE P]fOWN NEAREST ROAD
Hudson, WI. 54016 (71$ 549 -6731 Tro Tower Rd.
[x] New Construction Use Residential / Number of bedrooms 3 [ ] Addition to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow 450 gpd Recommended design loading rate • 5 bed, gpd /ft •6 trench, gpd /ft
Absorption area required 900 bed, ft 750 trench, ft Maximum design loading rate • 5 bed, gpd /ft2 •6 trench, gpd /ft
Recommended infiltration surface elevation(s) 93.99 ft (as referred to site plan benchmark)
Additional design / site considerations alt. site = 91.73' system el.
Parent material pitted outwash plain Flood plain elevation, if applicable na ft
S = Suitable for system CONVENTIONAL I MOUND IN- GROUND PRESSURE I AT -GRADE SYSTEM IN FILL I HOLDING TANK
U= Unsuitable fors stem ®S Cl U ®S ❑U ®S ❑U CAS ❑U ®S ❑U ❑S K]U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Structure GPD /ft
Boring # Horizon Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trends
:.1:: »; 1 0 -9 10 r2 2 none
2 9 -18 10yr4 /4 none sicl 2msbk mfr gw if .4 .5
Ground 3 18 -31 7.5 r4 6 none sl lcsbk mfr aw na .4 .5
elev.
97 ft. 4 31 -82 7.5 r4/6 none lfs 0sq mfr na na .5 i .6
Depth to
limiting
factor
+82 1,
Remarks:
Boring #
1 0 -12 10 r2/2 none 1 2msbk mfr cs if .5 .6
2
k.,. 2 12 -20 10 r4 4 none sil lfsbk mfr 1
.:,:.
Ground 3 20 -40 7.5 r4/4 none sl 2mcrr mvfr c1W na 1 .5 .6
elev. 4 40 -80 7.5 r4 6 none lfs lcsbk mfr na na .5 , .6
97.6 ft.
Depth to
limiting
factor -
Remarks:
CST Name:—Please Print Phone:
Gary L. Steel 715-246-
Address: 1554 200th. Ave., New Richmond, WI. 54017 m02298
Signature: 4 -23 -96 Date: CST Number:
PROPERTY OWNER Richard Stout SOIL DESCRIPTION REPORT Page 2 -of 3
PARCEL I.D. # pending Lot #55 r
Depth Dominant Color Mottles Texture Structure Consistence Roots GPD /ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
,.. .
1 -12 10 r2 2 none 2msbk mfr cs if .5 .6
r: :
��� 3 •<
2 12 -24 7.5 r4/4 none sl lcsbk mfr gw if .4 .5
Ground 3 24 -90 7.5yr4/6 none lfs lcsbk mfr na na .5 .6
elev.
95. ft.
Depth to
limiting
factor
+90" r
Remarks:
Boring #
1 0 -12 10 r2 2 none 1 2msbk mfr cs if .5 .6
RX 4
2 12 -25 10 r4/4 none scl lcsbk mfr gw if .2 .3
3 25 -41 7.5yr4/6 none lfs lcsbk mfr gw na .5 .6
Ground
elev. 4 41 -80 7.5yr4/6 none lfs osg mfr na na .5:: .6
94 ft.
Depth to
limiting
factor
+
Remarks:
Boring #
1 0 -10 10yr2 /2 none 1 2msbk mfr cs if .5 .6
5 <:<::
r4 4 none sl 2mgr mfr gw if .5 .6
2 10 -21 7.5
Y /
3 21 -80 7.5yr4/6 none lfs lcsbk mvfr na na .5 .6
Ground
elev.
94 ft.
Depth to
limiting
factor
+80"
Remarks:
Boring #
M
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD- 6330(R.05/92)
STEEL'S SOIL SERVICE
Gary L. Steel 1554 200th Ave.
CSTM2298 Richard stout New Richmond, WI 54017
MPRSW 3254 S E4SW4 S3- T28N -R19W (715) 246 -6200
town of Troy
4 lot #55- Country Wood
I N
1 " =40'
BM. = top of 1ti4d, of = s tey stoke' @ T00 SV st ke f 'lot #56
1q
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k
f�
X'
IV
30'
� -� 5 `
Gary L. Steel
4 -23 -96
• 'OCT -09 -98 10:02 PM BELISLE EXCAVATING 7182473038•1 P.01
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer I„U1>0
Mailing Address 3 (QA 754` f` )
Property Address
,, 1 CJ (Verification required from Planning Department for new construction) /-
City /State t� &V) , ti Parcel Identification Number
LEGAL DF..SCRIPTION
Property Location �C 'h, � 1 /., Sec. Town of (U F
Subdivision FU�� G� - .Got #
Certified Survey Map # , Volume . Page #
Warranty Deed # 5da , volume Page #
Spa house 13 yes Xno Lot lines identifiable yes.no
SST N MAINTENANCE
Improper use sad maintenance of your septic system could result in its premature failure to handle wastes. Propermaintmance
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, journoymanplumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal system
is is proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is leas than 1/3 lull of sludge.
Uwc, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards
set forth, herein, a set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification
stating that yours m has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
d
a 7of the a year ex on date.
1
Of — =`—Y —�
SI NATIJIM APPLICANT 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 ownet(s) of
the pEope3ty desert �bovcby i rtue of a warranty dead retarded in Register of Deeds Office.
S14NATURE OP APPLICANT DATE
'00.04, Any information that is rttis- represented may result in the sanitary permit being revoked by the Zoning Department. jjjj
04 Include with this application. a stamped warranty deed from the Register of Deeds office
a copy of the certified survey map if referetice is made in the warranty deed
APR. 16. 1 1;14PMiL., 9, 0009 P. 1
562407, Si ATE DAR OF WISCON5IN FORM 1- 1982
WARRAN'ry DCED
000uMENT NC. VOL � . PAU1 ,I y
".eA1Ul"R 0(r 1:i
This Deed, madrh,:l ,en Richard O. .$t4l7 + ST. CRD v
�1 __..�.•_ . --- Grenlan ICI IUD 15 19ir
and .__ Todd A r Schroeder and xar, in�t, Sr- broader, 10:30 A. M
hus and Wi.f i
Grantee,
Wim esseth, 'tlau Ate s4W Cianor, for a vidwbIC cons t1t ra, m
conveys Ih grantee i1w Ioilowing described real esiste in St Croix TM I88PACE RESERVED fOR RECORONYG DATA
Coumy; State or Wisconsin: •NANC RETVRN A01DRE58
Lot 55, Flat of Country wood First Addition, L -�!
Town of Troy, St. Croix County, Wisconsin.
Iti
2 AL- - -.L2,3.6„ 6.A.
PARR IDENTIFICATION NUMBER
.r
j
f
This-_,i, not humesteadproperty. �II
(is) (is not)
'G with all and singular the heredrtamenls end appurtarartees thereunto belokgmg,
And .._..HlC.kl —O
warrants Ih31 Iltc tale is good, indelcasible In fee Simple And frCe and clear of encumbr except
easements, restrictions, rights -of -way and covenants of record, if any,i
and will warrant and defend the same
haled this 14th . r _ dsy of July r 9 97 .
�• I
(SEAL) (SEAL)
Richard 0. Stout
I
(SEAL) (SEAL)
i�
AUTHENTICATION ACKNOWLEDGMENT
State of Wisconsin, j
ss
$C. Cro
Courtly.
ovthcMKan'd tins day of 19_ rcrsonarry came before me this day of
July . 19 the above named
w
Richard O. Stout
. I
j lT't'LC ML'a1bER STATE DAR OF WISCONSIN �..• ..... ^_
(u il4n, ptendtt Poulin �.
aurhnrtxd by V06 (%, wis SBatsJ Notary Public to me kn In be the pars « whu eaecrted the forcgo,ng
$ti1tC of )SC 011511 jn -1rum a and ucknowledg ' samgr
T HIS INSTAUMCNT WAS DRAUED BY `
Janct F. Stout ~-
Tr
�I Hudson, wi. 54016
� :ary Public. w -. Chanty.
(Siguaitims may be authMicated or ncknowledged, Ilmh are not My commisMon is parmantrtt (If not, star "pirAlWn dnt
nueeiiat) l L. °_. ia4 .fX�7a
Iv — vF:111%0 4q, saphnl thnuw tA Typed of por,ed Mew
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WARRANTY nFEO I vrm No. I - 190 1 mArouvay. wls
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