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HomeMy WebLinkAbout231-1066-00-000 ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT Owner Property Address City/State Legal Description: Lot_ Block Subdivision/CSM # N !d '/4 , t /4, Sec. 2a, T, ON -R � of - �s PIN # .� -'�C �6 c� �' , 8 SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer 1 e V Size ST/PC/ Setback from: House Well P/L Pump manufac+' o e Alarm location (HOLDING T ONLY) Setbacks: Service roa Vent to fresh air intake e Meter location Alarm location SOIL ABSORPTION SYSTEM � � 2 Type of system 400 Pile, N � idth J !' Length Number of Trenches Setback from: House ,�' Well ;a P/L Vent to fresh air intake S ELEVATIONS Description of benchmark �� Elevation q� Description of alternate benc k Elevation Building Sewer ` ST/HT Inlet f 0 ST Outlet 79, Ze PC Inlet PC Bottom Header/Manifold 6f 7 Top of ST/PC Manhole Cover e X Distribution Lines (L) 1�, 7 e ( ) Bottom of System (a-) Final Grade (�) 7 9 (-.t) 96 Date of installationfp a /99Permit number State plan number Plumber's signatur !a 4- �� icense number Date LO1 � q Inspector Complete plot plan a 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 b n TH ARROW INDICATE NOR Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: Safety and Buildings Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-: ST CRO X Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 338939 Permit Holder's Name: ❑ City ❑ Village XI Town of: State Plan ID No.: STOHR, BARBARA GLENWOOD CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: if M-100 7 1 Pew= le� Pla,, Q 1 231- 1066 -00 -000 TANK INFORMATION ELEVATION DATA A9900203 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic a �� Benchmark ,gD Dosing .894 2 -2-& O S Aeratio Bldg. Sewer --. 3 , Holding St /Ht Inlet 7Z.�(� ell ,0 t v TANK SETBACK INFORMATION St/ Ht Outlet 7 - 0 TANK TO P/ L WELL BLDG. Ventto ROAD Air Intake Septic t oo — NA x .ts Dosing NA Header / Man. 1 Aeration NA Dist. Pipe ,oQ Li U. a 7_ `T Holding Bot. System I ' ` PUMP/ SIPHON INFORMATION Final Grade q D M acturer mand ,2(� �/, $k{ Model Numbe GPM TDH I Lift L Ion tem TDH Ft Force Length Dia. Dist. To We SOIL A RPTION SYSTEM BENCH Width Lengt / No. T nches PIT No. Of Pits Inside Dia. Liquid Depth DIMEN I DIMENSION SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION TypeO CHAMBER Z / 2 f Mod Number: System: OR UNIT DISTRIBUTION SYSTEM Header /Manifold ti Distribution Pipe(s) / c, �� x Hole Size x Hole Spacing Vent To Air Intake Lengtlf Dia. Length 7 - 1 - 5 , S Dia. '( Spacing _4_� 7 S� SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over a Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center a� '� Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) s4 LOCATION: CITY OF GLENWOOD 23.30.15,NW,5E WALNUT RIDGE DRIVE o Plan revision required? ❑ Yes g No Use other side for additional information. f I�" ft _ �o SBD -6710 (R.3/97) Date Inspector's Signature Cert No Y_ ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: , j t " I e 3 F 3 .. ". " F e "m F ..... - ..... "..e . "" "" az.. a .. .�. ..� ... m, a a 5 f e ' a I e.. W � F E e 3 � « e ,v .. I � f t 1 "^ " F "mw "s d.......n s .. ,. ". .,.. s i mm e F v 8 f i { d 3 c H Y M " F 3 ....:" " "....... ...te �. �� m " _ 3 3 i ems -. E � i L 4 � m l " i z � 's s G z I — - ` �J ! Safety and Buildings Division & .Onsin SANITARY PERMIT APPLICATION 22010 B Wa ington Avenue In accord with ILHR 83.05, Wis. Adm. Code Department of commerce Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 1/2 x 11 inches in size. _f e C . • See reverse side for instructions for completing this application State Sanitary Permit Number 33$°13 Personal information you provide may be used for secondary purposes ❑ Check if revis lication !Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Property Owner Name Property L tion G A) va �/4, S 23 T -30 , N, R S E (or)® Property Owner's Mailing Address Lot Number Block Number G A / City, State Zip Code Phone Number Subdivision ame or SM Nu �rt er e� cad e k}i'� �,�:� (7i�) ���� iv r es T YPE OF BUILDING: (check one) ❑ State Owned PQ Lit Nearest Road pkt> 0 vil / Cs/4 N47 /d Public 1 or 2 Family Dwelling - No. of bedrooms Town OF iT��' load � r AW III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1❑ Apartment/ Condo �2 -' � o Q U D D 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 DQ New 2 ❑ Replacement 3_ ❑ Replacement of 4 ❑ Reconnection of 5. ❑ Repair of an ------ System ________System ----------- Tank Only --------- _---- Existing System - ------- _ ExistingSLfstem 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 1 1 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ® Seepage Trench 22 ❑ In- Ground Pressure s i X 7S 42 ❑ Pit Privy 13 [:]Seepage Pit �o 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. 17. Final Grade Required (sq_ ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) 9 js �,?o Elevation P C 0 1 9 -6 - 0 .�C'� �' 9 e ' Fe et *- Ec Feet VII. TANK Capacity in gallons Total # of Site INFORMATION Manufacturer's Name Prefab. Con- Steel Fiber- plastic App. New Existin Gallons Tanks concrete strutted glass App. T nks Tanks Septic Tank Ing ank ` jd �c',ffC /�/ 101 ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamberl I I ❑ 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) Plumber's Signature: (No Stamps) MP /MPRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): '( IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issuing Age I ature (No Stamps) Q / A pp roved ❑ Surcharge Fee) u Owner Given Initial �a �—• oo/ f/ Adverse D etermination / 2 / / 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$uildings'Di'vision, 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. 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 mustsign application form. IX. County/ Department Use Only_ X. County/ Department Use Only. Complete plans and specifications not smaller than 8 112 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. !! j Ay ti �iAe,l - -- _ - _-Av _ -- - I� � - I Yj V S � -- f I % I x y �?! 0 s g © p At _- i- I ! I ! I I I� I - I , j r - - - -- -- - - - -' -- - - -- --- -- I I I , I i I I j - ' I , I I - - - ' -!- - -- - ! ` i- ' I C I I I . 1 r I iii I -- - k�F-E- t L - _ -- Ll Wisconsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page of Bureau of Inte ,grated Services in accordance with s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and )` percent slope, scale or dimensions, north arrow, and locatiojiar+d to nearest road. .,, Parcel I.D. # 4D —d OD APPLICANT INFORMATION - Please a►�'�l info&"tion. Reviewed by Date Personal information you provide may be used for seco aq��'urposes�f., s. 15.04 (1) Property Owner Property Location ).� Govt t �,;> 1/4 s �1/4,S�3 T�Q ,N,R J� SWW Property Owner's Mailing Address ST CR0 X Lot- Block# Subd. Name or CSM# � C;Qlif3T�' /# AZ � �� �. INGCff tCL #/ f ; City State Zip Code hone Number City Village ❑ Town Nearest Road New Construction Use: Residential / Number of bedrooms _3 to existing building Replacement Public or commercial - Describe: n p Code derived daily flow gpd Recommended design loading rate � bed, gpd/ft trench, gpd/ft Absorption area required d y 3 bed, ft 9 " h / reach, ft Maximum design loading rate d bed, gpd/ft i 4 trench, gpd/ft p r Recommended infiltration surface elevation(s) e ft (as referred to site plan benchmark) Additional design /site considerations Parent material 6V A- 6 / r/ L 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 S ❑ U M S ❑ U CO S ❑ U ❑ S U ❑ S ® U 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 Ground I Ali � � .c? elev. Depth to limiting facto 3 in. Remarks: Boring # IVO Ground elev. f a ft. Depth to \� limiting fctr > Remarks: CST Name (Please Print) Signature Telephone No. A e S > 7��i fie, �� 7��° -a J,5 Address oZ ` Date CST Number � D Lv�00r f/ lv/ J�" �/ ' PROPERTY OWNER 9 6R1# S 7ro SOIL DESCRIPTION REPORT Page of .3 PARCEL I.D.# oZ �� O d d © d Boren # Horizon Depth Dominant Color Mottles Structure 2 Boring in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench 3 Y -86 . Yf 5 I: Ground e lev. Depth to limiting fa�cctoJl 3 Remarks: Boring # .� 74 Ground .Le v, r G' 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 # o- / 10 31.7- .S 2M Sd S M l� -� ...5• .3 S o � . 8 Ground ��le 7�' v /ft. Depth to limiting factor o�in. Remarks: Boring # Ground elev. ft. Depth to limiting factor in ' Remarks: SBD -8330 (R. 07/96) . R t 1_ aW=J Ix - lee O bt P__o JW el tm O'ce- -I--- t gal 13 41 I I r I I i r I I + �I I I , I I I - -- --� - - -� I - FT I I i F7 A-44 P-1 I � I t i - �- I � I 1 I I r- i- I 1 i r I i I I fI I I I ! I I I i I_- I i i I I ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Ic A Mailing Address C' r Property Address (Wrificatioa required from Planning Department for new coamuction) City/State _C� �C iV �c C- c dam% I "y Parcel Identification Ntunber IL' - e! e LEGAL DESCRIPTION Property Location ��' %, . ' s, Sec. z . T-C N R W. -of L N �c %�C C "� 1 y Subdivision G� ,¢ / /V 7` A ;, S "`/` s �' Lot # Certified SmTey Map it y 6_� volume / Page # Warranty Deed # SX o d 2 ?'1/ Volume Page # Spec house ❑ yes 0 no Lot Imes identifiable . IM yes 0- no S'YS1W WAIr1'MANCR uwand eofyomsepacsystemooaldresaltinits sists of pumping oat tau septic taaac every taupe P�� to baadle vrastes. Propera�abeaanoe con cxa:ffoct Pe S O of tau Yem or soot if leaded by:t Ucct od pcmaper. ' What you put.iaoo the system septic taak-as. a ft tment stage is tiu was cavoul- systcnL lie PtnPcdY owner agroes to submit to SL efoix Zug Dcpadmen t a . catificatioa foam, signed by do vw= and by a p ] nPhmiber, rest&odplumberorslioeasodpmaq =vecifyiagHeat(1) the oa-cite�rastiewa disposal:ystrm is im P� Operating coadition andlor (2) after impecaan and pampiag.(if neee my), lave septic to k-is less dm I13 full of sludge. . 1hc jmdessigoed have head tare above mqukmcnb sad sgroe to maintain ttu private sewage disposal system with tare somdatds set for(, h=ia,'as set by tau Depacimeot of Commane sad the Department of Natu'd Resoac+as State of Wis000sin.. Cedf',icativa sag that your septic system has beta maintained mast be oompktod Wd r Wm0d to the SL Qoix.County Zoning Office widda 30 days- of the throe year 'lion y SIGNATURE OF AP DATE i OWNER. CER ATION I (we) CC[* that all statements on this foam are true to the best of my (our) kmowledge, I (we) am (are) the owam(s) of f the Ft+opatY descn'bod abo y v of a wanaaty decd r000rdod is Register of Deeds Office. SIGNATURE OF APPLI DATE Any information t is mis- represented may tmult is the sanitary permit #���'• being revokod by the Zoning Department. « Include with this application: a sumpod warmaty dood firm the Raghter of Dec& office a copy of the certified muvey map if reference is made in the warranty deed WARRANTY l)FE0 DOCLJMFNI NO marvin C. Booth and Jean M. Booth AEGISTERS G an and WL e & ' Jamc�/A & Barbara J. -He.�ssnd_mo�)�fe,_ and -�iuJ��-B }tobx,' -___-______' °°mm=Jo`--' '----- -------------------------------------------- ,".00p^crne��".w,o�pEcono=au^,^ w°�c^^u .on"a� ` , o�, 'ow � ---------------------------------- � ^ � the u.o°mga,*"heu�uow m '-St.-!�zoixc^°r,� om+o u Barbara s�ohr - xme^/x o �u"a,: 505 wxp|r Street ~ , � Glenwood ci�y, w� ��0|3 � . Lot * of Csn #3224 Document 556963, vclome |}, Page ' 3224, Being x part of ovt\oto )a u 37 of the Assessor's Plat of Glenwood city, and \ocat�u in part of the %u 1/4 � of the BD )/4, and pact of the ws 1/4 of the sc 1/4 of Section zJ, T]Om, u15w, city of Glenwood City, St. croi^ Co, WI. ~ .� ~ � / � � ~ not m., ___-_'_-____-h ^+ � s,*�wvw"vx^uu, � ' | ` o^�Jm., oo.,f __Ao , w-�7 (7 ~ _ ,ouu � -Q -__ ___ �aau _--_-_ ° ~ _��s�e.-C._/� _ `��u ~� ` - ,�. ~- Bo`tk --�---- » ' t. aUTpsNr\car/ow a[uNU\v|EuG.msNc � *�.mu"us) ����e o� v/i^�o^,.n. St- Croix ^"owx^^..0 m.~ u^/~/ *m' b,,/' "u m.. �--2 �u/ Lit ----� --��� w9/_-,'w^�^`'w"� %1a an ���-__ � .0 /^v �------�'---` ^"ow..zd hx- �700,0r :.i ,m,` »-'-~`"nw\�,�' "|"`.:^x",o tile �.'*"'* ILi k^ /u X �� � ' -- � --1-a`qt�--/ Coll uN,�" .� �----------�—�---- - . ^km~�/�u p*^ ., .^^ 0ac���� ` 2001 om, � "/. m "mx`.0 m w"`^ `-°- . FORM NO. 985-A ,,. Won"- Stock No. 26273 6 Mq ��LFQ 2 N 0 199� ► 3 vr-. J $ a�;seSy1i Wq�SH N. of CERTIFIED SURVEY MAP NO. 3224 ti ? VOLUME li , PAGE 3224 cr M-4 A PART OF OUTLOTS 36 AND 37 OF THE ASSESSOR'S PLAT OF GLENWOOD CITY, AND LOCATED IN PART OF THE N.W. 1/4 OF THE S.E. 1/4, AND PART OF THE N.E. 1/4 OF THE S.E. 1 NW 4 OF SECTION 23, T.30 N., R. W., CITY OF GLEOOD CITY, ST. CROIX COUNTY, WISCON5N. LEGEND cern.r 1/4 ca. ` \\\ \\ nu/q/ i -0 COVERM W CORNK (AS NOTED) 23 -30 -15 \ ���G t* / Fd P Iron Ppe �\�\`�. • • • •`./ %'' o ------- SET 3/4" x 24" MAR WEIGHING STEVEN J. • `: 1.502 L-135. MR LNEAL FOOT I WAAK s n s 1610 SCALE:I" =150' o. v /Z>fljj ��'� WIENOMONYE •�� o 9 wls. Q 0 75 150" 300" / � l llittllllllt111 1 \I \ \\ I LkOatted Lands n N9 — �4w2ft I 35 PREPARED FOR: i r C. Mr. Mary Booth � I 1444 320th Street V a� Clenvood City, Wi. 54013 Q / I 123,324 50. FT. '( 2.83 AC. C. 58q'3739"W r Q, s g74 •yB'n"i 1 396.00" South 1/4 23- 30 -15Q W 1 6 Fd. N Iron Ppe �sQs 123,556 50. Ft. 2.84 AC. i CNI v - t25 ,45O 50. FT. 4pa�1v 2.95 AC. � o + � 60 � LOT S N se�gW04 157 3. 4 62 AC. Ft. 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