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HomeMy WebLinkAbout006-1015-30-000 w 1 L ST. CROIX COUNTY ZONING DEPARTMENT' AS BUILT SANITARY REPORT t- -- E r�rE� rry Y p,r - Owner �. ,u , � ' � v�X. y City/State ,.r si r - 0W -" Legal Description: Lot �_ _ Block Subdivision/CSM # y CC' �!' - 3 yr , '/. '1. Sec., T '3 % N -RAW, Town of PIN # SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer Size ST/PC Setback from: House 3 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: 5, (-=e � Width 3 .� ," Len eII /c� � � Number of Trenches Setback from: House 1 P� Vent to fresh air intake f , oC-- ELEVATIONS Description of benchmark 7 Description of alternate benchm Elevation GC % k `` Elevation Building ewer g L' ST/HT Inlet r ST Outlet„ C PC Inlet PC Bottom Header/Manifold —2z Z Top of ST/PC Manhole Cover Distribution Lines Bottom of System Final Grade l () Date of installation / Y/ Y- ermit number . 2 0,233 State plan number Plumber's signature License number _ �_ Date !� / Inspector � Compkle plot plan r i 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 w F INDICATE NORTH ARROW ` `0 f� 3 -13� aa�o L9 _ 263,2 a S ls� a y«� l z 3- o, t °U 5c� l SG j ,I • Wisbdn §in Department of Commerce PRIVATE SEWAGE SYSTEM Count ' Safety and Buildings Division INSPECTION REPORT k. CROIX GENERAL INFORMATION (ATTACH TO PERMIT) SanitaYP�rSSfj(o.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. SS LL LL .33 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: PRESTER, TOM CYLON CST BM Elev.: Insp. BM Elev.: BM Description: Parcel IaZ924 30-000 1 401 tub to *11 ( l —TAN INFORMATION ELEVATION DATA A9800443 TYPE MANUFACTURER CAPACITY STATION ' BS HI FS ELEV_ Septic_ (DU (� Bench r 4 103 t Dosing] Aeration Bldg. Sewer [ H7o:ldin S Inlet 1 03. to SI ,_,�7 TANK SETBACK INFORMATION r (�, W Outlet f :5 , 3 TANK TO P/ L WELL BLDG. Airintake ROAD Dt Inlet Septic A, Go 3?7t 7 �i NA Dt Bottom Dosing NA Header/ Man. / I. `fig Aeratio NA Dist. Pipe 1 63,6 1 Z_. 09 ' Holding Bot. System 1 63,0 , Y 1 PUMP / SIPHON INFORMATION Final Grade 7 • 9'(, ,/6 Manufacturer Demand 5+ 41c,, k, L. 6 2. (67 IC) D Model Number GPM TDH Lift L System H ead TDH Ft Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED RENCH idth ✓ Length r j No. Of nches PIT No. Of Pits Inside Dia. Liquid Depth DIMEN 1 3 DIMENSION SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHIN urer: 1( � SETBACK CHAMB INFORMATION TYP �l� OR UNIT Mode Numb SY tedw DISTRIBUTION SYSTEM Header / Manif Id Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake r Length Dia. `7 Length .7 Via- _�A Spacing lZ 4 2 Z� 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: CYLON 7.31.16.104B,SE,SE 2210 HIGHWAY 46 — LOT 1 tl 1 5t" -r+ . Xe y,•, S(. out (C 4o In wA,,7 Plan revision required? [:]Yes O No Use other side for additional informa0on. a� g9 fG 7 SBD -6710 (R.3/97) Date Inspector' ignature rt. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: I f e I e. E 3 3 W E 3 I y Safety and Buildings Division Vi SANITARY PERMIT APPLICATION 2 1 E. Wa i De r Madison, In accord with ILHR 83.05, Wis. Adm. Code 79 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8112 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitar Permit Number The information you provide may be used by other government agency programs ❑ Check if re to pr ou ation (Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INF RMATI N - PLEASE PRINT ALL INF RMATI N Property Owner Name Property Location IO+e�1 E1/4 jE 114, S T � , N, R /(Q E (or] Property Owner's ailing Addrgss Lot Number Block Number City, Stat ' K- + Z Cod Phone Number Subdivision Name or CSM Number (h l > II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ it� Nearest Road Vil age Public 1 or 2 Family Dwelling - No. of bedrooms Town of A rd tits 111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo (a — it) 1 53° 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. ❑ New 2. tA Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an - _____System ________System _____________Tank Only_______ Existing System ________ Exlstlnc�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 Z Seepage Trench-Q I4Ch &MbOr22 ❑ In- Ground Pressure 42 E] Pit Privy 13 [] � Seepage Pit ` C r a X I 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. /inch) Elevation A456 11 1150 q U3 •�- q� , Feet Feet Capacity VII. TANK in to allons g Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturer's Name Concrete Con Steel glass Plastic App New Exist in structed Tanks Tanks Ic ank ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ 1 ❑ 1 ❑ 1 ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation oj the onsite sewage system shown on the attached plans. Plumber's Name: (Print) I PI er's I natur s Business Phone Number: k4 `71 1a8= fo 5` Plumber's Address (StreWt. City, State, Z' Code): / [f�l.E' IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued Issuing Ag t Signature (No Stamps) Approved C] Owner Given Initial 0 orf Surcharge Fee) q Adverse Determination D /°v / 2�`�g X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD -6398 (R. 11/96) DISTRIBUTION: Original to County. One copy To: Safety 8 Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. ' 2. Your sanitary permit maybe 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. 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. ---------------------------------------------------------------------------------------------- - - - - -- 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. Wisconsin Department of Commerce SOIL SITE EVALUATION Division of Safety and Buildings -.� Page of Bureau of Integrated Services In alt 83.09, Wis. Adm. Code Attach complete site an on r not less than 81 must ' ` County f plan tJePe t , I I ? ...- iriclude, but riot limited to: vertical and horizontal ref r point ( kdlr+lr�n and St. C I r percent slope, scale or dimensions, north arrow, an `lion and distance to nearest road. Parcel I.D. # APPLICANT INFORMATION - Please pr t 1 inforliap rm X r;, R b Date PPC9191' u,a�A�� 1�, Personal Information you provide may be used for secondary ( ,�( 9 be > Property Owner ''; Prpe Location c � - } 5 T� Lot 5 6 1/4 6E 1/4,S T 3 I ,N,R E (o (a Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# a10 w I v,a P ,390 C State Zip Phone Nearest Road Code Phe Number City El Village T own par I WY 1 :51 - 7 � '71 S) a 9 -5 7 ❑ New Construction Use: ® Residential / Number of bedrooms 3 Addition to existing building (-Replacement ❑ Public or commercial - Describe: Code derived daily flow S 0 gpd Recommended design loading rate ._ bed, gpd/f1 --(P — trench, gpd/fa Absorption area required f O bed, ft - 7 6 0 trench, ft2 Maximum design loading rate ___ E _ - 7 bad, gpd/ft L Q trench, gpd/ft Recommended Infiltration surface elevations) 5C) - 3 9 C 8 M I ) it (as referred to site plan benchmark) ,, r Additional design/site considerations + . v s e sa,, S Me -� 1 • ' 5 kD o I A o S e t pis At Parent material \ 0. u + W a Flood plain elevation, if applicable � } ~ � tt 2 P t L S Suitable for system Conventional Mound In- ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system 55 S ❑ u 5� s ❑ u ©s ❑ u ® S ❑ u I ❑ s ❑ S 9U SOIL DESCRIPTION REPORT Bonn # Horizon Depth Dominant Color Mottles Structure GPD/ft � g Texture Consistence Boundary Roots in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed . Trencl o- y R 3 1 S;L am fr Sk es F .S P � e , a .3 Ground 3 1 O - L m 5 �C t r %,.> elev. f" !� — —° 5 L k mFr t F -9 , 5 Depth to s -S6 - 7. ' 51 K J CB s 0 -so, w C 07 D limiting 56 7, S yR 5 /( — 5 O-SCA y' l L , 7 , g tact r j in. Remarks: 5 + 1 u We.vm� y`&. Boring # 0 .7 YR S:L ambR rvt Q 5 ol .5 , te a., Io`Ioi S;L Ifsb MFr- CL-l-' a ,Q , , Ib 5; aOA k, F. w C Ground W IS190h 5L 1 e 5' . CW I J F ° ) el e . 5 37 -46 3 , S `t (� `l -- ---- -� 8 ` - 5 ,. L Ckw I V F � 7 . g {� 6 -11 7,5 YR /b I 0 41 L — , 7: , $ Depth to limiting 1 f ctor th - ti " �in. Remarks: 5 4. h or: ucr " Co 1 :9 (`n±S f CST Name (Please Print) Signature Telephone No. 55+ Y k - 7l 5 --�Y9_ .1 dress Date CST Number oZ Oo� 's St&v ?V ,r't f W 9 -� S -. g o1a I !c S 14 -, (P PROPERTY OW N" d v% w% sp c � r SOIL DESCRIPTION REPORT Pape of PARCEL LDA t —1 d 1S,_ — o Boring # Horizon Depth Dominant Color Mottles Structure 2 g in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed . Trench 3 C) 1 oyR 5'.L o1 f+nG Mfr 95 Ground 11- Iq 1f)`1 R ` - �L. dms►O k — M F elev. q4–S fE. 1113 1,b'ik S L ► c,s 6 k M Fr` Qw I Depth to S y3 -I I 7.5 `I 5� --- cJ - 5 rv► L — "' $ limiting ; factor Remarks: T h k p r. 1 p vN f v e h Boring # i Ground elev. ft. Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots P in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trencl Boring # Lj Ground elev. Depth to limiting factor in. Remarks: Boring # .............. Ground elev. ft. Depth to limiting factor _. _.._in• Remarks: `.:30 (R. 07/88) i 3 6cc,7 1.31VN Rlw-j NAA4 :r, yc ' (S. Oq dc-s. Parcc,l� c s +►rl aar a yc� Jr vi 9 i 1 dr.Ve..way � I F F i 6ar�Jc = o 3 X �ouSe 4 asr' s { lay Q s SOi1 E -Ts p �b ©Qm ^(Par +', ,1 5tec1 �cr� --- (vCV, - I, ♦ �o r �S, pa 5+ .... \ \ fcfe.re�ncl p t � 5 1 1 . st�P (�M I ®8r^a� to.��,— i51ab (tv�l> 1.11'1, �o� ad,c. gS,34 Q �JoralnoleS q�,75 Qb,34 B� 95,��r ���1� ,® we—it 9 �r , 9 t,' �a, S 3 16.51 B 3 ����a+ oh 'r0.NkDV�It{' 9Q. q 'iA 0 '. )}� t� Cy7, ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Th 0 m a s user Mailing Address (5ta%O kt WX P Lot Property Address NtvU lq(p utf pak a) I j - iW f (Verification required from Planning Department for new construction) City /State fj i JO Q Ak I IA J i Parcel Identification Number -- 10 1 5 " D LEGAL DESCRIPTION Property Location E ' / <,� '/4, Sec. 1 , T1 _N -R I Lo W, Town of Subdivision 01 fa -� �d , Lot # 1 Certified Survey Map # 3 1 /d yon , Volume Page # Warranty Deed # 0 , Volume /29 ,Page # Spec house ❑ yes I no Lot lines identifiable P 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 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. 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 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 of the three ye expiration date. S GNATURE OF VPPLICANT 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 describ a ove, by virtue of a warranty deed recorded in Register of Deeds Office. _T� DYE 2�1 SIGNATURE OF PLICANT 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 11% 129 PA STATE BAR OF WISCONSIN FORM 2 - 1982 572105 WARRANTY DEED DOCUMENT NO. Joseph J Rostka, Jr. and Charlotte N lcostta, REGIST�R'S OFFICE ST. CR IX CO.. WI his rife ascb %r It "Wd _ FES 0 2 1998 conveys and "rrants to Thomas R Sprester and LuAnn N. 8 :00 A M Sprester, husban and wife, as joint tenants .y -4k 11J, THIS SPACE RESERVED FOR RECORDING DATA NAME AND RETURN ADDRESS the following described real estate in St Croix Co®ty, State of Wisconsin: grok litllotW AMO* 08 � on pN ) tM� Wed TRANSFER 3 Q 5 °� 0 - 1015 -30 PARCEL IDENTIFICATION NUMBER. Lot I of the Certified Survey Map recorded in the St. Croix County Register of Deeds office in Vohune "2" of Certified Survey Maps on Page 390 as Document No. 340900 on June 17, 1977 being a part of the Southeast Quarter of Southeast Quarter (SE 1/4 SE 1/4), Section 7 Township 31 North, Range 16 West. This Wanxty Deed is given in full satisfaction of a certain land contract dated March 11, 1984 and recorded March 16, 1984 in Vohune 684, Page 81 as Document No. 391816 in the Office of the Register of Deeds for St. Croix County, Wisconsin. This in not homestead property. (is) (Ls not) Exceptiontowarrandes: Subject to municipal and sowing ordinances and recorded easements and restrictions of record, if any, and any liens or encumbrances created or suffered to be created by the acts or defaults of the grantees. Dated this 20th day of January /A.D. 98 . (SEAL) (SEAL) . J J. (SEAL) -�•��' (SEAL) • Charlotte N Rostka AUTHENTICATION ACKNOWLEDGMENT Signature(s) State of Wisconsin, ss. POLR Clunty. authenticated this day of 19_ PPesstmally came before me this 2OTe day of Jaanwar= , 19-9A-, the above named Jose J. Rostka: Jr. and Charlotte — h is wi TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by 1706.06, Wis. Stats.) to known t �t AV 1Vio " ecuted the foregoing i m e THIS INSTRUMENT WAS DRAFTED BY /� i �— D aniel N. Byrnes Lav Of R K C S. * i1r' 3 Keller Ave. N., Amery, WI 5400 Nutars PSiblic, ' k0 County Wis. (Signatures may be authenticated or acknowledged. Both are not My Ct a L ion is permanent. �If not, state expiration date. necessary.) JULY 29 • Names of person, mg !n am .apaaq should be typed or printed below their signanues STATE P 4R OF N ISCO \SL% NISC.TS' ;IJ B+an"Co InC. WARP kN I V DEED F rm No. 2 — 1982 Mdwatree INS 4 340900 CERTIFIED SURVEY MAP SE 1/4- SE 1/4- SEC. 7, T-31-N, R -16 -W APPROVAL OF THIS MINOR SUBDIVISION E 1/4 SEC. 7 DOES NOT MEAN APPROVAL FOR SEPTIC SYSTEM. REFER TO H62.20 N 88 28' -05" E 1 651 q. 1 651 at w 330.00' O p - ' z N 90o o � h J '00. �O to U W W fj) 2 J W h W BEARINGS REFERENCED LOT ( W u NORTH ALONG THE EAST LINE OF SEC. 7 5.09 ACRES rn M M m 0 M O N 100' 50 25' 0 100 3 SCALE- 1"- 100' .n o 0 O c ;g 5�1 l 50'I 340 z � j 1488R- 28 =05 "E 15.00 i L _J BARN W I Y o FI E p 0 1 APPROVED JUN T ry 197 +P EXISTING HOME N o_' tt p'CONNEU RESIDEN E � -- � O i � JUN 15 1977 »f. *1 6 0048 C.? i _ _ I N J = d wtio !- ST. CROIX COUNTY 8 S88o -28 -05 W U U) CompREHENSIVE PARKS PLANNING �, O 10.00' w AND ZONING COMMITTEE o O S01 31' -55 "E \ — N Iw 9.10 501 Z � 335.00' J S 88°- 28' -05" W (60� W LEGEND S88°- 28' -05 "W 1 i �NN11fff 47.27' I w •- HWY. R/W POSTS d�;yGQ/VS� V 0 - i /1 x 24 1 N IRON PIPE SET �/ �� WT. 1. z 68 LBS./ LIN. FT. s O f- 1� GENE C. � � - 90 HWY. WIDTH w SHAFFER • S -1325 HUDSON SE COR. 7 SEC.7 j�� O Q', (C0. MON.) NO UR a , THIS INSTRUMENT DRAFTED BY G.C. Shaffer VOL. 2 PAGE 390 #110 77 - -33 CERTIFIED SURVEY MAPS ST. CROIX COUNTY, WI. SEE REVERSE SIDE FOR SURVEYOR'S CERTIFICATE