Loading...
HomeMy WebLinkAbout006-1023-40-000 ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT Owner Address City/State ST COUNT- ZOW Legal Description: ZONING OFFICF Lot 5U.) - Block Subdivisio<C t- _)f vo 1 5Ff 113 V V4 ji, TA - Rjfp W, Town of CYLOQ PIN# - 1( SEPTIC TANK - DOSE CHAMBER --HOLDING TAN INFORMATION: Tank manufacturer :5K^tj — Size ST/PC L_ setback from: House 50 Well P/L �5' Pump manufacturer --Model Alarm location (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORYPTION • SYSTEM: Type of system: BetD Width 2 / Length 5 4- Number of T renc h es Setback from: House _�3' Well 29L;- P/L 0 Vent to flesh air intake od — ELEVATIONS. Description of benchmark S AS Description of alternate benchmark GAle-'A a Elevation W) - 0 Elevation- Building Sewer q5-3 " ST/HT Inlet ST Outlet _q4 PC W PC Bottom Header/Manifold Top of ST/PC Manhole Cover Distribution Lines Bottom of System Final Grade Date of installation _5_6_ r 6Pe mit number 3 & Q 5- State plan number Plumber's signature 23t�s License number Date Sftc? Inspector Complete plot plan f ! 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 3Ba iz. 50r �► 35� " 2� 9'd D r. INDICATE NORTH ARROW Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: Safety and Buildings Division ST. CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary,��rautBls: Personal information you provice may be used for secondary purposes [Privacy L , s.15.04 (1)(m)], 3 // // Permit Holder's Name: I Ej �7� Village Town of: State Plan ID No.: CATTS , BRETT -W(R CST BM E Insp. BM Elev.: BM Description: Parcel _1023-40 -000 TANK INFORMATION ELEVATION DATA A9800093 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic -5- r Benchmark �Q i / /O6• Dosing Aeration Bldg. Sewer Holding St /Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANKTO P/L WELL BLDG. Airl to ntake ROAD Dt Inlet irl Septic -s ' zo , 5 / NA Dt Bottom Dosing NA Header /Man. 3y, 9x,76. Aeration NA Dist. Pipe ; y` tea' c, Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH 1 Lift L ricti System TDH Ft H ead Forcemain I L th Dia. Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length / f No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS / 7 — DIMENSION SETBACK SYSTEM TO P/L I BLDG r WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION Typeo CHAMBER Mo Number: System: -G--A �Q �' y�U V OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. 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 E4 02 ` Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: CYLON 11.31.16.152B,SW,NE 2468 COUNTY ROAD H Plan revision required? ❑ Yes 02 —, Use other side for additional information. SBD -6710 (R.3/97) Date I p or's Signature Cert No. ADDITIONAL COMMENTS AND SKETCH ' SANITARY PERMIT NUMBER: I I 'I 'I i I I, N *L Safety and Buildings Division onsi SANITARY PERMIT APPLICATION 2 E. Washington In accord with ILHR 83.05, Wis. Adm. Code Department of Commerce Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County 5_1111 G.R ©( than 81/2 _ 2 x 11 inches in size. I • See reverse side for instructions for completing this application State sanitary Permit Number 3 © 7n._ The information you provide may be used by other government agency programs ❑ Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I. N umber I. APPLICATION INFORMATION -PLEASE P INT ALL INF RMATI N Property Owner Name Property Location 151 VA11:5 v4 1 ia, S j T 31 , N, R I (p Kr) W Property Owner's Mailing Address 24406 C,-,N 'RD N Lot Number Block Number City, St Zi�Co�oo� PcJ P,3 113 Numb Subdivision Name or CSM Numbe VOL, lo II. TYPE BUILDING: (check one) E:] State Owned Lit Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms Tow OF C.`fuom cri Ro III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 00 (p _ I C) — 4 0 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 KReplacement 3. Q Replacement of 4 E] Reconnection of 5_ Q Repair of an ______System _______System_____________ Tank Only______________ Existing System ________ Existing System B) Q 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 (K Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure >} a 42 ❑ Pit Privy 13 ❑ Seepage Pit 12 X 1 53 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. 5��ccsstm lev. 7. Final Grade Required (sq_ ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min./inch) l 1!47 Elevation 40+15 Feet Feet Cap HExistin VII. TANK in a Total # of Prefab. Site Fiber Exper. INFORMATION g Gallons Tanks manufacturer's Name Concrete Con Steel glass Plastic App New strutted Tanks eptic Ta glis It f oco —"" I l 000 0 ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ I ❑ I ❑ 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) PI mb 's Sign Uwe: p MPRSW No.: B Phone Number: ' ©►� 2i� ©�c�.r r 221 S%4 - 715� to3 367,6 Plumber's Address (Street, City, State, Zip Code): 14r a ► 3rt" M 15 pr<RoO tit" 54-g)g, IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate I ssued Issui Agent Signature (No Stamps) Approved El Given initial c p- CPU, nargeFee) � ��� , Adverse Determination OV X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD 6M (R 11196) DISTRIBUTION: Original to County. One copy To: Safety 8 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. 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, coptact 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. Ill. 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. VII;. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Ptu *er 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. w ---------------------------------------------------------------------------------------------------- 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. i rho p �-� 4wN e��.► OIT C ArS 5ok oek suc, I I, T5 tJ, IZ � ion -T© uj rJ © t_u ni - ST C'RP I X C c? �ovs� bleu- s l $iYl SmIAL,k- 4r- � '- ri ALT . aR A ^ fop Of bASW, -T1Zi S.W . C cR -Oej , of: G,�Ac�,6 1000,5 NL, S �Ck W 'D :f DgAir3 F iv�suD ED � - Wipconsin Department of Commerce SOJ I ITE EVALUATION Divisiqn of Safety and Buildings '� Page _� of - Bureau of Integrated Services in a alt v iti`s ILHR, 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/ inches must County include, but not limited to: vertical and horizontal r nand e @ point (f3 i S CIR0 ( X, percent slope, scale or dimensions, north arrow, an tionA to nearest road: Parcel I.D. # 13 � sT �` 10 23 - 4-c> APPLICANT INFORMATION - Please pr l info -.,, rr Reviewed by Date Personal information you provide may be used for secondary Property Owner t ,° �, Location `7 • ° ✓l�i�!� CA�s `�� vt. Lot 5 114 1 /4,S ( T 31 ,N,R W Property Owner' Address Q � 1 Lot # Block# Subd. Name or CSM# vOV iOe& 1>5 n3 City State Zip Code Phone Number Nearest Road WE �� ❑City ❑ Village ®Town t� I� WL 54•x? 1(115)24 G'{ Lot's �i �`� f�►� ❑ New Construction Use: ® Residential / Number of bedrooms Addition to existing building 5,Replacement ❑ Public or commercial - Describe: Code derived daily flow 460 gpd Recommended design loading rate . i bed, gpd4F • — trench. g;xW Absorption area required 445 ed, f1: ft Maximum design loading rate bed, gpd4 t>_ trer>ch, gpd/ft Recommended infiltration surface elevation(s) Bc - 5 - 55 `'1 I �� ft (as referred to site plan benchmark) q p ,-7 5`4 Additional design/site considerations 12. X � 4 �� n e c,c� nn l Yl t ;fJ CL-- Q A U - 9O 8 : N - 84 Parent material 0 iJ KCxA3 tJ Flood plain elevation, if applicable N 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 Cl U ®S ❑ U ®S ❑ U ❑ S U ❑ S JR U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPDM2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench o -tA 7.5YK 2 51 I 2iM r M r 815 2m4 .5 : . b 2 lc-= 7.5A?— " - 5y 2,ry abk 5 lm- - 5: Ground l� �� Ma'b k. f! 5 I .1 elev. y ft 4 to w,1 --- .� •, �s5 , Depth to limiting factor Remarks: Boring # �I..m0.b IC 0 -F} '1.5 3 Z S i j r 5.5 2m- . :, 4, 2 2 - � °_i , 5-t e.5 ---° � f I 2 i+n 1 t . S 1 n►-�j- IM ; . 2 It. 15-?s. 5( �-- 5) 2Mo b k t 1 ° � ' • {� Ground 4 51 P- 1 5 I trY,a b k m V r 55 ft. 5 l og?. m M1 . l :'5 44.4•z Depth to limiting �� fa in. Remarks: CST Name (Please Print) Signature Telephone No. - b Address Date CST Number 14•-i 1 711 A�/ �AR.1zafJ 01 i54at � 1 ,,, 2. 2 0 5�0+ PROPERTY OWNE CA TI�S SOIL DESCRIPTION REPORT Page �z of,�L PARCEL I.D.# Boring # Horizon Depth Dominant Color Moftles Texture Structure Consistence Boundary Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench I 7.5 `r2 3 Z- 5i l IM r im r 5 . : Z - m 95 Ij 1 .5 Ground Q - �J�2 {a �� Ime,,pl� I'r►�/��^ 5 � . e1q,v. it (q;S - U -7 Depth to limiting factor �in. Remarks: Boring # i8 5 m Ground t� Z- lon- 5 M-S elm. i, , (g2•Z5`� ; Depth to limiting factor +Bain. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # , e--9 ?.5Y?.31?. 5 ) �Z r a s . El z. 2L . 7,5YIL 513 51 2w.bK tyif 65 -5: ,M q. ! rAddD K m r Ground 4 - I LA l ow- 511A alev. it 0 .�2 Depth to limiting factor >_in. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBD -8330 (R. 07/96) • ,�� bKZ I T CA 3)3 PgapeQ..•c Lo - T ►c7r,3 Nc k4 se C, i 1,'i^3►n�,`R►��? it / 4 COSf3f4 1J�lJ =40 1 E�C15f. Ti L 0 $ $ A� To SM ALL- 4 'TOP Of � PS� "fRtrv, •—%W. Coa ok;52, OF GA2PG,� D 13acm Notts � A�•� "PARCH �,,. ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer n Mailing Address 2 4 Property Address — Pk i� k (Verification required from Planning Department for new construction) City /State Aj j , Parcel Identification Number 006 I 07- 3 ~44y LEGAL DESCRIPTION Property Location 30 %., ME. %., Sec. � Ti N -R, Town of ��fl� Subdivision Lot # Certified Survey Map # , Volume (05 , Page # 1 Warranty Deed # 51 q Volume 1088 , Page # 1°7":S Spec house 0 yes IN no Lot lines identifiable 09 yes ZT 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 masterplumber, journeyman plumber, restricted plumber or a licensedpumperverifying that (1) the on -site wastewaterdisposal system is in ro condition and/or e P P� oP��B 2 () aft r tion and if necessary) s eptic tank is less than 1/3 full of sludge. �c P�P�B ( �Y)� eP 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 yours tic system has been maintained must be completed d eP � mp tc an returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. 7j' X j �� _ 3 1311 SIGNATURE OF 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 owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. 3 ry / 9 SIGNATURE 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 OOCUMCNT NO WARRANT DEED ir♦ E ­ ­E3 FOR Rt_nw: ,raG ows• STATE: BAR OF N ' G — 19S2 � 5193'7 f 1�,�= .'j; r =" , 'S OFFICE REG' - _ - -- -- - - -- - ,,, Ronald R. Wiuff and Cynthia J. Wiuff, husband and .wife, ST. CROiX CO., Wl __. _ _ _ as joint tenants, ....... Recd for Rerord JUL 2 2 1994 conveys and warrants to Brett , D. _Catts_ C. B1ieSe A 13•�r 1 l JJ ' at - - fletster Of t.,e following described real estate in .... .... St. - - OlJC - 1� State of Wisconsin:' Tax Parcel No:. - - -- ---- - --- -- 4 F f !j A parcel of land in the Southwest One Quarter of the Northeast One Quarter (SW 1/4 N'S 1/4), Section Eleven (11), Township 'Thirty -one (31) North, Range Sixteen (16) West, St. Croix County, Wisconsin, described as follows: Beginning at a point 44 rods East of the Southwest corner of the SW 1/4 of N' 1/4, thence North 30 rods, thence East 16 rods, thence South 30 rods, thence West 16 rods to the point of beginnin6. p0 is �rr !I This ..... ' homestead property. I (is) Exception to warranties: Easements, restrictions and rights -of -way of record, if any. Dated this -- ... -_ .- dad of T' 19 94 r V. - (SEAL) r iLC , 'L (SEAi.I i H Ronald R. Wiuff jj - -- - -- - -. y __(SEAL) tsEAt.► - Cyta hia J. Wi f f � AUTHENTICATION ACKNOWLEDGMENT Ronald R . Wiuff, STATE OF WISCONSIN i Signature(.) ----- -- - --•------------- C In ttua J Wiuff ' -- — -- -•--------- ............ _County. l 1 authenticated this!.. of /f .July 19_ - Pzrsonally came before me this . _.....---- day cf 1 �ilA - --- 19 . . ..... the .Love Hamel - - ----- ---- i. Kristina 0 8 TITLE: MEMBER STATE BAR OF WISCONSIN -------- --------- - _ -_ - .. _ ------ .. -. ............ l (If not - -••- ------ __ ............ -•--- ----- --- 0 - authorized by § 706.06, Wis. Stats.) to we known to be the person who executed the foregoing instrument and acknowledge the same. TH:S INSTRUMENT WAS DRAFTED BY = Kristin Ogland - Attorney at La w \"scary Public _ Co unto, Wis. - - - - - - -- ------- - ----- - - -- -- - (Signatures may be authenticated or acknowhdged, Both My 6nunission is per:nanent.0f not, state ezp; ration a are not necessary.) date: __ _ -. _.- - -- 19 .. ) N m of pe—rA sisaing in any capacity shoubl b- Untii or pHnU4 lkb --„r -)•�a — ` WABRANT7 DEED STATE BAR CIF IL'SCONSIN W sconsn Lega! Hlan4 Co inc .� �� FORM !s- 2— 1? +L M,Rwaukee. W�Se0051n