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HomeMy WebLinkAbout012-1039-70-130 ST. CROIX COUNTY ZONING DEPART MIJN AS BUILT SANITARY REPORT - PECE!'��I Owner `- Address AP 2 f �� City /State ST CROIX S COUNT`/ ZONINGOFFICE Legal Description: ��11 Lot _� Block Subdivision/CSM # a2 92– r 'l ' /,/ '/+ Sec. /�, Tk-N -RLZW, Town of / PIN # t A /d 7y 70 /5 n SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer & I _ Size ST/PC Z2 DD Setback from: House WWell 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: .7A � �R'`�" * `_f W idth 3 • Length Z a� Number of Trenches 3 Setback from: House I 3,P-- Well P/L Vent to fresh air intake ELEVATIONS Description of benchmark r Elevation �� D Description of alternate benchmark Elevation 4 , 3 Building Sewer ST/HT Inlet 7 ST Outlet 3 PC Inlet PC Bottom Header/Manifold 1 77 Top of ST/PC Manhole Cover Distribution Lines Bottom of System Final Grade () , ` 3 () ( ) Date of installation */ / ermit number -1 State plan number rk Plumber's si atu e_ License numbe Dat ' / Inspector Compkte plot plan .r 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 4V �T v 0 � Z ICATE NORTH ARROW L Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Buildings Division Count 8T CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary P5W76Vi Personal information you provice may be used for secondary purposes [Privacy LaW, s.15.04 (1)(m)]. P,g4Q}i U,deE:S.Alame: LAURA � � Moll f wn of: State Plan ID No.: CST BM Elev.: ec Insp. BM Elev.: BM Descrip on: Parcel Tft'!FL 1039-70 -130 1 O©` 1 pp (� 6- - TANK INFORMATION ELEVATION DATA A9800060 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic c �ZO� Benchmark � 195 1 i Dosing Aeration Bldg. Sewer Holding St /Ht Inlet S 9K,-73 TANK SETBACK INFORMATION St/ Ht Outlet C ) �3 TANKTO P/L WELL BLDG. Airintratrke ROAD Dt Inlet �^ Septic yu 1 S f �� NA Dt Bottom Dosing NA Header /Man. (!, 4,6 `, g7.3V Aeration NA Dist. Pipe 0 6 Holding Bot. System 7.'rO T PUMP/ SIPHON INFORMATION Final Grade �1� 4931i� grjt Manufactu Demand Yv� L +,3 ,S l0 3•� Model umber GPM TDH Li Friction S st TDH"' Ft oss Forcemain Leng Ia. Dist. To Well SOIL ABSORPTION SYSTEM BE Width Length No. O Trenches PIT No. Of Pits Inside Dia. D pth DI N 3 -7V DIMENSION SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING< anu acturer: CHA INFORMATION TypeO MBER I Num er: System ov► `19 Gl OR UNIT DISTRIBUTION SYSTEM Header /Man ifold Distribution Pipe(s) �� x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length I Dia. Spacing — 7 IZ C-N- -- o 1 _�! 1 SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over �_ p Depth Over Bed/ T ench Center 3fQ Be c ges Topsoil ❑Yes ❑ No ❑Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCAT ERIN PRAIRIE 17.30.17,NW,NW 1625 160TH VENUE � �r / - 7 6 1 (Clkilry z 7- (.Y 00 f_0LMd6CN6Vj (:]o b� l -,�`� � ; K547 t e C/ F VII q1 Plan revision required? ❑ Yes 4 No Use other side for additional information. /•� CI:J SBD -6710 (R.3/97) Date Inspector's Signature a o. i I i Safety and Buildings Division SANITARY'PERMIT APPLICATION Bureau of Building Water Systems 201 E. Washington Ave - In accord with ILHR 83.05, Wis- Adm. Code P.O- Box 7969 Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 81/2 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit -7 The information you provide may be used by other government agency programs ❑ Check it revision to pre0ous application IPrivacy Law, s. 15.04 (1) (m)]. State Plan I.D- Number L APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Pro rty Owner Name Property Location `fj1 /4 1/4,S/7 T F0 , N, R EOM W Property Owner's Mailing Address Lot Number Block Number City, St6te Zip Code Phone Number Subdivision Name or CSM Numbe 'L4 017 ( > 6 — ,71976 II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ Ut Nearest Roa E] Village � � / Q Public 1 or 2 Family Dwellin - No. of bed rooms !q Town OF /�t► / b © /� �� III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo /'©7 - 70 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. K New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5_ ❑ Repair of an _____System ________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 41 ❑ Holding Tank 12 DJ Seepage Trench 22 ❑ In- Ground Pressure T 42 ❑ Pit Privy 13 ❑ Seepage Pit �/ L11 _z `/? �NF L�q 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) cm I v tion QO //VIP �/' / Feet �` Feet VII. TANK Capacit in g all o ns Total # of Prefab. Site Fiber- Exper INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App New Existing strutted Tanks Tanks ptic ank u >d ❑ '❑ ❑ ❑ ❑ 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 rs S gnature: (N to s) M/MPRSW No.: Business Phone Number: / �li`i/� / �z 7,701 7 1s 461 .;z 3 P umber's Address (Street, City, State, Zip Code IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit a (Includes Groundwater ate ISSUe Issuing Age t Signature (No Stamps) A pp roved ❑Owner Given Initial Surcharge Fee) B, Adverse Determination I top Zl1C/ X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SHD -6398 (R. 05/94) DISTRIBUTION: original to County, one copy To: Safety 6 Ruildings Division, Owner, Plumber 6©' KEN SCH M ITZ, INC WISCONSIN CERTIFIED SOIL TESTER SEPTIC SYSTEMS DESIGNED & INSTALLED ' MASTER PLUMBER # 3077 22835 SCHMITZ LANE SHELL LAKE, WISCONSIN 54871 (715) 468 -2434 con Asb �0 3X >R ' eAkl q s 9 llox/w / / }^ oc 1,.#al?. r tzn+ /t d KEN SCH M ITZ, INC. _ WISCONSIN CERTIFIED SOIL TESTER `� �Z7 SEPTIC SYSTEMS DESIGNED & INSTALLED MASTER PLUMBER # 3077 , 22835 SCHMITZ LANE /� �}� SHELL LAKE, WISCONSIN 54871 (715) 468-2434 r� hs0 f/t -/ �L L 3 7 ; ELLS 3'X 7;� 6 !/Awl �'x -7a wj 11 �11�;lx i 3c3� DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY &BUILDINGS INDUSTRY, ` DIVISION LABOR HUMAN NDLATIONS PERCOLATION TESTS (115) MADISON WI 79 (H63.090) & Chapter 145.045) LOCATION: SECTION: I TOWNSHIP /MUIITY: LOT NO.: BLK. NO.: SUBDIVISION NAME: M ��4NW�/4 17 /T30 N /R l7)c(or)W Erin Prarie 3 n/a n/a COUNTY: OWNER'S ACS NAME: MAILING ADDRESS: St. Croix Michael Riley 1622 160th. Ave., New Richmnnd, Wi. 54017 USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS: 99IResidence 3 n/a kiNew ❑Replace 3 -20 - n/a RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN- GROUND - PRESSURE: SYSTEM -IN -FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) ®S ❑U EiS ❑U S []U CAS ❑U ®S 51 c trench If Percolation Tests are NOT required D ESIGN ClaSS 2 RATE: If any portion of the tested area is in the under s.H63.09(5)(b), indicate: n / a Floodplain, indicate Floodplain elevation: decimal' PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTHXX ELEVATION OBSERVED EST- HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) B- 1 7.25 99.90 none >7.25 167 ,10yr3/2 1. 1.087.5yr4/4sil., 2.007.5yr4/4 l.s. 3.5077 5 r4. 6 co.s. B- 2 7.25 99.90 none >7.25 75,10yr3/2 l., 1.50,7.5yr4/4sil. 5.00,7.5yr4/4,s. . B 3 7.17 98.95 none >7.17 67 ,10yr3/2,1.,1.50,7.5yr4/5s.sil. 5.00,7.5yr4/4s. . B- 4 6.91 96.90 none >6.91 . 33, 10yr3/ 2, 1., 1 .25,10yr4/4,sil.,4.33,7.5yr4/4, Us. B_ 5 6.24 97.60 none >6.24 .58,10yr3/2,1., .83,10yr4/4, sil. 4.83,7.5yr3/4, .s. 6- PERCOLATION TESTS TEST DEPTH, WATER IN HOLE TEST TIME DROP IN WATER LEVEL- INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL -MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH P- P- P- trp 10IKI ) Carta ICW �Kj €SFI s: 1 :la 4d R w r ues �4.,_L °lll.t:: )ci €:>: P pue 1..9a -.SrtS aI }a i)WAI ld 0(41 Act Surf f s i��e,c„jjo,) V ��� rssr aru � cr a s .r � tri }11)I} Ni ISO' Iris sRjj JO uck' P t t.,an �sar�k a C�tz.a luaullaacf� aye c fu€ c> a l }a a �3 hr ,sr s t> 6itP tr�7 s ul dal, jsii.j rjjq q Ooda,z 7saj Jg s:!i •0 3H 1 01 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND • OWNERSHIP CERTIFICATION FORM Owner/Buyer 7 Irk) 4 tau,, V u�'k' 3 5 w 7 V d St c v 9 / 7 Mailin Address - �e I�fG Gj�oh -� �/1/ � g 2 ! � I4Oa - / Q ye h ue Property Address (Verification required from Planning Department for new construction) City/State �rrvt Or - 1 ri e� W f Parcel Identification Number LEGAL DESCRIPTION Property Location /'/ A %4, IV h ' /a, Sec. 17 , T -30 N -R /7 W, Town of 5rr� PYarr�e Subdivision , Lot # Certified Survey Map # `T $ 2 2 9� , Volume , Page # o V 7 1 Warranty Deed # � < q 7 , Volume �q a , Page # 6 Spec house ❑ yes ❑ no Lot lines identifiable yes ❑ no 18 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, restrictedplumber 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. 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 year expiration date. _ i!/',wO L � 3 / q / 9 SIGNAtbkll 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. -GyGA'4 P -11-1 - 1 1 1 1 19 SIGNATUI OF APPLICANT DATE I&* * * ** 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 r ~. •• V=Uir1zw 14 -6: . ' W "We Wand cseswvea ros nsoaaoMO 40 ft ftAS"i_N/1N OF WUMNSM )/ 0 f— 4937 we ? Kom for . tt�►11Ye..:� 1114�h!l�..Aa::�!!�t �i�l..��a1!��..� iv or�lig � iFEB aresnt; ts sale go am w ..... ...... ....................... ........ .................. ....«.. »............ ». ».�. » .. »... .. •......... .... wM..«..... . « «N......... »w...... « ....... ............ ......» mgtVM f0 ».. . «.««..................«.._ . ««........... »• ..r. ««.«. `- the eewplss�*one" nN aft" to »«.St. «ftau.««. Olea4. i f _ Vila lAtei Nei .............+................ - ta of the xorthwst Qsartaf Of tbs Qelarte (Nut of W }) of fktior Sawatess (17), TOWa*Dip Thirty - UM ierths of La ;s Sevrento" (17) hest, dsaeribsd as fellow: Lot 3 at Castified $=way Map filed 21, 19"2 in VDIMW "9"; Of Cestifiad lmr+7 Naps, pass 2476 an x Dame" Ns. "2"2. TOOMM iRiB A® Sf!lt.iNC 10 i; 66 foot ft4vate Zoadway Eaaewnt as sbaws ow said Certified Survey Nap. e• J I._ — _— _. �e TiY .__..ia..UOt........._. ►erwbad property. " Bnempum to warrantise: Dated ................... . .... «.... «..... dy et ............ ........................................ .......-° ................... . (SEAL).._. w.•......'........... L) ... ........ • Ni_ V...IU • ... ............... » .. ................... .... . ......................... __ .............. «._. «_...« ...M daal _......._($EAL) �....:l.1..(.. ...............(SEAL) • - . ............................................................... • vow - -�.. W ........................... ......... AUTUR =CAT :O N ACKNOWLSDOUNNT Z (a) arATS Ot WISCONSIN r. ...._ .... .....__«... « ------ -- - - - - -- jjr._tCn Coaaty. aatheatleated fib «......dp d__.._. __.. . «.._ . 1!_ «_.. 14eamAy ease before me this ' - ---- -day of JMMMJ « ..... .... «.... 19-1.1- the above named «_..._.�..... -- -__«.« ..._...... ___...._._ ..... wRAIMOSa v_ _ Edgy_ - dad. Sassa N--- AllA - - - - -- ` TITLE: I[S OUR $TATS BAIL OF WI$CONON �- ...«..�- - . ..... . .... ...... . ............... .. .... .... ... .............« N.__._ j.. .. «y...`...__.......... --- «----- .. � ' •--------- ----------------------- a>r ;p►+,r t ubd the he "me. THIG 111411TINIUMC ST W" DeArrco w bsinstra, Van DZk i Needhsm, S.C. -- � '�: =y . ... .......................... bbl Srntfii aailr�si 'dveriiis`,'boii'1'l7 ....................... - Iie.F -VA*N ea 6 -- W.-- 344L7­----­----- Nears h, Coua Wbx (Oftnatnrs may be authenticated or acknowledged. Both my � . iftato e:pi are not neeeseary.) O12awa, .! •maw .iedat b w .ap"Ne drdi M t.pw w ,rlat.A WOW tldr h •1faAM!! DAAa MA Awe Oe walua� - `�� 3 Wisconsin Legal Blanc Co.. aw- fOSel Na ! —lea '• ' p Milwaukee. Wisconsin i CERTIFIED SURVEY MAP Located•in part of the NW- of the NW- 1 of Section 17, T30N, R17W, Town of Erin Prairie, St. Croix County, Wisconsin. A ° LEGEND r o o o I" x 24" Iron Pipe Set, weighing 1.68 lbs. per linear foot v s N Roadway Setback Line Existing Fenceline v o Septic Vent c 0 Y .r. L �+ w OWNER v N L o Michael Riley L W 1627 160th Avenue A W 3 CO - ol New Richmond, WI 54017 C 10 — I C L 1/ O N Ol • v I CO M O N N} Corner of NW Corner of Section 17 Section 17 f6 0TI4 AVENUE I" x 24" Iron 2" Iron Pipe Found -- -- — - - -- -- - Pipe Set Nort lin of..t N W} ° ' " 7— S89 0 36 1 - 2 8 " t S89 °36'28 "E S 36 28 E 1017.57 300.011 ;3 562.59" �� 45 131 7.58' c S89 0 36 1 28 "E 528.36' E51 ) 7589°36'28';E 422.29' c >I 0 0 - < ..................... �? O. —. =.�. - rh o o p; cow oCn .y. Q N on o - House 5.51 Acres Inc. R /W• W z c 0 C. � o E' O en N M O S - I 240,162 Sq. Ft. W o N - Lei I v 4.79 Acres Exc. R/W a 1 e 0 o j U) ! of 208,563 S Ft. a W ; 50 � 33 1 501 0 3 Q I o I q 8.89 Acres Inc. R/W CO z -JI ° D o i ii , 387,419 Sq. Ft. _ s 0 w �* 526.66' 33.00' — ' © © v, 7.90 Acres Exc. R/W o w w I LLJi 0 � 0 344,129 Sq. Ft. o t° , f- -I �-- I o ' O '" -J w CJ I ° o' ° oo �v ' � 0 � JI z 3 F-- I 6.28 Acres Inc. R/W r 273,581 Sq. Ft. I J 5.93 Acres Exc.' R/W 258,330 Sq. Ft. ao 0 00 CO m ao 0 co m . . 11 0 00 000 (Tl I 0 cv 0 er o — 409.00' -- 5770. 66 3 3.00' " 33.00' 376.00' S89 51 44 "W 1019.66' J • UNP`a� , �C) L_ati�� . SCALE IN FEET 0 100 200 400 r C_,.u�� 1'V J This instrument drafted by Fran Bleskacek Proj. No. 92 - CURVE DATA CURVE RADIUS CENTRAL CHORD CHORD ARC TANGENT TANGENT N0. LENGTH ANGLE BEARING LENGTH LENGTH BEARING BEARING 1 233.00' 14 0 53 1 32" S07 60.39' 60.56' S00 0 23 1 32 "W S14 2 167.00' 14 S07 11 E 41.75' 41.86' S14 S00 3 200.00' 14 S07 °03' 14 U.84 51..98' S00 °23' 32 "W S14 4 200.00 14 S07 50.00 50.13' S14 S00 0 08 1 16 11 E 5 167.00 ,;14 S07 0 03 1 14 11 E 43.28' 43.41' S00 S14 6 233.00' 14 S07 58.25 58.41 S14 S00 11 E SURVEYOR'S CERTIPICATE I, Allen C. Nyhagen, registered Wisconsin Land Surveyor, hereby certify that by the direction of Michael Riley, I have surveyed, mapped and described the land parcel which is represented by this Certified Survey Map; that the exterior boundary of the land parcel surveyed and mapped is described as follows: A parcel of land located in part of the NW1 /4 of the NW1 /4 of Section 17, T30N, R17W, Town of Erin Prairie, St. Croix County Wisconsin; further described as follows: Commencing at the NW corner of said Section 17; thence S89036'28 "E, along the north- •line.of.the NW1 /4 of said section, 300.01 feet to the point of beginning thence continuing S89 "E, along said - north - line, 1017.57 feet; thence 500 "E, along the east line of the NW1 /4 of the NW1 /4 of said section, 880.00 feet; thence S89051'44 "W, 1019.66 feet; thence N00O00'00 "E, 889.42 feet to the poin of beginning Above describe arcel is subject to right -of -way for town road (160tH kvelue rd-. I, also certify that this Certified Survey Map is a correct representation to scale of the exterior boundary surveyed and described; that I have fully complied with the current provisions of Chapter 236.34 of the Wisconsin Statutes and the Land Subdivision Ordinance of the County of St. Croix in surveying and mapping same. Allen C. Nyha n Date