HomeMy WebLinkAbout018-1082-10-060 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM v
Safety and Buildings Division Count ST. CROIX
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar61196yb:
Personal information you provice may be used for secondary purposes (Privacy Lair, s.15.04 (1)(m)]. 3S 1 Jy 1L y
CMiVA,old ffAVTV: [qfj0 "ge ❑ Town of: State Plan ID No.:
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION ELEVATION DATA A9800308
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic �Zp�j Benc a y, V-6 1 /pp
Dosing
Aeration Bldg. Sewer
Holding St/ Ht Inlet 3.$2 (05
TANK SETBACK INFORMATION St/ Ht Outlet z /057
TANK TO P/ L WELL BLDG. pti c tVent
ke ROAD Dt Inlet
e ;Zv NA Dt Bottom
sing NA Header/ Man. • �� l d y
Aeratio NA Dist. Pipe TI- S lam 3�
S. . i r6
•zc.
Holding Bot. System 2- (.•4 O 1!— c� c.
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Dem ��
Model N ber PM
L Friction System DH Ft
emain Length Dia. H Dist. To Well
SOIL ABSORPTION SYSTEM
BE TREN Width' .i t '3 ength No. Of reriches PIT No. Of Pits Inside Dia. Liquid Depth
DIM N T DIMENSION
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manu acturer:
SETBACK
INFORMATION Ty C CHAMBER OR UNIT Mode Number:
S st
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pi �pei1) �� j x Hs al i ie x Hole Spacing Vent To Air Intake
Length =1— Dia. Length - Dia. - 5 Spacing 7 1 t 5F"t l Z O
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: HAMMOND 30.29.17,SE,SE 713 159TH STREET — MEADOW RDG LOT 6
(T c , 4A - a lac
T �
CO rw Ak_PC_U 64 vi
Plan revision required? ❑ Yes 0 No
Use other side for additional information. t 7 l 7
C SBD -6710 (R.3/97) Date Inspector's Sig ature Cert No.
Safety and Buildings Division
NV isconsin SANITARY PERMIT APPLICATION 2 01 W. Washington Avenue
I n 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 8 112 x 11 inches in size. C IZ 01 X
• See reverse side for instructions for completing this application State Sanita Permit Number
you provide may be used for seconds purposes
315
y p y secondary p rp C heck if revision to pre
Personal information s application
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RM TI N —
Property OwneLName Property Location 00,
U is 1 ia, S T Z, N, R/ ( E (or)
Property Owner's Ming Address O O Lot Number Block Number
City State Zip Code Phone Number Subdivision Name or CSM Number
11. TYPE OF BUILDING: (check one) ❑ State Owned o O Nearest Roa R Q U�
Public 1 or 2 Family Dwelling - No. of bedrooms own OF /1 0A r
Ill. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) j Kq
1 [] Apartment / Condo 1
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. I& 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 ®,Seepage Trench 22 ❑ In- Ground Pressure r 1 42 ❑ Pit Privy
13 ❑ Seepage Pit 3 — J r X b 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
Re uired (sq. ft.) Proposed (sq. ft.) (Gals/da 2 �Iap
ft.) (Min. /inch) /•2.n
zoro , f °2 Feet o Feet
Ca at o =
VII TANK in ga Ions Total # Of m Prefab. Site Fiber- plastic Exper.
Manufacturers Name n
INFORMATION Co steel
Gallons Tanks Concrete to lass A PP
o e g
New Existin struded
Tanks Tanks
pticTan k IV 6 S ❑ ❑ ❑ 1 ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ 11 ❑ ❑ E]
Vlll. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumbe ' Name: (Print) Plumber's ?gnature: (N t ps) MPIMPR" No.: Business Phone Number:
Soy/
Plumber's Address (Street, City, State, Zip Code):
C C C—s 4
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issu ng r t Si nature (No Stamps)
A roved SD % Surcharge Fee)
pp ❑Owner Given Initial '7 G S,7 / r
Adverse Determination ��O
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD- 6398 (R.11/97) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
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Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page \ of 3
Labw and Human Relations
• Division of Safety & B uildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site PI on paper not less than 81/2 i es an ifil -z-p- S`r.
. an must include, but X
not limited to vertical and horizontal reference point r'Ta�6lof ; scale or PA # _
dimensioned, north arrow, and location and dista R IEWED BY DATE
arest rid. % �1�1►�J C
APPLICANT INFORMATION - PLEASE P �, LL IIJfpF ON G
PROPERTY OWNER: PRCOERV LOCATION GO# i4
Of S E t/4 5 � 1/4,S 3u T _.`j. ,N,R VI E (01,Q)
PROPERTY OWNER':S MAILING ADDRESS „', L07 t BLOCK # SUBD. NAME OR CSM #
339 c` KBuRn,� p� • ,r > vk ANT
CITY, STATE ZIP CODE NEN ,MBER ❑ [:]VILLAGE MOWN NEAREST ROAD
RlC! -�`P L 0►vp lts>�.+�u ck� u o�l� S ( {,.
[X New Construction Use [ , Residential / Number of bedrooms y [ ] AdditiQn_ to existing building
I I Replacement [ ] Public or commercial describe
Code derived daily flow boo gpd Recommended design loading rate — bed, gpd/ft 5 trench, gpd/ft
Absorption area required � SS la o bed, ft2 vzuo_ trench, ft Maximum design loading rate • y -bed, gpd/ft • S trench, gpd1ft
Recommended infiltration surface elevation(s) %" 1►�S 1 ft (as referred to site plan benchmark)
Additional design/ site considerations S . V - BD ' l.Ljry G . MPr'�- Z� 4 r� AT UP S W'PE ND GE
Parent material u \w1� 3 Flood plain elevation, if applicable t-1 A - ft
S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable fors stem I PIS O U IRS ❑ U RS ❑ U as ❑ U EIS O U ❑ S LUU
1 ►.i�"l1f'C�- Pr- � DESCRIPTION ROORT p'L_ J
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boun, Roots GPD /ft
in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed jTrench
11 L _L*1 s bk y +. ► 'qF- es . 5 , t�
Ground 3 Z Z _32 S ct / - s t S b k In ui�_ A.w - 1 • �}
elev. 1 S �sl�1 �n v (2,1, . 6 - `
lu ft 3z -�y �• S `1 R y� �
Depth to L'_ S 1 Ts ��"'� 1ry1 U'FI- _ • `l ` . 5
limiting
factor
1 y
T
Remarks:
Boring #
INS
yam;
0- 2 3 l y — s� 1 2 `�s k�� eS — • s
Z Z si Z'FS�4� y►�F. c S • S 6
,$
m eLti - -? •�
Ground
elev
1 ft. Lj 38-88 a `t tz S ) tit \.) • Y -s
Depth to
limiting
fac $,
Remarks:
CST Name-Please Print Arthur L. W e e r e r Phone: 715-425-0165
egerer Soil Testing & Design Service -P.O. Box 74 River Fa11s,WI 54022'
Sgnature: a r cif Q =l 0'] Date: ; C � CST Numb
Ov l htlt�, 00 5 7 6
PROPERTY OWNER G Z SOIL DESCRIPTION REPORT Page 2. of
PARCEL I.D. ff V: N6
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft
in. Munsetl Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Try
o - q L o-t. \'z 31 V - S' z +sb� m ii,- cS - • s
1 3 : � Z q - Z lu lz. a — S •1 1 Z yr sbk m f,- s -S
Ground 3 2Zy8 - �,S � lz Y/Y S s my fv. �w • s • b
elev.
` Os. % ft. X18 - 63 lw tZ s /y — '�s 0 W YnU C_S _ •�( i.S
63 -�0 5 � V/
limiting f5
Depth to S ' - 1 `'1 R 3 l S� 0 r yv�,
factor `
3•,
i
Remarks:
Boring #
o `
1 0 -1 1 �`1 3l q t Z'F b►T m 'fr cS s
�f do -z,3 to "l 31 (� 311 Z h1 s b> »� `�►- cS - • 5 , b
3 23 -s tz- X11 - 1 s e sbk >- u'f t - c ►" - .�
Ground
1 0\1 . Z ft. hi U
Depth to
limiting
factor
Remarks:
Boring # r
:��: i b- l o w`1.a- � L y � S 1 2`{� s � k l�n'F►, c � , S L
5 Z Ib - z? w \ -t IL i
k..
Ground LL
elev. 3b -� �, lu `-1 tL y! S ti R
low ft.
Depth to
limiting
factor
i
Remarks:
Boring #
o - 1 b�1 �3ty s �1 Z'Fs rn'�� e • .`
1 0`2tZ31L si 1 Z�, m'F� � •5
Ground 3 4 (� -s�o)� In ►- e g L i .3
elev. y L)6 - 68 Vo - �L Sly y U - , y ` .5
I ra-`8 ft.
Depth to
limiting
factor
Remarks:
SBD- 8330(8.05/92)
PL P LAN Page 3 of 3
SCALE 1 "= 4 b '
�- IN
x
O
- �, O c- ��-1:�� S1zr�Tcli •
\ o n
J
gwl %# 2
IoS
8.3 S L'�L.to�t
�o
b�
i�T U�SIUPF Qtr
V ti rot S
»cst�s
biro& E 70 3E frT" LEUT ZS' F "XI
Vl.lEuL y
98- lb
_9i�,
(715 > - I4 00576
CST Signature Date Signed Telephone No. CST #
Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page . of -. 3
Labor and Human Relations
Division of safety & euik6ngs in accord with ILHR 83.05, UVis` Adm Code
COUNTY
Attach complete site plan, on paper not less than 81/2 x 11 inches in size. Plan must include, but ST • CtZ.p �( _ .
not limited to vertical and horizontal reference point (BM), direction and % of slope; scale or r? : t. FAFICEL I.D. #
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFO RMATION= PLEASE PRINT ALL INFORMATION EWEDBY DATE.
f
PROPERTY OWNER: PROPERTY LOCATION
NV \ U G �-( G914. Eel: S t 1/4 S e 1/4 3p T Z` i ,N,R 1Z E (orCWD
PROPERTY OWNER'.S MAILING ADDRESS LOT # I BLOCK # SUBD. NAME OR CSM #
339 C` ",� Au�we DR_. C' T Vk 5 G - M Et�w3w \2lD G
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY []VILLAGE MOWN NEAREST ROAD
l k Cc_"`P'LUIvp NCOQluek- (") (, .9 ZZ `V " t"l OK ob I "l o Y*
New Construction Use ( Residential / Number of bedrooms y [) Addition to existing building
[) Replacement (] Public or commercial describe
Code derived daily flow bOO gpd Recommended design loading rate — bed, gpd/ft -5 trench, gpd/fi
Absorption area required `so o bed, ft Imo trench, ft Maximum design loading rate • y bed, gpd$ • S trench, gpc*
Recommended infiltration surface elevation(s)>—1 it (as referred to site plan benchmark)
Additional design/ site considerations 71 -t( S- !{ S K 8D' w►vG . 1 k)► - Z-1 bee? AT UPgaw?E E'b GE
Parent material our12 uv1.y sN Flood plain elevation, if applicable hl A • ft
S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL T E]S HOLDING TANK
U = unsuitable fors Stem Ns ❑ u ®S ❑ u cgs ❑ u p � ®s ❑ u ❑ s O u jZu
SOIL DESCRIPTION R9 RT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consister>oe Bounclary Roots GPD /ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Tmnch
'N.tiivi$
Z VS- Z to ' 1 1 1 L — s 1 Zw> s bk m�� s - s
Ground 3 ZZ_32 1 S `t IL t,f !y S 1 �- S bk Yt u� • `d
elev.
lu \•S ft. A - LM l -S L /R Yl.L 1 g
Depth to
limiting
factorl 4 a
Remarks:
Boring #
Z Z o� 2.316 — si 2.'FSb�• \��� �S � • S b
Ground
elev. L( 38-88 t (3 `t R ) V`�t- • �L .5
\ oy•3 f
Depth to
limiting
factor $ti
Remarks:
CST Name: Please Print Arthur L. We e r e r P10t1e 715
g rer Soil Testing & Design Service -P.O. Box 74 River Fa11s,WI 54022
Sgnadue:
Date: _ S -� CST Num
00576
PROPERTY OWNER SOIL DESCRIPTION REPORT Page 2, of
PARCELIA# P�101N6
Depth Dominant Color Mottles Structure GPD /ft
Boring # Horizon Texture Consistence Boundary Roots
13 In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trerch
o -q to-. rz 31 - s' Z+Sb� m �� o-S - • S . �
Z q -zz „1u 2 3�6 — s 1 J - Z hi 3bh �- s ,S ,
Ground S `t R y/ y m v
elev.
� 'PS 0" YnUt- eS
Depth to S L3 - 0 5 `'1 lZ V/y S4 R 3 l Si
limiting O ti►-t y „ `�' 1, — N 1' ; - Z
factor
Remarks:
Boring #
1 0 -lo W SL)
4 Z
v3 31 b - st I Zvn bh »�`F� cS - •5' .�
3
J3-18 -1 -s l t�- �1 - S e Sbk > u f I ,. C 1,J • b
Ground
� el e v.:- 724- 1l3 %I L S l y — `� g o � ►-, »i v 'F l- - • �( .5
Depth to
limiting I
factor E
?
i
Remarks:
Boring #
1 5 Z 1 b - 2l L�1 �'t R l ( o S l Z ► Yl S b� yv1 F C_
3 L�_3to �. S tZSll - 1 s \ eSbk m v'�r c S
Ground II�
elev. 36 -�l b 10 `ti LL �!! s H % 3 l S i ' c e S �k 1�'i `� 1^ • Z- ; • 3
low ft.
Depth to j
limiting '
factor I
Remarks:
Boring #
o - s11 Z' -sb4� w►'� e • S �
31 `
3 �6 -qL S'-I 31y
Ground 5 K IZ 31 se-1 se � E. ha 'FL e g � . °Z � • 3 .
e►ev. 4 �6 6$ 1 ��-t iZ s o� 1n V - ,
1 0 , 2 -S ft.
Depth to
limiting
factor �
h
Remarks:
sBD- 8330(R.05/92)
PLOT PLAN Pa 3 of 3
SCALE 1 "= y0 '
O
�o
�c
g� '
�J '
emo s 5'
B.3 S ' .toy 3
0
5
b
1►J�`n'Pc� �' Jr`
s
off^
Y� U
VY3 ra cN �" \PAN p t lie - __-
By`'1 z - Lt 1vu.3'
VV EuL_ K w 4 a y
98- 1b�
044 ta7_• S —�� ( 715 ) 425 — n1 h5 14 00576
CST Signature Date Signed Telephone No. CST #
r -
ST CROIX COUNTY
SEPTIC 'TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner /Buyer .. J)AV i D j • (�
Mailing ddress So ,,,
I S
E - i L S tom- 0 s3o1C r w S'fD/ 7
fh
Property Address 11
(Verification required from Planning Department for new construction)
City /State Parcel Identification Number
LEGAL DESCRIPTION
Property Location S6' ' /�, SF ' /�, Sec. Off T N -R_�:LW, Town of &a oao w2
Subdivision EAR c > LJ 1�(ot3 , Lot #
Certified Survey Map # , Volume , Page #
Warranty Deed # SRj f g , Volume /33Z , Page # y5(o
Spec house ❑ yes l(no Lot lines identifiable R yes O no
SYSTEM MAINTENANCE
Improper rise 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 properly owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a
master phnuber, jouuieyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system
is in proper operating condition and /or (2) alter inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
1 /we, the undetsigned have read the above requirements and agree to maintain the private sewage disposal system with the standards
set forth, herein, as set by the Depaitrrrent of Conrinerce and the Department of Natural Resources, State of Wisconsin. Certification
Ling that y ur septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
y, of the tlr a ye "e piralion date.
SIGNA'T'URE OF APPL ANT 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
th operty d scribed )ove, by virtue of a warranty deed recorded in Register of Deeds Office.
SIGNATURE OF APP 'ANT DATE
* * * * ** Any information that is iris- represented may result in the sanitary permit being revoked by the Zoning Department. *"""
** inet+ude 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
f IEF'F::II_I I:_Of I: i F _b:_ 11LlfJ F1 : 1`15-- 24 f; -4 i48 Ju1 98 1 � :3.3 F. 021'02
� l�Ql 1,3.3?4GE46
0 STATE 13AR OF WISCONSIN FORM 2 – 1982
'kA'ARRANTY DFED
DOCUtvIENT NO.
Halle Builders, I nc., a Wi sconsin � �����'�s
✓ co . _ _.. a T. CR0I�ti
juM
con cys and warrants to — D avid J « G a y J a S i n l a lL'
9:30 A�„
y ~ P.o;�is ?�r car
__ W4YapCei�Tw ^�S�SSMAz{WTiRM!`VC�P
THIS SPACE RESERVED FOR RECORDING DATA
_ -- W NAME AND RETURN ADDRESS
the following tlescrihr.d teal estate in `at . Croix County, David Gray
Stain of Wisconsin: 2339 Skillman Ave.
North St. Paul, MN. 55109
PARCEL IDENTIFICATION NUMBER
Lot 6, Plat of Meadow Ridge in the Town of Hammond, St. Croix
County, Wisconsin.
TRANSFER
r
This is not homestead property.
XXX (is not)
Exception to warranties :Easements, restrictions and rights-of-way of record,
if any.
Dated this �� .+ u —_ day of May A -D - 19 98
Ha11e e 's,
(SEAL) By (SEAL)
(SEAL) _..._... — ._, ,.•. (SEAL)
ry R
AUTHENTICATION ACKNOWLEDGMENT
,I
State of Wisconsin,
St. Croix s'
--- County.
j authenticated this day of 19 Personally came before: me this - 4V day of
May 19_ -„ 9 $' the above named
Halle Builder Inc., by
11.CLr: MEMBER STATE BAR ()F WISCONSIN _....
(If not, t?nn M. GUliixson -
authorized by §706.06, Wis. Scats.) Not lY �Ub�IC to me known to be the person — o t�xec:utcd the foregoing
lr instrument a t-knuwledi;e. the same.
THIS INSTRUMFN I WAS DRAFTED BY Stat8 Of Wisconsin i It• 1 b � � • �� ° -,[ �
At torney Kristina Og land
Hudso WI 5401 _ Notary Public, <;r. Chee,i ____— •– County, Wis,
(Si,gnaturrs may he authenticated or acknowleJgvd. Both are not My commission is f,r.rrnanc:nt. (If not, state expitation dace:
• Namcs of persons signing in any calleuly should be Typed or printed below thrir ftnatu,ea
STATE DAR Or WISCONSIN Wluconoin Legal Clank CO30C.
Mawaukee. was,
,ire urLeury nrrn Torm Nn 2 – 1982 �
54'W
'47'1
pa
'434
'544
'304
54'8
'064
'54'B
'54'8
I
B'
w 33' 33'
— ,1315.69
325.87' 60.28 297.00' 33.Od
—
1282.69'— — I M
I 0
D
0
I
LOT 7 LOT 5 N ° 0 0
m
— o I�
2.00 ACRES w I 1.90 ACRES; 0) II'_
87,123 SO. FT. qo 82,547 SO. FT I > 0
a�O �' o m ,� 10
ril I =
LOT 6 Icy
o m m I
2.00 ACRES
� I
87,120 SO. FT. N89 0 53'18 "E 297.00'
0
I Fri I j�
Ln
w
\ W N m i 0) I L7
m W
N1 LOT 4:
°°-
N
S87 039'07 "W 293.89' ti 1.90 ACRES
w
I
82,547 SO. FT.
p C
W
I
LOT 3
\ 33' 33' w 33.00'
\t 2.00 ACRES ry m 297.00'
1� 87,123 SO. FT. CD S89 06 330.00 I ,
CD
\ ' I N 66
o
o� ! _
5 N 71 i 1
� I PLAT LOCAT 10
I(q� S89 ° 17'24 "E 338.49' O
t 0 C S M SECTION
- -- � C.T.H. ..TT,
LOT 2 0 Vol
4
t �I N +� - -
N
2.00 ACRES
w
r o� 87,119 SQ. FT. V, �OC74
NWI /4
• �j O
320.48' W =
ST. CROIX COUNTY ZONING DEPARTMPNT
AS BUILT SANITARY REPORT 1�
Per
&
Owner I �„
Address E
City /State L 5 - 7 \ ;f ,- �V� c ticE
Legal escription: �'` '•
Lot Block K)-A Subdivision/CSM #
'/• '/. LE, Sec. 3Q, T2aN -RLLW, Town of ff) PIN #
SEPTIC TANK — DOSE CHAMBER -- HOLDING TANK INFORMATION:
Tank manufacturer _ �.1� �Q S Size ST/PC 1-160 Setback from: House < Well -" P/L �0
Pump manufacturer Model —
Alarm location s - ) / I C, e
(HOLDING TANKS ONLY)
Setbacks: Service road /UA Vent to fresh air intake Aj 4 Water Line
Meter location /U)9
Alarm location i'l)
SOIL ABSORPTION SYSTEM:
Type of system Pa e e- 1 { � _ Len Number of Trenches
hes
Setback from: House - Well p/L, Vent to fresh air intake > S�
ELEVATIONS
Description of benchmark S-� /3'1 I r Elevation
Description of alternate benchmark D u 5E ou -, oA f ro^) Elevation _ /0e.
Building Sewer CD , ST/HT Inlet - Q 10 � ST Outlet/ I O q, a �O PC Inlet
PC Bottom Header/Manifold 1 6q, g Top of ST/PC Manhole Cover - 7
Distribution Lines (�) , - 7� LO 36 (
Bottom of System 6 3 (o Z , 76
Final Grade (() (� r ,1 (Z)
3
Date of installation ? / / Permit nu r I I State plan number IyA"
i'
Plumber's signature �1 - License numberl'Yl CD 3 Date� /�/ 18
Inspector
Complete plot plan Or
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
INDICATE NORTH ARROW
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