HomeMy WebLinkAbout018-1082-10-070 ST. CROIX COUNTY ZONING DEPARTMENT
AS BUILT SANITARY REPORT
EI
RE CEIV ED
Owner y aAxA Z lnmQ P" �
Address -- .-"1 '7 A /S 57 MAY 0 ;,r V)98 �
ST CROIX
City /State 1 Gc.l S , rOuNTY
zONINGOFFIcE
Legal Description: y
Lot _7 Block Subdivision/CSM # hz� "4
'' /. '/4 _Y& , Sec.. , T om? N -R/;�_W, Town of PIN # / 8 - /a c 4 - Ra - R m 2
SEPTIC TANK — DOSE CHAMBER — HOLDING TANK INFORMATION:
Tank manufacturer 14v, v , fl Size ST/PC/ -- Setback from: House ZZ Well P/L �/0
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: -t V Width A Length 47 Number of Trenches �-
Setback from: House 3 7 Well P/L > Vent to fresh air intake Y
ELEVATIONS
Description of benchmark %o PC/C . `
Elevation �
Description of alternate benchmark os T ` Elevation /da• s`7
Building Sewer /0 7 Y ST/HT Inlet `7 ST Outlet � J"�
PC Inlet --
PC Bottom Header/Manifold / 0 Top of ST/PC Manhole Cover A y
Distribution Lines
Bottom of System
Final Grade () `00, S () ( )
Date of installation 3 0 Permit gumber 3o763 F State plan number
Plumber's sign4turq License number /h/ 7yS� Date- of
complete plot plan
��o
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
�r
2,2
INDICATE NORTH ARROW
Wisconsin Department of Commerce Count
PRIVATE SEWAGE SYSTEM
Safety and Buildings Division
INSPECTION REPORT - f, GYOi,X
GENERAL IN (ATTACH TO PERMIT) Sanitary Permit No-:
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
PAtr 11 1 wk� arm e
CST BM Elev.: Insp. BM Elev.: BM Descriptt n: Parcel Tax No.:
q k (ti ,o/fr _/oho$' ...ZprZOt�
TANK INFORMATION ELEVATION DATA 44,F00028'
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septi > k j26a Benchmar „5796 /a5'Wo 700
Dosing 1.2L -/e/ 74
Aeration Bldg. Sewer 0,/ 99 p6`
Holdin
g _ - -- dD i/IE inlet �o • fi �q• S
TANK SETBACK INFORMATION 00 Outlet .( or
TANK TO P/ L WELL BLDG. Ai�rTlMake ROAD Dt Inlet �✓ /„
eptl t �, 7iTi + 23 + NA Dt Bottom k-
Dosing NA Header / Man.. p6 r
Aerati NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade SYS 1 ,00 -57
Manufacturer Demand • *1-1 S 1 ! Ido X111 le
Model N IF GPM
T Lift Friction S Ft
rcemain Did. Dist. To Well
SOIL ABSORPTION SYSTEM
TRENCH Width + Length No. Of Trenches PIT No. Of Pits Inside Dia. Liq epth
D IMENSIONS 1g & l DIMENSION
SETBACK
SYSTEM TO P / L BLDG WELL LAKE / STREA LEACHING Ma cturer:
INFORMATION Type Of f 2 BER Mod el - NooTb er :
SystemlJ40&4 7� W q - OR UNIT
DISTRIBUTION SYSTEM l la /
Header/Manifold Distribution Pipe(s) � x Hole Size Hole Spacing Vent To Air Intake
Length ! .� Dia. Length (07 Dia. �� Spacing rte ! ! A- SI S x Z7 ?- S6
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over eptn UT owed xx Mulched
Bed /Trench Center Bed/ Trench Edges ❑ Yes ❑ No Yes ❑ No
COMMENTS: (Inc u Iscrepancies, persons present, etc.) ?1"2 j6y7k 5 f w��a�„r t� C.,t
f.6A4 ' jo J� 4& el , / taU� 4 4W IDIdl 5e,v-w
CN�� w" 14� 5 Ida O �Dncr n.cat ��1, u ° 4v
j f C
Plan revision required? [:]Yes M No
Use other side for additional information.
SBD -6710 (R.3/97) Date Inspector's S nature . Cert. No.
SANITARY PERMIT APPLICATION 2 01 afety and E. Washington
Ascons I r i . A m. de P.O. Box 7969
Department of Commerce n accord with ILHR 83.05, W s d Co Madison, WI 53707 -7969
• 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. S T
• See reverse side for instructions for completing this application State Sanitary Permit Number
3 ?fj
The information you provide may be used by other government agency programs ❑ Check it revision to previous application
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION �- >d �', .2o ., a o
PropertyQyrner Name Property Location
/!� Sk 1 /4 ;, 114,S a o T 2 , N, R /,> E (orx' -Cor
Property O nerIs m ailing Address Lot Number Block Number
/S0 2 7
City, Sta Zip Code Phone Number Subdivision
W, e or M Number
/,t/ lN'� liS*)G9�'QyG
11. TYPE OF BUILDING: (check one) ❑ State Owned ❑ C ity Nearest Road
❑ Village
Public E 1 or 2 Family Dwelling - No. of bedrooms 2 Town OF Ag oigna a 16
III. BUILDING USE (If building type is public, check all that apply) Parcel Tax N
1 ❑ Apartment/ Condo
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.dj New 2 ❑ Replacement 3_ ❑ Replacement of 4_ ❑ Reconnection of S ❑ 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 kZ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑Holding Tank
12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 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) e Elevation
6 a* /.Zo 0 . — ' Cl Y. 7 Feet /0 / Feet
Capacity
VII. TANK in Ca allo s Total # of r Prefab. Site Fiber- Ex per-
INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic A p p
New Existing structed
Tanks Tanks
Septic Tank'' Z GU 7 — /Zvo 4 Ce, C ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber I — — ❑ ❑ ❑ 1 ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT 1
I, the undersigned, assume responsibility for installation of the site sewage system shown on the attached plans.
Plumber's Name: (Print) Pluffiber' g tun o r MP /MPRSW No-: Business Phone Number.
rcr D
Plumbe s Ac dress (Street, City, State, Zip Code
&m l�s S you
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued ssuin gen Signature (No Stamps)
/f� ���f
Surcharge Fee) ��
X Approved E] Owner Given Initial ( S f [Q (J / /
Adverse Determination at
X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL:
SBD -6398 (8.11/96) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
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Wisconsin Department of Commerce SOIL AND SITE EVALUATION
Division of Safety and Buildings Page �_ of
B
> L,-nau-cif Integrated 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 497
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
5 >8 - /o6t- ZC
APPLICANT INFORMATION - Plgdii f� a n. Revi ed by Date
Personal information you provide may be used for keF&dary p.4W rivac 15.04 (1) (m)).
Property Ow er Property Location 1 6�
f "t Govt. Lot SE'' 1/4$� 1/4,S a o T ,79 N,R /� E (or)40
Propo Owner's Mailing Address Lott # Block# Subd. Name or CS M#
/- X Z i ✓' �' uNN /
City State Zip od r ❑City ❑Village ® Town Nearest oad
Wd f Yo V, C1 An &7 o �O 0A.-C
[� New Construction Use: ® Residential / Number of bedrooms Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow 4 M gpd Recommended design loading rate bed, gpd /fl trench, gpd/ft
Absorption area required 1 7 00 bed, ft ' >c- trench, ft Maximum design loading rate bed, gpd /ft trench, gpd/ft
O
Recommended infiltration surface elevation(s) —� / $ Y ft (as referred to site plan benchmark)
Additional design /site cons ations IA —Y .41 tj 'y
Parent material ide Flood plain elevation, if applicable ft
S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
U = Unsuitable for system S❑ U W S �1(U MS BU i s S U ❑ S ® U ❑ S 19 U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2
in. Munsell ou. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
f
d - sL /rACs,C h,$f1X_W a I✓ /vF I ..s�
Z VZ s-Y f 313
Ground 3 3 1 4 5 e 7 ryR SIG t'S d � A In A.
Depth to
limiting
factor
> 1dr in.
Remarks:
Boring #
0- X
Irs
Ground
elev.
Depth to
limiting
7 r f , aCtor
f in. Remarks:
CST Name (Please Print) gnature Telephone No.
Address Date CST Number
3? 2Z s + � ,� w1 S'v� 1 .2-/0, 9 7 yo 9
2 ; Min < SOIL DESCRIPTION REPORT ,
PROPERTY OWNER — Page Z of 1' '
PARCEL LD.#
Boris # Horizon Depth Dominant Color Mottles Structure 2
Boring Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench
Ground
elev.
!a 1, 4L ft.
Depth to
limiting
factor
'7 JOin.
I
Remarks:
Boring #
/ o. a ), ryoull SL zovxx,(' hir�iP caw IaG y S`
F
Z 7, -/S W 313 !a' !nom Qw '7 S
3 A
Ground
JO D Z, ft.
Depth to
limiting
factor
> /0'L in.
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots D
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Boring # , JZ ? altz. s// -- SG 10, -Adle AV. Q w Jac
3 �A2 7sY� le Fs 05t 101.4
Ground
elev.
/s 3 ft.
Depth to
limiting
factor
7 i0A in.
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
SBD -8330 (R. 07/96)
STC -105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
MAILING ADDRESS IN �' )c — 72 -
PROPERTY ADDRESS '717 1 S I A '5T, I'
(location of septic system) Please obtain from the Planning Dept,
CITY /STATE
PROPERTY LOCATION - 1/4 1/4, Section 30 T �N -R �,�
'SOWN OF ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMIIER
CERTIFIED SURVEY MAP , VOLUME PAGE , LOT NUMBER 7
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 licensed septic tank pumper. What you put into the system can affect the function of the septic tank
as a treatment stage in the waste disposal system.
St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost
of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that owners of all new systems agree to
keep their system properly maintained.
The property owner agrees to submit to St. Croix Zoning a certification forth, signed by the owner
And by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1)
the on -site wastewater disposal system is in proper operating condition and (2) after inspection and
pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum.
I/We, the undersigned have read the above requirements and agree to maintain the private sewage
disposal system in accordance with (lie standards set forth, herein, as set by the Wisconsin DNR.
Certification stating that your septic has been maintained must be completed and returned to the St. Croix
County Zoning Officer within 30 days of the three yea piratio� date.
SIGNED-
>� t
4; DATE: 2 L 9�
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
8 T C - 100
This application form is to be completed in full and signed by
owner(s) of the property being developed. Any inadequacies w
only result in delays of the permit issuance. Should tl
o development be intended for r esale by caner /c c (s)
house), then a second form should be retained and completed w;
the property is sold and submitted to this office with
appropriate deed recording.
----------------------------------------------------------- - - - - --
owner of property -/ Z • n+w.K
Location of property 1 /4 S,6 - _ 1/4, Section sad ,T -R
Township 1 4Q A lJ Mailing address 7% ., J /S
Address of site
Subdivision name Lot no.
other homes on property? Yes No
Previous owner of property .one.
Total size of property 2,0 ac x. .
Total size of parcel 2.0
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house) ? Yes
Volume and Page Number as recorded with the Regis
of Deeds.
---------------------------------------------------------------
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND 1 .
NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition,
certified survey, if available, would be helpful so as to av,
delays of the reviewing process. If the deed descript
references to a Certified Survey Map, the Certified Survey
shall also be required.
i
PROPERTY OWNER CERTIFICATION
I (we) certify that all statements on this form are true to
best of my (our) knowledge that I (we) am (are) the owner(s) of
property described in this information form, by virtue of
warranty deed recorded in the office of the County Register
Deeds as Document No. , and that I (we) presen
own the proposed site for the sewage disposal system or I
obtained an easement, to run the above described property, for
construction of said system, and the same has been duly recorded
the office of the County Register of Deeds as Document
ignature pplicant Co- Applicant
Z.6. 9r
pate of Signature Date of Signature
~ TD s y STATE BAR OF WISCONSIN FORM 2 — 1982
WARRANTY DEED
DOCUMENT NO.
Halle Builders, Inc.,
conveys and warrants to. Paul G. Zimmer and Suzanne M.
Zimmer, husband and wife,
THIS SPACE RESERVED FOR RECORDING DATA
NAME AND RETURN ADDRESS
the following described real estate in St. Croix County,
State of Wisconsin:
�I
018- 1068 -20 -200
PARCEL IDENTIFICATION NUMBER I
Lot 7 of Plat of Meadow Ridge, St. Croix County, Wisconsin. j
j
I
it
i!
I
This
is not homestead property.
=X (is not)
Exception to warranties: easements, restrictions and rights -of -way of record, j
if any.
Dated this 12th
day of January , A.D., 19 98
y
Halle 1 rs,
(SEAL) By: (SEAL)
(SEAL) (SEAL)
I
I I
j
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) State of Wisconsin,
ss. (
St. Croix County it
authenticated this day of , 19 Personally came before me this 12th day of ;!
January ' 19 98 , the above named'
Halle Builders, Inc., by: l
ii
TITLE: MEMBER STATE BAR OF WISCONSIN
I
(If not, Connie
M
authorized by §706.06, Wis. Stats.) M . G U IiIXF60ft known to be the person who executed the foregoing
Mate PUbllOnstrument d acknowledge the sa
Nota
THIS INSTRUMENT WAS DRAFTED BY O f Wisconsin �J �✓
Attorney Kristina Ogland
;I
Connie M. Gullixson
Hudson, WI 54016 Notary Public, St . Croix County, Wis.
(Signatures may be authenticated or acknowledged. Both are not My commission is permanent. (If not, state expiration date:
necessary.) 12 / 9 AX 2 . 001 .)
• Names of persons signing in any capacity should by typed or printed below their signatures.
STATE BAR OF WISCONSIN Wisconsin Legal Blank Go., Inc.
WARRANTY DEED Form No. 2 — 1982 Milwaukee. Wis.
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FIr74TneN,ovaTCUe iXin .. _.., �. .. _
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V
MEADOW RIDGE OWNER
RALLE SOIL
IW M 0
M[ls RIL7RI0
LOCATED IN PART OF THE SEV4 OF THE SEV4 OF SECTION 30, T29N, R17W, IN THE TOWN OF
HAMMOND, ST. CROIX COUNTY. WISCONSIN; BEING LOT 3 OF CERTIFIED SURVEY MAP RECORDED
IN VOLUME 9, PAGE 2684, AT THE ST. CROIX COUNTY REGISTER OF DEEDS OFFICE.
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