HomeMy WebLinkAbout020-1322-40-000 i
ST. CROIX COUNTY ZONING DEPARTMENT
AS BUILT SANITARY REPORT
ner
idress
'ity /State _ /,4. n ,� G .,,� ?-yam
Legal escription:
Lot,f1jW Bloc Subdivision/CSM # s ,p6 iA,
'/, Jw '/, , Sec. 1 , TAN -R/f _W, Town of PIN # o --o
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION:
Tank manufacturer 61e r- -/cs Size SVPQ U/ Setback from: House > -.7 Well > 'a PAL —
Pump manufacturer — -- Model - ---- --
Alarm location
(HOLDING TANKS ONLY)
Setbacks: Service road Vent to sh air intake Water Line
Meter location
Alarm location
SOIL ABSORPTION SYSTEM
Type of system: , Width 12- Length S.J'" Number of Trenches
Setback from: House >S7_ Well > /DV PAL Vent to fresh air intake > wy
ELEVATIONS
Description of benchmark ' Elevation / ®O.,
Description of alternate benc k 41 Elevation
S
i21•h� -4 7 ' --
Building Sewer ST/HT Inlet -2 ST Outlet Qj d"� PC Inlet "
PC Bottom Header/Manifold 5P,? Top of ST/PC Manhole Cover 91. y
Distribution Lines () () ( )
Bottom of System () q 2. .3 •
O O
Final Grade
Date of installation r //-V Permit nu er Z0 76,r7 State plan number
Plumber's signature License number / 1 ,fU Date //1 /1
Inspector_
^a 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
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INDICATE NORTH ARROW
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' Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count Safety and Buildings Division
INSPECTION REPORT ST. CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary T
Personal information you provice may be used for secondary purposes (Privacy La I s.15.04 (1)(m)).
PBRRId16' Ipa UCTION INC. ❑ I & C Nage Town of: State Plan ID No.:
CST BM Elev.: Insp.. BIV Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION' ELEVATION DATA A9800027
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic % k h
Bencmar
Dosing
Aeration Bldg. Sewer 9e., 7 /
Holding St /Ht Inlet /
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P/ L WELL BLDG. Air i to ntake ROAD Dt Inlet
ir
Septic / S: 7 ' NA Dt Bottom
3, .z
Dosing NA Header / Man. 07, 3 9' , 23 J cr
Aeration NA Dist. Pipe 71 (' 2-11
(D
a
Holding Bot. System ` 9"
PUMP / SIPHON INFORMATION Final Grade .( t'
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
m ead
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width , Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMEN I N DIMENSION
SETBACK
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: ' INFORMATION TypeO j., CHAMBER Model Number:
System: ,! < ,� S J/ �� �cJ, OR UNIT
DISTRIBUTION SYSTEM
Header / Mani old 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' G� + Bed /Trench Edges , "" Topsoil ❑Yes ❑ No ❑Yes E] No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON 10.29.19,SW,SE 663 TODD LANE SCOTT ACRES LOT 4
�P
Plan revision required? ❑ Yes ❑ No
Use other side for additional information. '?
SBD -6710 (R.3/97) Date In pe or's Signature Cert No.
f
SANITARY PERMIT APPLICATION 0 Safety and 1 E. Washington A e.lion
Vi sconsin In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
Department of Commerce 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.
• See reverse side for instructions for completing this application State Sanitary Permit Number
307(037
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.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION
Pro rt y Owner Na a Property Location
va 1 /4, S T , N, R E (ottW
Property Owner's Ma)ing ddress Lot Number Block Number
w
Clt Zip Code Phone Number Subdivision Name oI- G,SAA.AIafnber
cot O ( > o
11. F ILDI NG: (check one) ❑ State Owned it�r Nearest Road
�. ❑ o age
Public 1 or 2 Family Dwelling - No. of bedrooms T of vCrti
111. BUILDIN USE: (if building type is public, check all that apply) 1 �arcel Tax Number(s)
1 ❑ Apartment/ Condo — a
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. ❑ Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5, ❑ Repair of an
______System ________ System____ ___ ______TankOnly______________ 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 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
qST ] 149- Re uire (sq_ ft.) Proposed (soft.) (Gals/day /sq. ft.) (Min. /inch) Elevation
�� Feet IM V Feet
VII. TANK Cap acit in allons Total # of Prefab. Site Fiber- Exper.
INFORMATION g Galtons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existin structed
Tank Tanks
Septic Tank 4620 ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ 1 ❑ 1 ❑ 1 ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of a onsite sewage system shown on the attached plans.
Plu ber's Name: (Print) Plumber's Signature: St ps) MPRSW No.: Business Phone Number:
vim 1' 7ff - A4r JX'
Plu is Address Street, City, State, p Code):
d < 23
IX. COUNTY /lDtPARTMENT USE ONLY
❑Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issu Ag ntSi nature(NoStamps)
Approved []Owner Given Initial r 80 So Surcharge Fee)
�j
Adverse Determination ` (l�
X NDITI NS OF APPROVAL/ REASONS FOR DISAPPROVAL:
SA46 Pew SISID - GM (R.1111/96) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
1
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PLUMB G
���
>�o , #3233 #32 Road
ROBE Wl FtS"
Phone 73666
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X Zot
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j a� � / Sur vi�ort /eCd
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�GcJ 970
,70
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.A- < M
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DAVE f
Licensed Perk Tester & Plumber
#3213 #3289
V 'tY Heights Road
1 * 1 4d ��N S, b ISC'Om!. im '54023
Phone 749 -365.6
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END V -T vY
3 j 6
,..JIVrlaconsin Depot Unent of Industry SOIL AND SITE EVALUATION REPORT Page l of 3
La�JOf % Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but
not limited to vertical and horizontal reference Po int BM , direction and % of slope, scale or PARCEL I.D. #
( )
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
W CONS Z GOVT. LOT w '1/4 1/4,S /p. T .� N,R 9 E (Zffl
PROPERTY OWNERISVAILING ADDRESS LOT # BLOCK # I SUBD. NAME r OR CSM #
�o
CITY, STATE ST , ZIP CODE PHONE NUMBER []CITY VILLAGE MOWN NEAREST ROAD
ffC QkC r-- !.o' -P Old (�' 1 1164 1
[A New Construction Use [/] Residential I Number of bedrooms y [ ] Addition to existing building
[ ] Replacement [ ] Public or commercial describe
Code derived daily flow 400 gpd Recommended design loading rate _ bed, gpd /ft gpd/ft
Absorption area required — bed, ft _Z� trench, ft Maximum design loading rate _ bed, gpd /ft gpd/ft
Recommended infiltration surface elevation(s) a,3 - 97 m 3 </ 9 -49 ' ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material r— 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 m S ❑ U El S 0 U [ S 11 U ❑ S 01U ❑ S m U ❑ S � U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft
.............:....:..
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
F
�o 7
L h C s F .s
Ground !p S 6 G 3X S
elev.
Depth to
limiting
factor
r ..
Remarks:
Boring #
` O SQL Z C 5
on
G r n
ou d
elev. el L 7
Depth to
limiting
factor
Remarks:
CST Name:—Please Print , ,wz / 7 Phone: 7 S�
l/ Zp►y1N
Address: o ��
Signature: Date:
3 . ^
r PROPERTYOWNIER y.! '=�Z Tif SOIL DESCRIPTION REPORT Page
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PARCEL I.D. 7! : ;c,94 At ,� S L, 7'4
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bouncl3y Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
Ground 3 7. > S '® S A M L S
elev.
ft. _ S A4 L
Depth to
limiting
factor
Remarks:
Boring #
�.. Z d —Z to -- SrG M F/L CS F
Ground 3 s 7. > _ — — g— rL MSS ,� s , o ,
4± ft. L — .8
Depth to
limiting
factor
D � u
Remarks: 3 L v zzo ,4< g /�'TieeSjuc�4
Boring # .
Ground " S K X • 8
elev. ! L G
"—
De to S� ! S �S�
limiting
fa ctor
Remarks: 3 /o
Boring #
mg
��
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD- 8330(R.05/92)
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R08ERTS. -VaIM 44023
Phone 7"56
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OIL- ST CROIX COUNTY
ev SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer
Mailing Address 2—c" C'
Property Address ��C o
(Verification required from Planning partment for new construction)
City/State )44 ° - Parcel Identification Number /J O — /Z yU
LEGAL DESCRIPTION
Property Location, ' /4, f;— '/4, Sec. T_ fN -R_W, Town of �wxll-
Subdivision Lot #.
Certified Survey Map # , Volume Page #
Warranty Deed # S ��,� s , Volume 7 , Page #
Spec house ❑ yes `A no Lot lines identifiable ® 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 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
statin that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
days f the three y
I expiration date.
SIGNA 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 / de ribe above, by /property virtue of a warranty deed recorded in Register of Deeds Office.
SIGNAT 1 017 APPLICANT DATE
* * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Depa * * * * **
** 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
WARRANTY DEED
4
Document NL!mber
Return Address MAY 10 1796
G 11:00 A'
Parcel I.D. Number. 020-1011-00
Joseph A. Klewicki, a single person, conveys and warrant/ to Delta Construction, Inc., a Wisconsin
Corporation, the following described real estate in St. Croix County, State of Wisconsin:
Part of SWIM of SETA of Section 10, Township 29 North. Range 19 West, St. Croix County, Wisconsin,
described as follows: Lot I of Certified Survey Map filed April 24, 1996, in Vol. 11. page 3083, Doe. No.
542664.
T
TANSEER
This is not homestead property.
Exception to warranties: Easements, restrictions and rights-of-way of record, if any.
Dated this day of May, 1996.
(SEAL) (SEAL)
----Jdseph A. KlewiclU
ACKNOWLEDG-MW-1%'T
STATE OF WISCONSIN
COUNTY
Personally came before me this �nk day of N 1996, the above named Joseph A.
Klewicki, a single person, to me known to be the pehon(s) who executed the foregoing instrument and
acknowledge the same.
Notary Public County, WI
My commission expires 2 Corwors
THIS INSTRUMENT WAS DRAFTED BY: p - consin
ublic *
Attorney Kristina Ogland sow Of Wis
Hudson, WI 54016
BEING LOT I OF CERTIFIED SURVEY MAP RECCIRUEU IN VOL. Ii,
5 RhY•Y C
PG. 3083, AT TF E• ST. CROIX COUNTY REGISTER OF DEEDS OFFICE.
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PLAT , LOCATION Oq�2' 4 - 0
•" =�•�� - - -- ►0,0 --•-- tillltYM'ff1G:tLCitAtf.C(C!1'lY
iiii� 1 Align C.
Myhr •n, rv� tutorsl Nlscanala Land iucveyy r, htr «try cert
• - tent In full trA pisnre vlth the provisl•.A of Clwpter 216 of the Miscor
statutes, and under thu direetten of Delta 00(.etruetion, Inc., Owner of
lanA dryeribed on this plot, I turn surve)•a4, di+idrwl ant aAlged 6(
w - - -HE ACPV; that such plat correctly represents the exterior bc" darles and
ot; oul.ivtslon of the land eury ed; and that this plat to located is pert
t the rill /4 Of the t /4, in Section 10 T2901 81911 Tcou of Inv!7on,
,L Croix C i
woty, %isccnaln; being Lot 1 Of Certified urvay Nap Recorded
Slolcw 11, Oey:,ss 1091 at the it. Croft Cuouty Reylater of D""u out
further &octtbed as tollovs:
8�' X Jr-•:•INL!^y at the SL/4 Cotner of 8ecttcn 10; thane! 899 °13 71•i1, alv:g
ppp south tine of the sat /4 of said section, 1311.21 ttict to tho ea"t lint
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-SW---, - -SE - -- the $41/4 of tl-e SR1141 tbence W'30 along sold east lire 104'
r6c .:-,n 1 l teat to the rvlrtb l ne of the Of sDrN sold lot I thence 114)
se Von'+y real north line, 1319.11 feet to the north - south 1/4 ILna of 1
! rticm.; them:* 900n2S•1 ong 4'11, al said north - south tin#, 1049.31 teat
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