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HomeMy WebLinkAbout020-1324-70-000 ST. CROIX COUNTY ZONING DEPARTMENT , AS BUILT SANITARY REPORT Owner -S,4 /n 44 t,. L R. Address /Q q 9 J j, `< % 11 / G /e c s,.J City /State 4u bSQ W W l Legal Description: , r Lot Block Subdivision/CSM # ?A a ht 4 �` Ili 4E - ' /a '/ , Sec. �, TAN -R _AQ Town of y � a PIN # = - DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer WE 1 E& Size ST/PC / Setback from: House � Well 40 P/L 60 Pump manufacturer ' Model �•..- Alarm location �-- (HOLDING TANKS ONLY) Setbacks: Service road -- Vent to fresh air intake """ Water Line Meter location Alarm location ow— SOIL ABSORPTION SYSTEM 1r7kF1 L.T, a T01L Type of system: Width 3 Length S $ Number of Trenches Setback from: House IoS' Well 10 P/L 1 "? Vent to fresh air intake 1 0 ELEVATIONS 'A Description of benchmark (,Z ,', 4J c7 A( E f Elevation 1 Dd • 0 ' 4 i Description of alternate benchmark CIE MA N HO( <*e Of t'1... d I O Elevation Building Sewer ST/HT Inlet i ST Outlet I .`7 PC Inlet - PC Bottom Header/Manifold I Top of ST/PC Manhole Cover 0 C ` Distribution Lines ( ) O ( ) Bottom of System( ) s 5S ( ) ( ) Final Grade ( ) ( ) ( ) L� Date of installation / / Permit number 307 7 4 3 State plan number Plumber's sipsliture a License number Wt 5 ` a wo Dates Inspector tj bet 4A— Complete 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 - rax ©z o -132 y - 4 0014 cT / 0 t-u &,0 P+ c c.'7'To I? F E '0W/ ]U sI C � > 1t I" .► ro 0o ►NtA► r OUT UE LL USA A s wi Lt Nb"r S T�(LL.EQ ' V INDICATE NORTH ARROW r WiscoFisin Department of Commerce PRIVATE SEWAGE SYSTEM Count Safety and Buildings Division INSPECTION REPORT 3-k Goi GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)). 3 0 - 77X Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State Plan ID No.: 14 41— CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 10 1 o ro svr o 's D Do - 13 -70— ou-D TANK INFORMATION ELEVATION DATA 8 CooI� TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. 12.E ! Bench rwb Dosing Aeration Bldg. Sewer Ig Holding St/Ht Inlet 3. 1 1& .0 S TANK SETBACK INFORMATION St/ Ht Outlet 70 0 - r TANK TO P/ L WELL BLDG. Air I ntake ROAD Dt Inlet ir e t (pv tti►f S� 2- NA Dt Bottom Dosing NA Header/ Man. 1 1 08• Aeration N Dist. Pipe 11• J 1.7I_117 X07. C Holding Bot. System t 3. ,i PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand c I f) Model N IF GPM TD Lift Friction stem TDH Ft Forcemal ength Did. Dist. To Well SOIL ABSORPTION SYSTEM BED Width s Length No. O ff Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 �7 l DIMENSI SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHI INFORMATION T ype CHAM M Number: System �7 ( 0� ih,�w OR UNIT DISTRIBUTION SYSTEM 9 S yv - uc�� Header/Manifold ; yG x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length �ZS�[)ie- 3 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 Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) WoovJ G�o �GV► C 1.) i )Vl ( KO � ; III l�t� C pez46 • " I a• Ate f3n/► —� � 5��. - b,,�,Fi �.� c�v� �I YYNI slz �l a � Plan revision required? ❑ Yes No s I Use other side for additional information. �( SBD -6710 (R.3/97) Date Insp dor's Signa a ert. Safety and Buildings Division Vi sconsin 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 a than 8 1/2 x 11 inches in size. ST • See reverse side for instructions for completing this application State Sanitary Permit Number 30 - 7 7 Z- 3 Personal information you provide may be used for secondary purposes Check if revision to previous application [Privacy Law s. 15.04 (1) (m)]. 10 I? 00 fi 6/42W 6�W Rol. State Plan I.D. Number I. APPLICATION INFORMATION - PLEA PRINT ALL INF RMATI N Property Owner Nam Property Location 519 NF 1/45,.4] 1/4,5 / z T2y ,NrR / E (oiGi Property Owner's Mailing Address Lot Number Block Number X *t / te r-/ 30 City, State Zip Code Phone Number Subdivision Name or CSM Number 11. BUILDING: (check one) C] State Owned El E3 lt Nearest Road Village H v0 S4 N ��0� / set• Q Public 1 or 2 Family Dwelling - No_ of bedrooms, own of n III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number 9 s) �a, 9. 1? • //_ [ 7'Q 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 2, E] Replacement 3 ❑ Replacement of 4 E] Reconnection of 5 ❑ Repair of an - _____System -------- System _ _________ _ __ Tank Only ------------- Existing System _________Existln 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 s-� I OFw1Nt1A/�p 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) . Elevation ,5 S� - 1 � _S C Z ' .19 1 ft-­ bb ( S Feet 111.O ' Feet VII Ca . TANK in g gal lons Total # Of r Prefab. Site Fiber- plastic Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass App. New Existing structed Tanks Tanks Septic Tank r Holding Tank (OG ( U.9 )� t3 Q.-. ❑ ❑ ❑ 11 ❑ Lift Pump Tank /Siphon Chamber ❑ 1 ❑ 1 ❑ I ❑ I ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumbe(s Signature: (No Stamps) MP /MPRSW No.: Business Phone Number: I•� i r�0 Wm. f !19 Ak S - 03,S'oa: '3 ?10 ~ � 6 9 2.. Plumber's Address (Street, City, State, Zip Code): IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved- Sanitary Permit Fee (Includes Groundwater D ate Issued Issui Age Signature (No Stamps) �^ A ❑ Surcharge Fee) pproved Owner Given Initial Adverse Determination �— X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.11197) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber rY� W I 7,4 , / 0 <,€ .c o7r " Z* o s clk-fz Cj ` , r,sT 67 a �m..._.. o A+ i o u. Cz a te-- -- - --��-� iE 3 se 30 r TS rs_.{ i -i- -, U Q 7 b x ! 7C3 c (� N E Q N w co Lo r \ - T +:. X 0) ( O 1p N G) Q co Q co (� N — f O r (d O M N v. C V-' O Oc a 0 - O O D_ O N X 4 L O, E O c0 4 Q J Q z G) > CO C U y X m N p C U.� -6 2— wl Q U co J Co _D c� a — Z3 Q c � c cu N> O N O J m LL E O '� _ NA !3: 1, a bo cn �3 ~ m • � ,gyp N \� � a � Q E N � V 0 o - CD O a vCO o E Y CO WE r , cl1 O So \ m o � LL x E C m -- m _ Z 70 W - f a S o «a � � rn a • � ,� UJ °' ro co v N_ W 0 u� T co CO N 5 Q 3 d p $" CZ � co a) W � L u °' r I� C13 v <W � a Safety and Buildings Division �. ■�r.r■ 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 8 v2 x 11 inches in size. Crd l XA • See reverse side for instructions for completing this application State sanitary Permit Number 3 O - 7'7a3 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 INFORM - PLEASE PRINT ALL INFORMATION Property . Owner Name ���� Property Location /! 1/4 1/4,S T ,N, R/ E(OGW Pro 'B ox Oyrner's Mailing Address Lot Number Block N umber Cit ,State Zip Code P P ne Number Subdivision Name or CSM Num er # f.) 1) � W ell 55w 2'7 (09 1 ffNe ares�tRoacl G 3 S I. TYPE OF BUILDING: (check one) E] State Owned Cit ,, tt E] Public 1 or 2 Family Dwelling - No. of bedroom Town OF n JI �S�N 60ar C,LOW III BUILDING USE: (If building type is public, check all thatapply) Parcel Tax Number(s) 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 _ JVNew 2 ❑ Replacement 3 ❑ Replacement of 4 ❑ Reconnection of 5, ❑ Repair of an ystem 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 E] In-Ground Pressure 42 [] Pit Privy 13 Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill VL 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/ 610c) ft.) (Min. /inch) Elevation 610c) R �0lo•,� S Feet v I Feet VII. TANK C apacit y gall Total # of Prefab. Site g Fiber- Exper. INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App New Existing strutted Tanks Tanks "t*f eptic Tank faO +Q U" /'s F14 ❑ ❑ ❑ ❑ ❑ Tank /Siphon Chamber El 1:1 1:1 Lift Pump a /S on Cha be El El P VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumbe Name: (Print) Plumbs ignat re: (No Stamps) MP /MPRSW No.: Business Phone Number: Plumber's Address Street, City State, Zip Co 0C COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps) A rOVed �D / 8 Surcharge Fee) / I �f $) pp ❑ Owner Given Initial / I , �►'Slr � a 2/ c18 et, Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD -6398 (R. 05/94) DISTRIBUTION: original to county, One copy To: Safety & Buildings Division, Owner, Plumber A( 44C- cu k ©A 7 oea DO WE L st 2a NOT C k-rT 'T L PA A Dw Dir, RC4vii?17VW7 I AMIJ Wh7f 0 AkFA zoo (jVo S e. AL rp IeON El, = 10t,ibo" — 'A •I � � t l►n Cl t 2 LA m t 0 t = �r - o I Pt ol r I `� Ll N. c I - N, v U Z " Fn N� o O �o N �� z j-Q Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page 1 of -3 ` Labor and Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY St. Croix Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. P#aq'mustiric dA iut A . not limited to vertical and horizontal reference point (BM), direction and %O'Slope, scale or ; KARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION- PLEASE PRINT ALL INFORMAT~IQN' a . IEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION Sam Miller GOVT. LOT /dE 1/45J. 114,S 12 T 29 N.R 19 E (or) W PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # Trout Brook Rd. 50 -- 2nd Addn to Tanney Ridge CITY, STATE ZIP CODE PHONE NUMBER E)CITY []VILLAGE MTOWN NEAREST ROAD Hudson W i . 54016 ( ) Hudson T122ey Lane [ ] New Construction Use[ ] Residential / Number of bedrooms [ ] Addition to existing building Replacement [ ] Public or commercial describe Code derived daily flow gpd Recommended (design loading rate bed, gpd /ft trench, gpd/ft Absorption area required bed, ft trench, ft Maximum'design loading rate _ bed, gpd /ft g trench, gpd/ft Recommended infiltration surface elevation(s) - - - - - ft (as referred to site plan benchmark) Additional design/ site considerations Soil evaluation done for plat approval. Parent material Flood plain elevation, if applicable ft S = Suitable for system Q 0 VENTIONAL 0 ND IN- ROUND PRESSURE I AT- RADE SY TE,,� IN FILL HOLDING T K U= Unsuitable fors stem EX S❑ U S❑ U S❑ U �S ❑ U �S ❑ U ❑ S U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bwxr ary Roots GPD /ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed ITmr& r A 0-14 10 -,2 V1 L T rh sbl; 1'h r Cw Z 0 . rt $, 4 -3g TS 4/4 _ SL l r� SJ < rnFr, q j j 10 ,A Ground $ -7Z iray,o, 4 3.� elev. a o.9� f 7Z -12 " 2, /6\/k4 / 4 S M r M Depth to limiting factor Remarks: Boring # ww A 0-1 16\gal i �- I �, Sb M4; C W 2 0 0 5 : J Q ` 8 2 !-Q 7. S yP 'SL I � r /h 5 --� 0 .S Ground / elev. _ 1 iQ 4 M r m .7 Depth to limiting factor > 1v.% Remarks: CST Name:— Pleasppnnt Phone: 386 -4080 G. Johnson Address: p,0. B ow. 1 Signature: Date: Oct. 96 CST Number: 3484 PROPERTY OWNER SOIL DESCRIPTION REPORT Page Z Of 3 f PARCEL I.D. # 6 . Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench 3 6-/6 W/ k 3/ 77 r C L-J T- 2 $ -' co 7.sYR 4 J SL 7►m log rh Lj 1-5� b. -S Ground q -- elev. 1 g3 6 - 3 /6- /R 4 S yV► 1'Yt 1 d.7 Depth to limiting facto Remarks: Boring # p 8 , q -?- TS S I_. I � S�� M -r q 1 6 , 8 W:> Ground w ` elev. Depth to limiting factor Remarks: Boring # PM a -3� cLo 2-� o. :S- QQ Ground �2. .'7 O. elev. & 4 � CZ 6.1 10 � .5� ft. Depth to limiting , �ct� Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: eon OoONO n� orn l c� a QQ� F L - u D Z D �r b p N o Z D P � / ot 4 p t/o � 1� r- 0 LA O 4 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer 7 31W M t1 C..AFA Mailing Address z Property Address _ _ /O ,? MOON /AP (Verification required from Planning Department for new construction) City /State K J O S 0 T/ Wt Parcel Identification Number 0 Z® ' I a ? LEGAL DESCRIPTION Property Location Yf - %4, y W '/4, Seca T N - R , Town of yO y 0 A subdivision 7"/� ffr� 4 te14 -,e , Lot # _7d Certified Survey Map # , Volume 40 , Page # Warranty. Deed # -S40 S , Volume / a 3 , Page # � + Sec house ` � yes ❑ 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 stating that your septic system has been maintained must be completed and returned to St. Croix County Zoning Office within 30 days of the three year expiration date. A OF APPLICANT DATE "y oWNER CERTIFICATION certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of gr-g roptity described above, b virtue of a warranty deed recorded in Register of Deeds Office. F ATURE 6f XMICANT DATE * * * * ** Any information that is mi5- 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