HomeMy WebLinkAbout020-1266-80-000 ST. CROIX COUNTY ZONING DEPARTMENT !\
AS BUILT SANITARY REPORT
Owner
Address 16S c t °'
� IAI(L;iM YJ iC
City /State woS u N urc
Legal Description:
Lot l a — Block Subdivision/CSM #
T I N -R_Lj W, Town of L,b1 ON PIN #
z Y. -2 t9,1 3a 9
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION:
Tank manufacturer W f t—S Size ST/PC 1 0 ,0 P Setback from: House Well + P/L
Pump manufacturer r—> Model
Alarm location
(HOLDING TANKS ONL
Setbacks; ce road Vent to fresh air int,*e ..� .. ° - - -- Water Line - - °-- ~-- -- -- _
Me ocation r ~ -
Alarm location
SOIL ABSORPTION SYSTEM:
C(�ti '�41A p
Type of system: Zti f' I tKof n r Width Length Number of Trenches 3
Setback from: House 4 Well ��' P2 1 3 Vent to fresh air intake 5 0 t
ELEVATIONS
Description of benchmark _ �) � w RN e V\ yk G p t(PQ Elevation 1U � -
Description of alternate benchmark V Elevation
Building Sewer ST/HT Inlet ST Outlet.- PC Inlet ------ ' N
1�
PC Bottom Header/Manifold 9 Q;U Top of ST/PC Manhole Cover �� V
Distribution Lines (I�) (� �- 3 4 (� 3
Bottom of System (� 4 3 •� �a S �{ (� g� , o y
Final Grade
Date of installation / / Permit number 3 8 State plan number
Plumber's signature License number b Date /-) , V
Inspector
complctc plot plan K
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
We►1 3 �oVu u>�
40 r A
.v
t
INDICATE NORTH ARROW
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and Buildings Division Count Y ST . CROIX
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) SanitaryMt[T
Personal information you provice may be used for secondary purposes [Privacy L , s.15.04 (1)(m)].
L UEDTKE . "DART che Rage Town of: State Plan ID No.:
CST BM Elev.: Insp, B ,,Il M Ele BM Description: Parcel1i�b_:1266-80 -000
/UU . C/� �)
TANK INFORMATION ELEVATION DATA A9800219
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic ,J. X rf Benchmark �—
Aeration Bldg. Sewer
Hol - St /Y( Inlet
TANK SETBACK INFORMATION St J F 1 Outlet p'
TANK TO P/ L WELL BLDG. AirI to ntake ROAD Dt Inlet
irl
Septic Z ,c�� NA Dt Bottom
Dosing _ NA Header/ Man.
Aeration _ NA Dist. Pipe
Holdin Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Ma turer Demand
B`Y'I"Cf
Model Number GP
TDH I Lift Friction System TDH Ft
oss Forc ain Length Dia. Fi Dist. To Well
SOIL ABSORPTION SYSTEM
ength No. O Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIM
BED/TRENCH Width / L DIMNI N
SETBACK
SYSTEM TO P / L BLDG WELL LAKE / STREAM LEACHI anu acturer:
INFORMATION Type 0 f1 Q, s C��r C
HER Mode Num er:
System: {fit., R UNIT
DISTRIBUTION SYSTEM
Header / r Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air intake
Length Dia. Length Dia. Spacing
I
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.) k n SIA0 _1
LOCATION: i HUDSON n. f .19.130.9 NW, W 858 MCDIARMID D IVE - 02 r Q> 1a}?
o
0
P�%
7. / ✓�' /_ F ,
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD -6710 (R.3/97) Date inspector's Signature Cert No.
Safety and Buildings Division
Iti scons i n SANITARY PERMIT APPLICATION 201 E. Washington Ave. 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 8 112 x 11 inches in size. r /'
• See reverse side for instructions for completing this application State Sanitary Permit Number
.3l sg , 3
The information you provide may be used by other government agency programs []Check if revision to previou ) application
IPrivacy Law, s. 15.04 (1) (m)).
State Plan I.D. Number
1. APPLICATION INFORMATION - PLEA E PRINT ALL INF RMATION
Property Ow r Na a Property Location ` a /a 1 /4, S T N, R ` E (or) W
1 ,
Property Owner 'sM�ilingAd�lress � � Lot Number Blockrlt{rtlber
City, Sate Zip Code Phone Number Subdivision Name or CSM Number
uc� (113 671 SuA� ' e_
11. E BUILDING: (check one) ❑ State Owned ❑ C Nearest ROO
[I Vil age
Ll Public M 1 or 2 Family Dwellin - No. of bedrooms ja Town OF !1 s (- D)
111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) ��JJ
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 online B, if applicable)
A) 1. jMNO 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-K] Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit << 3 — ?i X �2Sa 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. Syst Elev. 7. Final G
1'. Req recl (sq. ft.) Pro sed (s . ft. (Gals/da /sq. ft.) (Min. / qch) 14 f o Eleva�i�og�tt I ° �� °
'c S i � y ,u Feet T.- +6•SWeet
VII. TANK in g all ons Cap acit y Total # of Prefab. Site Fiber- Exper.
INFORMATION New Existin Gallons Tanks Manufacturer s Name Concrete st on- Steel glass Plastic App
Tanks Tank
eptic Tank I ® ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: Print) Plumber's Signature: (No St mps) MP /MPRSWNo.: Business Phone Number:
Plumber's Address (Str et, City, State, Zip Code):
A0 VIL 3 J_' D
IX. COUNT D91 USE O
❑ Disapproved Sanitary Permit Fee (includes Groundwater ate I ssued Issui g Ag Signature (No Stamps)
X Ap proved Surcharge Fee)
❑ Owner Given Initial �O 8
Adverse Determination `VZ)
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SsD-SM (8.11196) DISTRIBl1TtoN: original to county. one copy To: safely i sridr+gs Division. owner. Humber
i
I•; t�. I_. ra I L l} { A 11 1 \U' D
;� `� I� 1, I • .I �_,I�I, ___,
JV
AT L! NS
A I
' I f ��It�•KI1- r l.pu 1 V� .
s p NOT4 Well
• � " DtiKv�Gl! �
I a'
L
; •• USIN5 T dt?-40L Syr +ri 1
• Q V w 2
►3 �, �� Alf 4 0 �
Vie
• � •� 185 -
�u 6 l b , Z Ufq = )U0, 4
FRESH AXIt IREFiS�AND OBSERVATION PUB
CRnSS SE CTION
--_.•_
C.— Approved Vent Cap
: Minimum 12" Above
Ei na1_ Gra il_._.._ _
L I oE.S o
_ 4 Cast Iron
Above Pipe Vent Pipe
To Final Grader
M arsh Hay O Synthetic Covering
Min. 2" Aggrey'�il
• Over Pipe
Distributi F-- Tee
o��
• Pipe _........_.� .t
• Ipa �v Aggregate Perforated Pipe Below
Beneath Pipe << Coupling Terminating P
Bottom of System
t
o e
Labor and Human Relations use' SOIL AND SITE EVALUATION REPORT Page / of 3
Division of Sa fet y if Buildngs in accord v�`Ih ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than S 1/2 x 11 inches in size. Plan must include, but S7, CiPoi X
not limited to vertical and horizontal reference point (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
SD if 0 et I/E Z, GOVT. LOT Nze 1/4 sw 1/4,S 2, � l T 2-9 ,N.R /�F E (or) W
PROPERTY OWNER':S MAILING ADDR LOT # BLOCK # SUBO. NAME OR CSM #
3 40 57 �o / %',V G- ESS vit /2 – 5t1 v2i,;4?6-E
CITY STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE N NEARES ROAD
Xv. 5 5 110 ((P /4 7 3 3 - q 8 U D So Aj 1 41C ' 'e'4 .a
(
New COnStrUctiOn Use [ vj - Residential / Number of bedrooms `/ () Addition to existing building
[ j Replacement [) Public or commercial describe
Code derived daily flow &0 D gpd Recommended design loading rate bed, gpolft ' S trench, gpd/ft
Absorption area required Np bed, ft2 /-1-V0 trench, ft Maximum design loading rate _N� bed, gpd/ft � S Uer>dt, gpcit(t
Recommended infiltration surface el evation(s) - 3 ft (as referred to site plan benchmark) r
Additional design /site considerations r�vE 7a 0 P *S & or /s z-pS ,
Parent material Flood plain elevation, if applicable N ft
S = Suitable for system CONV ENTIONAL PS OD w - -o PRESSURE A SYSTEM IN HOLDING TANK
U= Unsuitable for astern LA'S ❑ U ❑ U LETS O U 3"S 0 U O S ❑ S 2T
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourday Roots GPD /ft
in. Munsell Qu. Sz. Cont. Colo Gr. Sz. Sh. Bed Tiench
` r a -f / /D/le 3 12- Sij / -'54e ,1-Y, e c'S if y S
k3 511 2 jiP e-5
Ground -,,75 /o ye 3/3 .5 Lam, 6/�
elev. S/ /
/a3 e ft. S- �/P� f3,�,�p � — vf.
Depth to 7S y e 3 f2 �„ a t �� s ✓c
limiting
factor
Remarks: - a_ o� �i '�3 /MOST 2/sF -Pe - 116v L,/�, �-
Boring # �
h.. 3 2 3 7, S
Ground `'P 7
elev. ; Y -V 75- y3 ?3�y vvrz� ! S/ /7` i»► / — ! Y 5
/03, 410 ft.
Depth to 7 S
limiting
factor
�v •/
`�`�— Rem arks:
CST Name: — Please Print �O ,p T- Z( L I C 7 - Phone: 715' _3RG _ P s
A ddress: 155 O i of el z iyaPsd u bi "S' CJ-7A-
Signature: Date: CST Number:
�J
ORIGINAL
PROPERTY OWNER SOIL DESCRIPTION REPORT Page of
PARCEL I.D. # L41� 1.2 " S'U- v `i'
Boring # Horizon Depth Dominant Color Mottles Texture Structure Cor4stence Bwxk3y Roots GPD /ft
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ffiii
3 / O /0 3/ S� /, / f S4k n�►� fib C'
y - /G /o le 3 s/ Z, 4"f CS lot s
Ground /D y / '7
elev.
/oS ft.
Depth to
Limiting
fac
Remarks:
Boring #
E3 /�- )O 7.S R 3/ , fs /, f �,, llxe es' s i , v
3 7 0 7 , s"Y pe-p S. Or a s
Ground °
elev.
it
Depth to
limiting
rac3pr, ,i
Remarks:
Boring # 13
2 .S / 2.w, ,6.� ei f/e CS If . S
`
Ground 3 . D. S r�►.� q S -- . 7
rev 75 `,� .�►, f� — - y.s
Depth to
limiting T 9� 4�`/ /7 /(�/ft �t'�27 i�Lrs .v
factor
Remarks:. S /i US T NO P ?, 70'
Boring #
eve
Ground
elev. it
Depth to
limiting
factor
Remarks:
QOr% OooMO nC MM
sa
I
SO • c.o Z- t_ .
0
N
y
4 0
�p I m N
V
v
c
0
0
0
3
d
O `
y
w �
—�' ,—c� � fft�TTO•cJ l� /ll It�G'�
I
L ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer Oil- (,an5 f' )Q�'r L J � k e
Mailing Address (008 1. zxl ak6�A Pei �Ad -,p Lux
Property Address
(Verification required from Planning Department for new construction)
City/State Parcel Identification Numbe
LEGAL DESCRIPTION
Property Location Y•, ;, Sec. d_�, T-44N R W, Town of A�(- dSDA1
Subdivision A VILAC4-e Lot #
Certified Survey Map # Volume Page #
Warranty Deed # a - 21) JI L Volume Aw page ## 3�5�
Spec house M yes 0 no Lot lines identifiable . qyes p. no
SYSTEM A1A1NTENANCE
-
finpriopa use and maintenanceafyourseptic systenicouldresult in its preniaturefid to handle wastes. Pwpamnatenance
consists of pumping out the septic tank every three years or sooner, if needed by a licensed pump= What you p ut into the system
can affcd&C function of the septic task as. a treatment stage in the waste disposal systear,
The PrQPCr(Y owner agrees to submit to St. Crone Zoning Department a certification fomn, signed by the -owner and hY a
P iommYmaaplunkier. restricted Iumberora
p IicensedPumperverifying that (1) the an -cite wasterwaterdisposal system
is is
Proper operating condition and/or (2) (2) inspection and Pumping.(rf necessary), the septictank rs less than 1/3 -full of sledge.
11we, the underdped 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 of Natural Resources.
hating that your tic t urces; State of Wisconsin.. Certification
septic system has ban maintained must be completed and returned to the St, Croix County Zoning Office within 30
days of the three year expiration date.
&J— . s /0 9
SIGNATURE OF APPLICANT DATE
OWNER CERTIh'ICATION
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 4cscnW above, by virtue of a warranty deed recorded in Register of Deeds Office.
S IGNATURE OF APPLICANT DATE
« « « « «« Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. *« « « ««
.6
«« Include with this application: a stamped warranty deed &our the Register. of Deeds offrce
a copy of the certified survey map if reference is made in the warranty deed
VOL 8 pni 3 53 100q
STATE BAR OF WISCONSIN FORM 2 - 1982
WARRANTY DEED
DOCUMENT NO.
John Q- Keller and Debra M KelleL hlLband and wife U CROIX CO r W1
JUN U 3 1998
conveys and warrants to Rart t T,jip-dtk,-.- a cingle person
8:30 AM
0214tor of Beads
li
THIS SPACE RESERVED FOR RECORDING DATA
;j NAME AND RETURN ADOAEGS
the following described real estate in Croix County. ii
State of Wisconsin:
FV 16
[)20-1266-An
PARCEL IDENTIFICATION NUMBER
Lot 12, Plat of Surwidge.
TRANSFER
FEE
This is "vIt homestead propeny.
(is not)
Exception to warranties: Easements, restrictions and rights-of-way of record, if any.
Dated this day of may A . D .
(SEAL) 0 (SEAL)
Ychin a Kplicr
(SEAL) y O (SEAL)
S ,gl'vra M KPII#br
AUTHENTICATION ACKNOWLEDGMENT
I.
j Signatures) State of Wisconsin.
County.
authenticated this day of —.19— Personally came before me this day of
May 1921L—, the above named
Bra da Po ulin John Cy. Keller and Debra A& Keller,
TITLE: MEMBER STATE BAR OF WISCONSIN Not ary Public huablad and wife
(If not• Wis
authorized by §706.06, Wis. Stars.) state e
—9vo be the perso S who executed the foregoing
inst rd acknowledg t same.
II THIS INSTRUMENT WAS DRAFTED BY Z I
rum`7 51 It
Attorney Kristine Ogland
Atto r
I Hudgan-30 54016 Not4 lic. County. Wis.
li (Signatures may be authenticated or acknowledged. Both are not My commission is permanent. (If rt , ?,at
on date:
necessary.)
11 Names of persons in any capociiy should be 1 ) - P&d
STATC BAR OF WISCONSIN Wiscoron I-dow Bisr* Co.. I�
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