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HomeMy WebLinkAbout020-1307-10-000 a � ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT Owner D Av l D t 9, so Ki Address Co v Q. sap c. C; City /Stat ST coax Legal Description: Y Lot E l _ Block Subdivision/CSM # &M6RA �►�. }I IAJ4 7 ' / 4 Sec. D - 1 . T oll N -R 19 W, Town of HuosaN PIN # 01v- l3o7- to —GYY> SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer -zRV1 Size ST/PC 1 - O Setback from: House 18 Well �sV P/L > S C3 Pump manufacturer Model Alarm location (HOLDING TANKS ONLY) Setbacks: Service ro Vent to fresh air intake Water Line Meter location Alarm ' n SOIL ABSORPTION SYSTEM: � �� Type of system: �" � 1 as Width Length Number of Trenches Setback from: House 3 V' Well 2 0 P/L 7 -S b L Vent to firesh air intake ELEVATIONS Description of benchmark - ro P � � " �e �► (V � � afi C uRwe rt Elevation (V Q > O Description of alternate benchmark Elevation Building Sewer ST/HT Inlet 3& ST Outlet 97 PC Inlet PC Bottom — Header/Manifold Top of ST/PC Manhole Cover , OS Distribution Lines w g�• (� g �$ ( ) Bottom of System) Final Grade (N) Date of installation ! - 0 — / / Permit number 3 1 S U a State plan number Plumber's signature �6 License number IX.)-g0 a )•ate Al Inspector u I') Complete plot plan or } J 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 wvdi � MbIAal-L of lm Exil 6W �n 3 U, _ 4 6-POR -u6t" R ors INDICATE NORTH ARROW N `A/iscofisin Department of Commerce Safety and Buildings Division PRIVATE SEWAGE SYSTEM County: ST. INSPECTION REPORT CROIX GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Personal information you provice may be used for secondary purposes [Privacy La s.15.04 (1)(m)]. 315924 der itkloJ Na TAVID & EMILY ❑ P Town of: State Plan ID No.: CST BM Elev.:- Insp. BM Elev.: BM Description: tiUll j1�V Parcel Tax No.: 020- 1307 -10 -000 TANK INFORMATION ELEVATION DATA A9800313 TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV. e t' Benchmark 1C)3-(.; lc9 Dosing A 14, e>AA t o3. 3 S` 8 '1 V3 Aeration Bldg. Sewer /n3• mom Hold St1of St/of Inlet (p3 IZ• ®� ��, i.6`j TANK SETBACK INFORMATION 't W Outlet 103.39 12•L� 9/ • 3 t TA P/ L WELL BLDG. A Intake ROAD Dt Inlet 70 NA Dt Bottom Dosing A Header / Man. IZ• L oJ D. �' _ eration NA Dist. Pipe 12 Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade n; d Manufacturer Demand l -lo sw 0 103 ;.e3 l03•S Model Niyh M 5 µt 1,0 5,37 TDH Li L oss ff e riction S m TDH Ft Forcemain Length Dia. Dist. To well SOIL TION SYSTEM BED / X RE Width Length No. Of Trenches PIT No. Of Pits Inside Dia- Liquid Depth DIMEN N 3 7 DIMENSION SYSTEM TO P/ L BLDG WELL LAKE/STREAM ACHING Manu ac SETBACK AMBER u INFORMATION Type O r i Model Number: SystemQCMVe4, J �(o 'Z0 1 O NIT DISTRIBUTION SYSTEM Header / Ma�fold r Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length V0 Dia- Length = Q-w 3y 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.) LOCATION: HUDSON 27.29.19,SE,SE 691 BLUE JAY LANE Plan revision required? ❑ Yes d No Use other side for additional information. -� 1 15 1 0 t o d SBD -6710 (R.3/97) Date Inspector's Sig ture ert. No. Safety and Buildings Division 201 E. Washington Ave. SANITARY PERMIT APPLICATION Vi P.O. Box 7969 Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code 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. _5Y (frol� • See reverse side for instructions for completing this application State y Number The informatio n 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 1. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATI N P rt y Own r N e Pipperty Location L S &1/4 5,! a 114 S 17T o7 c I , N, Rl9 E (or) W ;z Property Own ' ding Address Lot Number Block Number zJzue G0_Al J Cit , tate Zip Code Phone Number Subdiv ision Name or CSM um er 1 ( ) fy/ +e ) II. TYPE ILOING: (check one) ❑ State Owned it N rest Road Village �-^ Public 1 or 2 Family Dwelling - No. of bedrooms Town OF Uar° J G III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) a 7_ a 19 A 5 7 33, 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) q) 1. New 2 E] Replacement 3, [3 Replacementof 4_ E] Reconnection of 5_ [] Repair of an y_stem System Tank Only 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 r*5eepage Trench aS1Nc 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 0�'% �'ttAj,, S 4-e A., 43 [] Vault Privy 14 ❑ System -In -Fill ; - VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 13. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required sq. ft.) Pr �ed.) (Gals/da sq. ft.) (Min. inch) H $S -Uo E1 71 a O Q a - ` 67 WFeet L 9t Feet VII. TANK Cap acit y in g allo ns Total # Of Prefab. Site strutted g Fiber- Exper. New Existin INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App T nks Tanks Septic Tank or Holding Tank r C U ❑ ❑ ❑ ❑ ❑ -L+ Lift Pump Tank /Siphon Chamber k EN T I ❑ I ❑ I ❑ 1 ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Pl� r's Na int) Plumber's Sig ature: (No Stamps) MP /MPRSW No.: Business Phone Number: Plum�'s�ress (Stre� ity, State, Zi�Code Ll IX. CO © © NTY / DEPARTMENT USE ONLY ❑Disapproved Sa_garyPermitFee f� ^c�udesGroundwater ate slue Issuing ge tSi ture mps) A roved -29 Surcharge Fee) pp ❑Owner Given Initial l��`%4 7 ; / Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD WN IRA 1/96) DKTROUTHM: 069W r to Cow rty. one copy To: safoq a tiwiarxs t)6n". owner. nweeor E C 1 ..•.N ••....­ • 11 A ._N k !.lI.hs: L I C E N S_. Alt f. �y3 Sufic y ur�NS ZN- Fi)1"Kp��R �� b�.�,�r r � y i Q 3 /. 8 s�. •AE.. � e.� ao�' ,tz $`�0 5• .; �Ia' °�- ----�a ��, 4'' 0= 13.e�,e�, !'►'IorcK lip �.� �,�, O 1400 3b S� Q ME • pro' hfi<< c✓ y �vrt�o►.� Nafi� oM� Wa i s �on11V , bW So' FKUr, _ N A: ' 1 " t ' FRESH AIR INLETS AND OBSERVAPION PIim CROSS SE CTION Approved Vent Cap �. Minimum 12" Above Grzp� Einml or •= 4" Cast Iron Above Pipe Vent Pipe To Final Grade Marsh Ilay O Synthetic Coveri liy Min. 2" AggretI _ Over Pipe \Y I • Distributioi4 •F— Tee pipe I Aggregate —__ Per Pipe Below Beneath Pipe Coupling Terminating A / 2TO __ _ Bottom of System Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Pagel of 3 Labor and Human Relattons Division of Safety 8 Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY 5 ceol Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but PARCEL I.O.8 not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION PLEASE PRINT ALL INFORMATION REVIEWED BY GATE PROPERTY OWNER: 1111RbIA0 �fi /S L�9ti� a4 • PROPERTY LOCATION 1pll al- ;B /'//-' A/ — D�iA /,P.y y GOVT. LOT SE 1/4 5- /4,S 2 7 T 29 ,N,R /f E (or) W '•S MAILING ADDRESS i i P OCITYD OV OCK fl SUBD. NAME OR CSM PROPERTY OWNE /y 8 /� ov£r� 3 / ��1 \ i l l s PtinS� ,336 �•�OBF -S $T C ,1 J G �IUMR R� � NEARES T ROAD CITY, STATE ZIP CODE PHONE NUMBER ILLA E 9f6W /UST ✓� L� T, MV L /t1 N• u V-50 / Y r ew Construction Use [ k"esidential / Number of bedrooms ` °� 3 [ J Addition to existing building eplacement [ [ Public or commercial describe derived daily flow 6 gpd Recommended design loading rate bed, gpdAt trench, gpd/ft 2 bed /tt • oo trench, 2 Absorption area required 9V bed. 11:2 7 sy trench, ft Maximum design loading rate , gpd 9P� Recommended infiltration surface elevation(s) P CA 3 it (as referred to site plan benchmark) Additional design / site considerations Parent material SAS 6 /3 vrt'�' i('7 Flood plain elevation, if appli6able 4 It coy�NT� S = Suitable for System MOUND IN -G D PRESSURE AT -GRADE S - W -FILL HOLDNIG TANK U= Unsuitable for sy stem [yJ s 0 U ❑ S O U p S O U C O U O S SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD /ft Boring # ri P Texture Consistence Baalxfary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed terttcftt 2, She �v6e 67S Z ' S •� - y y sl,� /A Ground 1 - % / S. ©� S G - .0 f�/ D - z ft. Depth to limiting , factor 4 Remarks: Boring # F S1 L 4» S m vf.C' �C' S � S I . Ol � 13 l � %J i Ground Depth to limiting factor Ll I Remarks: _ / CST Name: — Please Print ? � Q E P_ r 74 1- � I' C 14 7— Phone: �/5 . 3 P6 ddress: H V I)SO.J 40�s • .j��� //- (o - j` Signature: �-¢ Date: CST Numlter: This test site APPROVED OR for a conventional septic system. PROPERTY OWNER `/ SOIL DESCRIPTION REPORT Page ? 3 PARCEL I.D.# GO SG I r0. r3 t' P D H MIS Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bwxby Roots GPD /ft In. Munsell Qu, Sz. Cor!t Color Gr. Sz. Sh. Bed Tiench s a, c s -o Ground elev U Depth to limiting factor Remarks: Boring # Q - /D °fie `� /Z J �� ZfS�i� errv7�ie �lS 2f •.S = . L kV - 3J 0 Ye z E-1 - Ground 3 _ /O y Si / 2 f Sh.0 �,e 4 s r , 57- . sc Zz it. o a y r Depth to limiting factor Remarks: Boring # /Q 1,P 3 1 S� vf,E' et M"" S Z f S y 30 �. re y s . Ground : elev. � z, 30 It. i Depth to limiting factor �� I Remarks: Boring # ' I F-3 P Ground elev. ft. Depth to limiting facto Remarks: con wi mio n[,n •l1 Al L ,dT SAO Lbf . EUATI'cw ' r / 4 /3 y 54rzz 30 6CALF Sy S t hrloAoS �' /Ey�r�oa ioo, o ' ?F o 4 z 0- /ow T/ 2 ! 9 7. 0' 8 90 O v k w � iy3 3 /3 3 y 0 0 N °30'10 "W 664.12' S < 57 q �Q S 45' 50' 00 "W 86.82' �+ S44 ° 10'00 ° E 66.00' S7g 2l'41 "E r Z/8 r I So S9 (� 0 3 \� g S89 ° 30'15' W 942.42 ; Z .u. ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer tD any! Ennt-. L, 0 Mailing Address _ 1372 'PIAE ViI�W (F-A%L ( ou.�.-eo�.l 11 '' t1 W 54'o82.. Property Address a`r — (Oil a Lit E J Pf `l l, fJJ E (Verification required from Planning Department for new construction) City/State dLA050&- �-(� Parcel Identification Number 0 1 3p? — 1 o LEGAL DESCRIPTION Property Location SE r/,, SE %., Sec. - 2- - -7 -- , T 29 N -R 1 9 W, Town of O µp 50 t j Subdivision H u ►�B «z.D H I l.L- `f -*4 , ¢ D Ain s n o,•t Lot # 5(0 . . Certified Survey Map # _ A . Volume . Page # I Warranty Deed # 554 Volume _ 12 3'4- . Page # 1 Spec house 0 yes Vno Lot lines identifiable yes 0 no SYSTEM MARMNANCE Improper use and maintenanceof your septic system could result is its pnuzrat=1a lure to handle wastes. Pmpermamtenance 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 affed &C function of the septic tank as a treatmeat stage is the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a cutification form, signed by the owner. and by a masterPlunbc4]ourneymanPlumber� restrictedphu:mberora licensed pumper verifying that (1) the on -site wastewaterdisposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 fifi of sludge. Uwe, She undersiped have read the above requkements and agree to unirMir 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 beta maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. (� 1 SIGNA 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 owners) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. L SIGNA F PLICANT DATE « « « « «« Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. « « « « «« .L •« 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 - a r-nnesoIa, t:orporat: ion._ !! APR JJ1 La�.1d ly ..C. Peterson and Emi . Peterson, Husband and I41if 11:15 A. con „•y = iunl uarr:uily to L.... e . �# � M ... ........... ( Mu9tstn. o Deo-s _ ................. ....... ..... the following rlescrihcd rc:d cslale in ...... St . Croix _.. ...County, I titalc of Wi:�consin: Let 56, Humbird dills Third Addition, Tax Parcel No: ............................ Town of Hudson, St. Croix County, Wisconsin r 59 L i This is not - _ . _ _ homestead propert }•. j4k (is not) F:xcctrtion to warranties: Easements, restricitons and rights -of -way of record, if any Dated this _.15th. - ..... ....... ... day of April_ I9._9Z _.(SEAL) HUMBIRD LAIND CORPORATION (5„Ai,) • ._ .. _. . ........ ._ .... ............................... -by: - _�G�tifL ... �.. Austin J. Baillon, Tts President _ ........ ........_...- .................. (SEAL) _..(SEAL) .................. .. _ AUTHENTICATION A CK N0WLEDGMENT Signaturc(s) _ - -_ - .. STATE OP!1706CX)� MIN14ES TA ss. .......... .. . .........._County. nuiheniicatea this --. .... .day oi._......................... hl...... Persen”: _ came b_ me this .... Uth.....da of . ............. April ------ ._.-......... 19 .97... the above named ,Avatin_-J_ B- ill ..n..- President. Af....._.. -_ • ............................ .................................... .... ..... TITLE: MEM11FR STATE BAR OF WISCONSIN v . ...............--- ---.....--•---.......... ............................... (If not, --• -- -....._..._.......- -• •--• .......................... authorized ........... •-••-- .............................. —.. -- ......... y . 70G.OG, Wis. Stata.) to me known to Z•e the person - ........... who executed the fore oir. instr -- sent and ncknovhdge th- .as+rea.; I THIS INSTRUMENT YEAS DRAFTED Df _ A n C I' NON ...... hand- .CorpQxaCiQn � - - -... ����•; ?.r�IGT ?au Al " ON COUNTY ........................................... .hin k�.;,,.. - -•-- -- - • -- --.. . . Notary Cubit[ Kas ); (Signatures may be authenticat or acknowic(Iged. 130th nay Commis" K rermanent.(1f not, state expiration � are not necessary.) date: - -- Jaguar - 31 ..... ............ ... ._..• M2000) •Nnrrir• ar -- prr.rn n+ •Ignin; in any rn parity .h.uJd he ty,, or piul�d Ldr +r it,. it •ign.ninr.r - - - - -- 4 - -- � - - -4- -- — 1 2. 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