HomeMy WebLinkAbout020-1336-20-000 ST. CROIX COUNTY ZONING DEPARTMENT
AS BUILT SANITARY REPORT
Owner 5"�`f/'/ 1r&L` /2
Property Address '71 S crt,) f I.. f x - r D D
City/State H v Q S d l4 t„ c) l S' von ! �.
Legal Description: _
Lot y Z. Block Subdivision/CSM # �"' f ! &
'/a W' /a, Sec. - �Kj, T-Zj`N-R/2j0 Town of 14 t� J -S in W PIN # O Zc
SEPTIC TANK DOSE CHAMBER — HOLDING TANK INFORMATION
Tank manufacturer (4) 15� l k- Size ST/PC /"/ Setback from: House 5!4 We1V 4' 1 P/L 76
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
i
Type of system: IL fWor Width Length S` Number of Trenches
Setback from: House 71 " Well /VCy ' PAL 7_T Vent to fresh air intake ,/ S`G
ELEVATIONS
" " C> C14
Description of benchmark Elevation
Description of alternate benchmark / t t O UP S E ME A11 -6 ^' ' A' , I t Elevation lot, 4
Building Sewer — ST/HT Inlet .00 " * ' S ST Outlet (A ') Z -" q8 PC Inlet
PC Bottom Header/Manifold ��5 " 9 �' Top of ST/PC Manhole Cover
Distribution Lines (W) (o -S (P ,
Bottom of System S , Q 0 - �. (�) 2. o = �7 �► ( )
Final Grade ( ) /- Q - I 1 , 7
Date of installation I / /V Permit number 3 5 ? g State plan number
Plumber's signatur ( Wt f� License number �f"f`i LS "D ®p DatW / / S
Inspector
Complete plot plan
1 ! P4
NOTICE Please provide the following:
• A plan view sketch showing everything within 100 feet of the system.
• Two horizontal reference eP
oints to center of septic tank manhole cover.
P
• Show alternate benchmark if applicable.
PLAN VIEW
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INDICATE NORTH ARROW Q
S j sin Department of Commerce PRIVATE SEWAGE SYSTEM y:
Safety aid B Division Count
INSPECTION REPORT ST. CROIX
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)]. 315878
Permit Holder's Name: ❑ City ❑ Village Ifi Town of: State Plan ID No.:
MILLER, SAM HUDSON
CST BM Elev. Insp. BM Elev.: BM Description: Parcel Tax No.:
0006� t /00.00 020- 1336 -20 -000
TANK INFORMATION LEVATION DATA A9800266
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic 911 Benchmark
Dosing
Aeration Bldg. Sewer h
Holding St /44€-lnlet
TANK SETBACK INFORMATION St/ W Outlet S
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic �� ' /o/ / c� / NA Dt Bottom
2`
Dosing NA Header Hfti,
Aeration NA Dist. Pipe
Holding Bot. System /0, pry 9 71
.�0
PUMP/ SIPHON INFORMATION Final Grade 3 / z <,
Manufacturer Demand ' C ,_
Model Number GPM
TDH Lift iris n System TDH Ft
Forcemain Le th Dia. m Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width s Lengt , No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS �J 05 �-' DIMENSION
SETBACK
SYSTEM TO P/ L BLDG WELL LAKE /STREAM LEACHING Manufacturer:
INFORMATION TypeO ,s't47 CHAMBER Model Number:
System:' .l,,. - r:.e 75 ( / (o OR UNIT
DISTRIBUTION SYSTEM
Header /Manifold 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
J✓ 1 . r
Bed /Trench Center Bed /Trench Edges (j Topsoil ❑Yes El ❑Yes E] Na
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON 27.29.19,NW,NW 785 WILFRED RD— BADLANDS PRAIRIE LOT 42
r ✓
zf, �.�
Plan revision required? ❑ Yes No I
Use other side for additional information.
SBD -6710 (R.3/97) Date t, n sffectWs Signature Cert. No.
i �n Safety and Buildings Division
SANITARY PERMIT APPLICATION 201 W. Washington Avenue
` ��s P O Box 7302
Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code
p Madison, WI 53707 -7302
• Attach complete plans (to the county copy only) for the system, on paper not less County I
than 8 112 x 11 inches in size. S4, (f r6l X
• See reverse side for instructions for completing this application State Sanitary Permit Number
Personal information you provide may be used for secondary purpo , ess; n Check if revision to previous application
(Privacy Law, s. 15.04 (1) (m)). 7 9 5 W' I / CL.� �C G�
State Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION
Property Owner Name Property Location
4 & W14 S �� T N, R E(
Property Owner's Mailing Address Lot Number Block Number
CI y, Sta a Zip Code Phone Number Subcfivision Name or CSM Number
11 . TYPE OF BUILDING: (check one) ❑ State Owned ❑ it y Nearest Road
Village
Public EK 1 or 2 Family Dwelling - No. of bedrooms, L Towrt OF
111 BUILDIN USE: (If building type is public, check all that apply) Parcel Tax Number(s) a7 a 9. p . 7 O a
1 E] Apartment/ Condo 0 Z O - / 3 3 40 Z. 7 0
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 Q Hotel/ Motel 9 Q 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, Q New 2. ❑ Replacement 3, ❑ Replacement of 4_ Q Reconnection of S. ❑ Repair of an
__System ________System _-, __ Tank Only______________ Existing System ________ Existing Sy tern
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 Trench51DE W(N0SQ 22 ❑ In- Ground Pressure - ❑ Pit Privy
13 ❑ Seepage Pit /iy v T'p r_ X 3X 7� 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
- 5-4=> S -40 "? 3, - 40 _ g7• Feet /o!• S Feet
Cap acit y
VII. N ORMATION in gallo Total # of Manufacturer's Name Prefab. S i a Fiber- plastic Exper.
Gallons Tanks Concrete Steel glass App.
New Existin structed
Tanks Tanksl Tanks
Septic Tank or Holding Tank /On E - ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber, ❑ 1 ❑ 1 ❑ ❑ ❑
Vlll. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature (No Stamps ) MP /MPRSW No.: Business Phone Number:
it l�( �.fJ,� [..t -- ��S c .S�' ! S✓�o
Plumber's Address (Street, City, State, Zip Code):
IX. CO N / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate slue Issuing Age tSi ature ( St
Approved E] Owner Given Initial Surcharge fee)
Adverse Determination /'����
X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL:
SBD- 6398 (R.11/97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
Safety and Buildings Division
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 �� t
than 81/2 x 11 inches in size.
• See reverse side for instructions for completing this application State sanitary Permit Number
:315
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 INFORMATION
Property Owner Name Property Location
Af 11-4-1541— N 4,1114 U) 1/4, SQ -7 rBlock , N, R / E (o W
Property Owner's Mailing Address Lot Number Nu mber
City, State Zip C d Phone Number Subdivision Name or CSM Nunlbey
tit l * )z7 r4N IR1
I ll. TYPE F BUILDING: (check one) E] State Owned [1 02 Nea £t Ro
VII ag
Cl e
Public 1 or 2 Family Dwelling - No. of bedroo Town OF
III. BUILD[ USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo 6 316
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 ew 2 ❑ Replacement 3. ❑ Replacement of 4 ❑ Reconnection of 5_ ❑ Repair of an
__r 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 C] Holding Tank
12Xeepage Trench 22 ❑ In- Ground Pressure / 42 ❑ Pit Privy
13 ❑ Seepage Pit c - . 5 -' X 75 43 ❑ Vault Privy
14E] 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
`T5a qw . � 7,1 D 1, Feet
Capacity
VII. TANK in Ca allo Total # of Prefab. Site Fiber- Exper.
INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
New Existing strutted
Tanks Tanks / �y
Septic Tan 1 000 1 Wt L� ❑ I ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ I ❑ 1 ❑ 1 ❑ 1 ❑ 1 ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signatu e: (No ps) MP /MPRSW No.: Business Phone Number:
ffi 1�� �D�N L•� AAe&s -o3Sao 3 %-
Plumber's Address (Street, City, State, Zip Code): t /
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issue Issuing Age i ure (�lo Stamps)
" Approved ❑ SUr�hargeFee) �
Owner Given Initial b D
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD -6398 (R. 05194) DISTRIBUTION: original to County, One copy To: Safety & Buildings Divu.ion, Owner, Plumber
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Wiscon DVart of Industry SOIL AND SITE EVALUATION 1 3
4bor and Human Relations Page of
Division of Safety and Buildings 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 St. C r O i X
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
'71?0 ' -/a 7 . _0
APPLICANT INFORMATION - Please print all info ' J i n. Re'VMI ed by Date
Personal information you provide may be used for secondary purpose vay "law, s. 15.04 (1) (m)):
t ,
Property Owner Aw Property Location
Richard Stout��� Govt. Lot NW 1 /4NW 114 ,G27 T 29 ,N,R1 9(or) W
Property Owner's Mailing Address fit' Block# Subd. Name or CSM#
1 353 Awatukee Trail ^'"d ,;,.42 l Badlands Prairie
City State Zip Code Pho ber �C ;. _ osity F] Village f ] Town Nearest Road
Hudson WI 4016 (71 5 , . -67 Y4': udson jState Hwy 12
® New Construction Use: ® Residential / Number of a Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow 600 g pd Recommended design loading rate p ed, gpd /f12 8 ��rr �� gpd /tt
Absorption area required 858 bed, ft 750 trench, ft Maximum design loading rate • ' bed, gpd/ft gpd /ft
Recommended infiltration surface elevation(s) 96.8 ft (as referred to site plan benchmark)
Additional design /site considerations
Parent material G deposit 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 U s ❑ U R1 S❑ U I RI S El ❑ S �] U ❑ S q U
SOIL DESCRIPTION REPORT
Boring Horizon Depth Dominant Color Mottles Structure GPD /ft
9 Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
1 1 0 -10 7.5yr2.5/1 none L 2mabk fr s f .5 '.6
2 10 -38 10yr3/4 none sl 2mbk vfr s If .5 '.6
Ground 3 38 -89 10yr4/6 none In s osg rtl s - .7 .8
elev.
9 . 7 ft.
Depth to
limiting
factor
Remarks:
Boring #
1 0 -12 7.5 r2.5/1 none L 2mabk nfr
2 2 12 -3 10 r3 4 n
3 36-84 10yr4/6 none s :)sg nl CS -- .7 : 8
Ground
elev.
101 .
Depth to
limiting
factor
8 4 in. Remarks:
CST Name (Please Print) Signature Telephone No.
�fraAu SGI��.a�. �fr'er� 4 ` ' .ate''°° 7 /s - 3FL 3�� f
Address Date CST Number
�, -d gl� a A l l, t 7 97 27 94 d
PROPE OWNER Richard St O Ut SOIL DESCRIPTION REPORT
Page 2 of 3
PARCEL I.D.#
Boring # Horizon Depth Dominant Color Mottles Structure 2
Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed . Trench
3 1 0 -16 7.5 r2.5 1 none L 2mabk mfr Cs 2f .5 '.6
2 116-48 10yr3/4 none S1 2mbk mvfr Cs if .5 ;.6
Ground 3 48-89 10yr4/6 none ms osg ml CS -- .7 ;.8
elev.
100- 8t•
Depth to
limiting
factor
8 9 in.
Remarks:
Boring #
1 )- 16 7.5yr2.5,Ll none- L 2mabk mfr 2f
2 16-42 10yr3/4 none S1 2mbk mvfr ES .5;.6
3 2 -9 10yr4/6 n one ms osg ml Cs -- .7 :.8
Ground
elev.
1 01.�t .
Depth to
limiting
factor
9 0 in.
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Boring #
1 -16 7.5 r2.5 no e L Is f
5 2 16-4p 10yr3/4 none S1 2mbk mvfr Cs f .5 '.6
3 8 -9 10yr4/6 none ms osg ml Cs -- .7 ;.8
Ground
elev.
Depth to
limiting
9 0
factor
in.
Remarks:
Boring #
Ground
elev.
ft. '
Depth to
limiting
factor
in.
Remarks:
SBDW -8330 (R. 08/95)
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer _� �- it
Mailing Address _ ' 1_A1L
Property Address 7 ` GCJ�`� 7'` k oA
(Verification required from Planning Department for new construction)
City /State 40b So u 1 Parcel Identification Number 40 ZD - 1 3 0
LEGAL DESCRIPTION
Property Location t /4, It W '/4, Sec. Z7 , T Z 9 N -R I ,, own of # O
Subdivision 'akb 1^.4 m jo 4)2641 ki , Lot #
Certified Survey a # s& Volume Page #
Y P g
Warranty Deed # S8 $3S , Volume 3 , Page # -3
Spec house [X yes ❑ no Lot lines identifiable K 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, restrictedplumber 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.
Uwe, 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 the St. Croix County Zoning Office within 30
days of the three year expiration date.
TURF _011-APPLICANT DATE
- �: A)WNER 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
�prty described abov by virtue of a warranty deed recorded in Register of Deeds Office.
K /
SIG ATURE OI? XPPLICANT DATE
* * * * ** Any information that is mis- 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
VOL
581835
STATE BAR OF WISCONSIN FORM 2 — 1982
WARRANTY DEED
DOCUMENT NO.
REG1��T�E� �
,S �7F FICE
ST. CRO�k Co,, WI
RICHARD C) STOTIT - Rsc'u 4: r t rncor<}
JUN 2 5 1998
conveys and warrants to 6AM h . 3 :30 P M ,,gy�pp
It
THIS SPACE RESERVED FOR RECORDING DATA
NAME AND RETURN ADDRESS
the following described real estate in C roix County
�i �Sly7 Iri / tL c2
State of Wisconsin:
Lots 37, 38 and 42, Plat of Badlands P4,�OX /s l
Prairie, Town of Hudson, St. Croix County, 6 1,6
Wisconsin. 2v�
PARCEL IDENTIFICATION NUMBER
TRANSFER
- FEE
is not
This homestead property.
(is) (is not)
Exception to warranties: easements, restrictions, rights -of -way and covenants
of record, if any.
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