HomeMy WebLinkAbout026-1039-70-000 S'F- CROIX COUNTY ZONING
s AS RUIL I' SANI'T'ARY REP01 '1'
Owner r Address
City /State �o-.? S -. 7 _ `
9 8
ST Old
COU"
r
Legal Description: ', ? c�'AiGO FCE
Lot Block Subdivision/CSM 11
Scc- (�, T :3D N -RAW, Town of PIN tt 6
SEPTIC TANK — DOSE CHAMBER — FOLDING TANK INFORMATION:
Tank manufacturer�
�A N W5 Size ST/PC 1 Setback from: House a$ Well P/L
Pump manufacturer Model
Alarm location
(HOLDING TANKS ONLY)
Setbacks: Service road Vent to fresh air intake Water Line
Meter location
Alarm location
r
SOIL ABSORPTION SYSTEM:
Type of system: Width Length S` Number of Trenches
Setback from: Souse 3' Well P/L � Vent to fresh air intake /02 Fs '
ELEVATIONS
Description of benchmark - � � � 10d-1k t
Elevation
Description of alternate benchmark Elevation
Building Sewer ST/HT Inlet ST Outlet 48 , o7 PC Inlet
PC Bottom �' Header/Manifold S Top of ST/PC Manhole Cover `f
Distribution Lines
Bottom of System
Final Grade
Date of installation / 6/9 Permit tuber oa3oZ State plan number
Plumber's signature License number go?0.53, Datc //V// p
Inspector
Complctc plot plan
w
NOTICE: Please provide tlic 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
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count y
Safety and Buildings Division
INSPECTION REPORT ST. CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Personal information you provice may be used for secondary pu rposes [Privacy L V, s.15.04 (1)(m)]. 320232
CUNNINGHAM, LARRY RI OINI� Town of: State Plan ID No.:
CST BM Elev.:- Insp. BM Elev.: BM Description: Parcel Tax No.:
� 026- 1039 -70 -000
TANK INFORMATION ELEVATION DATA A9800421
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
BenchW 104418 16C)
Dosing
Aeration Bldg. Sewer
Holding St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom
Dosing NA Header/Man.
Aeration NA Dist. Pipe MID
Holding Bot. System °J. C�(l,
PUMP/ SIPHON INFORMATION Final Grade — (,o ->(-eke ( 98;
Manufacturer emand Z.o /�.
Model Number I I GPM
TDH Lift Friction 5ystem Z TDH Ft
oss Head
Forcemain I L th Dia. _ Dist. To Well
SOIL ABSORPTION
_AEDf TRENCH Width Length No. Of PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS �Z 7 DIMEMSI
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEA A RING Manu
SETBACK ac
CH
INFORMATION Typ umber:
Sy tem b 1p �oo OR UNIT
DISTRIBUTION SYSTEM
Header/ Distribution Pipe(s) x H j I Size x Hole Spacing Vent To Air Intake
Length r] � Dia. Length Dia. L� Spacing �_ j7h'l
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 E] Yes El No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: RICHMOND 13.30.18.187B,NE,NW 1431 160TH AVENUE
'E _3 a -Ff Zo, w o _ slore
Plan revision requir d? ❑ Yes g No
Use other side for additional information.
SBD -6710 (R.3/97) Date Insp ctor's Signature ert. o.
1 4' SANITARY PERMIT APPLICATION Safet and e Division
hcons P.O. Box 7969
Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison yyl 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 12 x 11 inches in size.
• See reverse side for instructions for completing this application State Sanitary Permit Number
3 20 2_3-
The information you provide may be used by other government agency programs ❑ Check it revision to previous app 1 ion
[Privacy Law, s. 15.04 (1) (m)]. ( r �►
O J (/ ' `/ State Plan I.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMA N
Property Owner Na P pe Lo tion
'1/4 �+'(,t�1A, S 13 T �'�. N, R 1 f(or) W
Property Own is Mailina Address I Lot Number Block Number
�h A u 'e
City, State Zip Code Phone Number Subdivision Name or CSM Number
i ,.7 , UZ
or ( -AX IS 73
II. T P B ILDING: (check one) ❑ State Owned 0 La Near ROa
Public 1 or 2 Family Dwelling - No. of bedrooms o town of ` 1O A'��
111. BUILDIN USE: (If building type is public, ch all that apply)) Parcel Tax Number(s)
1 E] Apartment/ Condo / ✓ Q• `? • it 7,3 0.;w l 0 3 q — 70
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. D(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 E] Specify Type 41 []Holding Tank
12 Seepage Trench 22 ❑ In- Ground Pressure ' Z + z 75 42 C] Pit Privy
13 E] Seepage Pit J 43 ❑ Vault Privy
14 ❑ System -In -Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate S. Perc. Rate 6. System Elev. 7. Final Grade
Required (s . ft.) Proposed (s g. ft.) (Gals/day /sq. ft.) (Min. /inch) n I Elevation
qw; Feet C 8 Feet
VII. TANK Ca
in a ut s Total # of Prefab. Site Fiber- Exper.
INFORMATION g Gallons Tanks Manufacturers Name Concrete Con Steel glass Plastic App
New Exist in structed
T nks Tanks
❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ 1 ❑ ❑ 1 ❑ 1 ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for ipstallation of the onsite sewage system shown on the attached plans.
Plumber's Name: int) P tier's Si atu : (No amps) MP /MPRSW No.: Business Phone Number:
OALLI-a RLAx-C ,� o 5 [ 5
Plumber's Address (Street, City, State, Zip Code).
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved S itary Permit Fee (Includes Groundwater ate Issued issuing Agent Signature (No Stamps)
t<Approved ❑ Owner Given Initial n CD Surcharge r ee)
Adverse Determination 0 C/ Ioa
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD (R.II196) DISTRIBUTION: Original to County. One copy To: Safety B Buildings Division, Owner, plumber
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C r US S S �e}Ipr'1 - - p 4' 1 '
l �C17 ��S i C'.!►�
V1 (\" �rtu lY�.
L-4 31
Fifth Ali And OD$oilrollon Pipe
• Approrid V$nl Cap
•'' Allnlmunr
12' Abor$
Flnal Grad• '
i
TO- 42' ADor$ PIPP _ 4 Casl Iron
To F1n$1 Or$do V$nl Pipe
uarrn
it Or $�nlMlk Co uln
• Lln 2' Ayyropol$
0.$r Plp$ ..
Dltl /IIIYIIOn
Plpo �' 0 0 0 Tao s
b' Ayyr$yol$
a$noelk PIP$ 0 Porlor$lod Plp$ below
o �'Co�pllny Tuminollnp AI
Bouom of Sislom
P rUpoNcD Pine.) 19 '%(I{ -
��cJ..T
SOIL FILL
DISTRIBUTIOI.I PIPE '
,r. APPROVED SWPETIC COVCA
2 "OF 11,GGREGATE -/� `�! OIL 4. OF STRAW
zt:. OR MARSU I1A`i
�LEV. OF / 16E1; Y (.�OPlz - 2 1 /Z AGGftCGATE
-- Cv ---�
DISTRIF5UTI10M PIPE TO INC AT LEAST INCHES 6CLOW ORIGILIAL GRADE
AQU AT LCASTLO IIJCHEf, BUT 1.10 MORE THAIJ 42. IM01CS BELOW FIAJAL GKAor
MRXIMUtA DEprVi of EXCAVATIOP F4 011 OR16V AL 6F ADF- WILL BE 13ro
IucHEs
!'ur/IMUM 05MI OF EACAVAT100 rRoP� 0,Ik'6 NAL GRAPE WILL INCHE S
S161JE0:
LICEIJSC IJUMBER: 'ana3�
d q r �.
DATE:
Wisconsin Department of Industry SOIL AND SITE EVALUATION J
Lab` r and Human Relations • Page J of 3
.Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis.
...,__ _ .__ County
i I an 8 1/2 x 11 inches in siz . P ust
Attach comp lete site Ian on paper not less than e m
P P PaP .,
include, but not limited to: vertical and horizontal reference point (BM), ctfoh.and !\;' Sf C >r- / y
percent slope, scale or dimensions, north arrow, and location and dis C neares*ad. #
RECEIVED `\ O ab-
APPLICANT INFORMATION - Please print all info r on. l ei#ered by 'Date
Personal information you provide may be used for secondary purposes (Pri c w, s. (184 19 } �. oil 1 Qe)
Property Owner FVpQ"cation
Y` �/lil.`n Yt i7 of 4)1/4,S 13 T30 ,N,R J� (or) W
I'V Property owns s Maiiing Address Lot # Bloc bd. Name or CSM# L 4
I City State Zip Code Phone Number Nearest Road
&AAA R larn04 � 5 1 ) ay,6 - 3S ❑ City Village 4 Town / D
❑ New Construction Use: Residential / Number of bedrooms Addition to existing building
Replacement n Public or commercial - Describe:
Code derived daily flow 50 gpd Recommended design loading rate 5 bed, gpd /ft -o-4—trench, gpd/ft
Absorption area required q0Q bed, ft "75o trench, ft Maximum design loading rate j S bed, gpd/ft _ #4 0 trench, gpd /ft
Recommended infiltration surface elevation(s) . ft (as referred to site plan benchmark)
Additional design /site considerations
Parent material lj a.5 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 El U E] S 29 U Dd S El U EIS 4 U 1 [Is ®U EIS 2 U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
Ground (, - g [ r
elev.
��ft•
Depth to
limiting
facto
in.
Remarks:
Boring #
D /l, r AIR 1 , - J
_3
9 94C r A /4 —
M Sb� rn3 r l .S
Ground p'g s 71r1 phi
v
�� ft.
Depth to
limiting
factor
VOL Remarks:
CST Name (Please Sign atu Telephone No. t
Address )ate CST Number
no A)&j u&7 rw 7 8 4 LY0 o 5.r 7
PROPERTY OWNER ��-•+ C U hnj n4 A gv„ SOIL DESCRIPTION REPORT page oQ of 3 .
PARCEL I.D.#
Borin # Horizon Depth Dominant Color Mottles Structure 2
g Texture Consistence Boundary Roots
k in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
.....
r W 4y;
Ground
elev.
9aft•
Depth to
limiting
factor
i
�in. '
Remarks:
Boring #
LLL
Ground
elev.
ft.
Depth to
limiting
factor
in.
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /fe
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Boring # ;
YC
Ground
elev.
ft.
Depth to
limiting
factor
' Remarks:
1.
Borin J #f
E3
Y
Ground
elev.
ft.
Depth to
limiting
factdr
iri. ` Remarks:
SBDW -8330 (R. 08/95)
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ST. CROIX COUNTY": ZONING,.OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
This is to certify that I have inspected the septic tank presently
serving the 11 rl y / 1n residence located at:
Icy
/9_ • 1 /4, N 14) , 1/4, Seca / T N, R ..IS W, Town of
lGLt1,1r1r1.5'Y%C� Upon inspection, I certify that I have found the
tank and baffles to be in good condition, and it appears to be
functioning properly.
Last time serviced
Did flow back occur from absorption system? Yes - Not (if no, skip
next line)
Approximate volume or length of time: ._ gallons minutes
Capacity:
Construction: Prefab Concrete _ _ Steel Other
Manufacurer (if known):
Age of Tank Z n own
n
.
(Sign (Name) Please Print
(Title) (License Number)
• --� 9�
(Date)
Form to be completed by licensed plumber (x.145.06, Wisconsin Statutes)
or Licensed Disposer (NR 113 Wisconsin Administrative Code)
Plumber (applying for sanitary permit) Certification:
In accepting the above statement regarding existing septic tank
condition, I certify that the tank to the best of my knowledge will
conform to the requirements of ILHR -83, W' Adm. Code (except for
inspe ction opening over outlet baffle).
Name n C1: '� �.• Signature
5/88
I
' ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer 4, 41f & ✓ �9N� �/�� �� ,� C v nriy��v -r �x�A ^�►
Mailing Address / 11 % /� !7
Property Address -
(Verification required from Planning Department for new construction)
Off L 3
Gity4tate _ �i C /7��r a nr/. Parcel Identification Number
LEGAL DESCRIPTION r f � { F p F 7 F N Gv Xy G
Property Location VY 6, ' /4, Al E '/4, Sec �, T _3�t_ N -R_/_g Town of
Subdivision Lot #
Certified Survey a # V o l ume Page #
y p of g
Warranty Deed it 71) 9 , do , Volume , Page #
Spec house ❑ yes E� 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
g q g P g P Y
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 t$e three yea piration date.
NA OF APPLICA 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 7prope de scribed a e, by virtue of a warranty deed recorded in Register of Deeds Office.
S NA OF APPLICANT 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