HomeMy WebLinkAbout026-1040-30-000 CROIX COUN'I'Y ZONING I) I'AIU'MEN'F
AS BUILT SMATARY RE1
Owner v k C,
Address
City /State
Lcgal Description:
Lot Block Subdivision/CSM 11 -'
'/. lV(�t /, S Scc. :L3, T - 3 41 -R - AW, Town of to cj PIN /I
SEPTIC TANK — DOSE CHAMBER — HOLDING TANK INFORMATION:
Tank manufacturer
Size ST/PC Setback from: House L Well X46 P/L /.5 .
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:
Type of system: B-aJ Width T Length 1- S Number of Trenches
Setback from: House � Well /020 P/L /,LO Vent to fresh air intake 9 "
ELEVATIONS:
Description of benchmark
Elevation
Description of alternate benchmark - Elevation
Building Sewer - ST/HT Inlet - ST Outlet 9y, -2 PC Inlet —'
PC Bottom Header/Manifold 93, Top of ST/PC Manhole Cover 9 B 9
Distribution Lines( ) 9 3, to ( ) ( )
Bottom of System ( ) C � a, S ( ) ( )
Final Grade ( ) 9 -S I ( ) ( )
Date of installation 9 / /fJ /`I Pcrmit number 2ca W Y, State plan number
Plumber's signature License number D. :J' Date 9
Inspector
complete pia plan K
f
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.
P 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 Permi
Personal information you provice may be used for secondary purposes (Privacy L , s.15.04 (1)(m)].
Permit Holder's Name: ❑ Ci a Villa e Town of: State Plan ID No.:
OLIEN, BRUCE OND
CST BM Elev.:- Insp. BM Elev.: BM Description: Parcel TdAo_:104D --30 -000
TANK INFORMATION ELEVATION DATA A9800424
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Benchm 1-6&
Dosi ng
Aeration Bldg. Sewer
[ Holding St /Ht Inlet
TANK SETBACK INFORMATION e'p Outlet 74
TAN TO P/ L WELL BLDG. ventto ROAD Dt Inlet
Air Intake
Septi NA Dt Bottom
Dosing NA Header / Man. 7
Aeration NA Dist. Pipe
Holding Bot. System %D Gja,
PUMP / SIPHON INFORMATION Final Grade .off 95-t ct
.o
Manufacturer Demand 12eA �(o 0
Model Number GPM
TDH Lift Friction System TDH Ft
oss Forcemain Length Dia. H Dist. To Well
S L ABSORPTION SYSTEM
BED RENCH Width / Length / No- Of Trenches PIT No. Of Pits Inside Dia- Liquid De th
EN 1 N DIMENSION
SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING manu
SETBACK CHAMBER
INFORMATION Type 1 Model Number:
Sys O 1 OR UNIT
DISTRIBUTION SYSTEM
Header /Manifold r � Distribution Pipe(s), x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length Dia. # Spacing l0 72-1 ff
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 El Yes ❑ No ❑ Yes ❑ No
COMMENTS (Include code discrepancies, persons present, etc.)
LOCATION: RICHMOND 13.30.18.192B,NW,SW 1545 140TH STREET
q
Plan revision required
ed. ❑Yes j No
Use other side for additional information. S 1
SBD -6710 (R.3/97) Date Inspector's Signature Cep
SANITARY PERMIT APPLICATION 201 E. Washington l Avve.
.Wisconsin P.O. Box 7969
Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 - 7969
0 Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 1/2 x 11 inches in size. t
• See reverse side for instructions for completing this application State sanitary Permit Numb
3�Zo 2,-y2
The information you provide may be used by other government agency programs ❑ Check it 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
Pro ert wner Name \\ /h � F Properf Location
kJ t'vLCA. 1` -f V / U /4 (,)1/4 S 1 T 3 O N, R 1 r) W
Propert Owner's Mailing Address Lot Number Block Number
City, State Zip Code Phone Number Subdivision Na a or CSM Number
II. TYPE OF B DING: (check one) ❑ State Owned it Iyy Q Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms C)
Vil OF , `t�-
III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) f�)/ f� �h
1 E] Apartment/ Condo l �• 3�• J�. j 0r�o �f T� v O
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. T<Replacement 3. ❑ Replacement of 4 ❑ Reconnection of 5. ❑ Repair of an
System ____ystem _____________Tank Only______________ Existing System _________E ---- System
B) ❑ A Sanitary Permit was previously issued. Permit Number Mate Issued
V. TYPE OF SYSTEM: (Check only one)
Non- Pressurized Distribution Pressurized Distribution Experimental Other
i ASeepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 [:]Holding Tank
1 Seepage Trench 22 E] 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
Z/& Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation
l ,9� SO .� 9' r-$ Feet Feet
Capacit
VII. TANK in g all o ns Total # of Prefab. Site Fiber- Exper.
INFORMATION g Gallons Tanks Manufacturer's Name Concrete con Steel glass Plastic App
New Existin structed
Tanks Tanksl Tanks
Septic Tank or Holding Tank ^ El El ❑ 1:1 1:1
Lift Pump Tank /Siphon Chamber ❑ 1 ❑ I ❑ 1 ❑ ❑ I ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for install of the onsite sewage system shown on the attached plans.
Plumber's Name: (Pr Plu er's Signatu : (No amps) MP /MPRSW No.: Business Phone Number:
71.5 Q_ 35
Plum 's Address (Street Cit , St te, Zip C e):
, c � t 0t
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issue Issuing Agent Signature (No Stamps)
jApproved Surcharge Fee) ❑Owner Given Initial
Adverse Determination -1 0 Aw
I P ill "PIN 01
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD (R11/96) DISTRIBUTION: Original to county. One copy To: Safety & Buildings Division, Owner. Plumber
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• C,rvSS S �C}It)1, o� � I�, r I-, Y
• flash Alf 111191► And Obiefvallon Plpe "' ��c6mc, �f� S`(C,
y CIS Vv, ®�
• ^ Mlnlmum 12' Aaare
111101 Giede N lad �c�5��, M Y�')
4--d- 1—co.,01AV ' Above Plpp 1' Call Ira"
e$ 0fade V.nl Pipe
.�k Coming
* At10sepole Plpi Tea a 0 0 — a�epole ath Pipe ° PelloveL.d pi". 11.10.
o —Co.pllnp 1e At
00110m 01 Sy11em
7(o f
Q rupv)cp P1rl.. l 11 c�r�,c�< _
SOIL FILL
DISTRIBUY101.1 PIPE `
• �� APPROVED S4)Jp4r - TIC COVCR
2 "oiF AGGREGA11—�� ` OR 4" or S-ranW
OR MARSH HAY
l° OP AGGREGATE
F 4as FEE
LEV. O �lz-21 /z
DISTRIBIJT100 PIPE TO BE AT LEAST – 11J
A►JU AT LEASTtO 11.1CHE5 BUT K10 MORE THAI) 42 0 LOW F GRADE
m1rtuM DSPr}i OF EXCAVATIOIJ FX oRi&w 6RADa WILL BE � _ 11JCHES
. nNIMVM (NPT)t OF EACAVATIO" r 0a 1 64 JAL (SRAM WILL aC
INCHE S
SIGu
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LIGC►JSC UUMBEIi: ---,2 J
DATE . —_
Wisconsin Department of Industry SOIL AND SITE EVALUATION Page of
Labor and Human Relations
Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis.
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 <
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
Q 6 -_soya
APPLICANT INFORMATION - Please print all information Reviewed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner Property Location
P�
Govt. Lot V UJ 1/4 5'�J1/4,S 13 T 3 Z) ,N,R l Etw W
Property Owner's Mailing Address Lot # I Block# I Subd. Name or CSM#
S / o 'tN -- -
City State Zip Code Phone Number Nearest Road
P" Am � � S'401 ( 7'► S ) tP ' y 91 E] City ❑ villa Town 0 .f
❑ ew 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 gpd/tt
Absorption area required 00 bed, ft 2 /iL_rqS _ trench, ft Maximum design loading rate _ bed, gpd/ft 1--q trench, gpd/ft
Recommended infiltration surface elevation(s) 9,2"640 ft (as referred to site plan benchmark)
Additional design /site considerations
Parent material Flood plain elevation, if applicable ft
S = Suitable for system Conventional Mound In- Ground Pressure I AT -Grade 703 em in Fill Holding Tank
U = Unsuitable for system s U Ks ❑ U 91 S❑ U � S 11 U S ® U
SOIL DESCRIPTION REPORT f°
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2
W M* in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench
2 a>
Ground 3 7 ' S
e ev. `l 3
Depth to
limiting
factor
Remarks:
Boring # / d -' /O 3 ! k f OLD
Pas o 1 r 5 r 6
Ground a b J r3
r o
limiting
fa
in. Remarks:
CST Name (Please P Sr nature Telephone No.
O W e, 1 S ID -S
Address W� Date � CST �Numbe
�
�Q t'q rn
PROPERTY OWNER ewe-e 6 h -e k% SOIL DESCRIPTION REPORT
Page c;Z of 3 `
PARCEL I.D.# Q(, — /Cq p 3 6 () C
Boris # Horizon Depth Dominant Color Mottles Structure 2
9 Texture Consistence Boundary Roots
•••.: > in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench
Ground 9 bk Ch
elev _
91- ft. p �' S 0 YIl S "" s7 g
Depth to
limiting
factor—
Remarks:
Boring #
Sap
3` '
i
Ground
elev.
ft.
Depth to
limiting
factor
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 # ;
Ground
elev.
ft.
Depth to
limiting
factor
in ' Remarks:
Boring #
Ground
elev.
ft.
,
Depth to
limiting
factor
in. Remarks:
SBDW-41330 (R. 08195)
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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 re
serving the A sently
r� � cs o `
A kfU residence located at:
— W1 /9, �v` 1 jq, Sec . ��
T R -- 1 < W Town of
Upon inspection, I certify that L 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 No
(if no, skip
Approximate volume or length of time: -*/'Or) next line)
gallons minutes_
Capacity: j &z,) c
Construction: Prefab Concrete +
Steel Other
Manufacurer (if known):
Age of Tank nown):
(Signature) \ ase O�
(Name) Ple Print
i
(Ti
j .
1 J
(License Number)
10 -q
(Date)
Form to be completed b
or Licensed Disposer (NR 113 license
Admini trat ve Codeonsin Statutes) )
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 i Adm. Code
inspection opening over outlet baffle (except for
Name \��,
Signature
MP /MPRS
5/88
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer
Mailing Address 4 {"
Property Address
(Verifi required from Planning Department for new construction)
City /State V ,g ,� 'K mo , � VT Parcel Identification Number 2 �o — IO YO - 30 -0 03
SLM7
LEGAL DESCRIPTION
Property Location 4� ' /4, S UJ ' / Sec. 13 , TAN -R W, Town of �1m0 _ .
Subdivision v (+ ,Lot #
Certified Survey Map # , Volume , Page #
Warranty Deed # _ 9 (A , Volume 7 7 l0 , Page # :3 y -5
Spec house O yes [ no Lot lines identifiable )0 yes O 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 the St. Croix County Zoning Office within 30
da= e xpiration date. Cj / c�
! l �rBl G
SIGNATURE OF 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 owner(s) of
the operty describeA above, by virtue of a warranty deed recorded in Register of Deeds Office.
G
f! /
SIGNATURE 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
09/"02/98 WED 15:54 FAX 1 715 268 7207 NW SAVINGS BANK -►44 NEW RICHMOND Z002
S & N LAND SURVEYING
HUDSON, Wi.
386 -2007
NAME Northwest Federal Banking and Savings New Richmond
ADDRESS 532 South Knowles Avenue
Hudson, WI 5401
DESCRIPTION West 467 feet of North 467 feet of NW] of SW1- of T30N, R18W, Town of.Richmond, St. Croix County, Wisconsin.
Olien
'PLAT DRAWING
This is not a complete Land Survey
467'
nShed
.._.... ... y` �61
Ho r.
Q
A.) � S• Garage
er
The location of improvements on this drawing are approximate and are based on a visual inspection of the
PFemises, the la "dinansini are taken from plats and deeds of county records, This drawing is for
infoFinational purposes only and should NOT be used as a conplete Land Survey.
!Northwest Federal Banking And Savings has agreed to Naive these„ requ- irements -of A- E7.02, A- E7,03,
A= E7.04, A -E7.05 1 - 5 , -AE7.06 1 - S and A- E7.07. The purpose of this paragraph is to comply with
ALE7.01 (2).
tiap No. 93 -01 -201
Drawn By M.E.
ALL04 c Date 5
Scale 1" = 100'
Vnj.11ll'
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