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HomeMy WebLinkAbout026-1041-90-000 ST. CROIX COUNTY ZONING DEPARTMpI'p AS BUILT SANITARY REPORT LIV ED Owner c/v� > S �?; "9 1998 , 1 u Address S _ s r UN City /State MO.—) )z c, n��, i �> ,� ,� �c vial c��=F r Legal Description: Lot Block Subdivision/CSM # '/• € ' / + dam, Sec. /,L,; TLN -R�&, Town of r� ��� r PIN # -� _ � , j SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer Size ST/PC, r , l Setback from: House /� Well P/L C ZL / Pump manufacture_ r- Modd Alarm location (HOLDING TANKS ONLY) Setbacks: Service road Ven h air.intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM Type of system: ' Width / y Length -� Number of Trenches Setback from: House - e 5 Well 12L� P/L �_� Vent to fresh air intake 2 r ELEVATIONS Description of benchmark �'� <-�' Elevation 14,'l 0 / Description of alternate benchmark Elevation Building Sewer ST/HT Inlet , a - ST Outlet PC Inlet PC Bottom Header/Manifold �� Top of ST/PC Manhole Cover _ Distribution Lines Bottom of System O 07 O ( ) Final Grade Date of installation V9 71 � ) � ? Permit number - 3 t State plan number Plumber's signatur -��, . '��.� License number Date cf / Inspector 0 '� c� Complete plot plan Or T y 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 �e wy 6 V 3 10 � �e'l L 6 I � INDICATE NORTH ARROW Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count Safety and Buildings Division bT. CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) SanitaGyNipit-NO.: Personal information you provice may be used for secondary purposes (Privacy , s.15.04 (1)(m)]. Permit Holder's Name: ❑❑ e Town of: State Plan ID No.: RISELL, JOSEPH CST BM Elev.: Insp. BM Elev.: BM Description: 02 9Q - 1041-90-000 TANK INFORMATION EVATION DATA A9800213 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic �V �� Bench j /DO -/ Zob Dosing Aeration Bldg. Sewer Holding S #t Inlet 3,dSs Z e?-4- TANK SETBACK INFORMATION St W Outlet 3, 3� q6 .76 TANK TO P/ L WELL BLDG. V* 4 In take ROAD Dt Inlet Septi r (D NA Dt Bottom Dosing A Header / Man. 2- Aeration NA Dist. Pipe q3 Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade 2- 97 Manufacturer Dema !.7 �g, rL Mode umber GPM TDH Lift Friction System DH Ft Forcemal nth H Dist. To well SOIL ABSORPTION SYSTEM BED BENCH Width Length , No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth -WMEN 5 DIMENSION SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHI G INFORM anu m INFORMATION TypeO 'I f OR UNIT CHAMBE a Nu er• S,ystenL�",7"e4 `I DISTRIBUTION SYSTEM -6 Head er / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake if P 9 Length Dia. Length A Dia. Spacing f- tS(Ni( �jG f Z?Z 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 C] Yes [] No ❑ Yes E] No COMMENTS (Include code discrepancies, persons present, etc.) LOCATION: RICHMOND 14.30.18.202D,SE,NE 1572 140TH STREET Oa Z6' Plan revision required? ❑ Yes 0 No < Use other side for additional information. SBD -6710 (R.3/97) Date Insp is Signature Safety and Buildings Division Vi scons i n SANITARY PERMIT APPLICATION 201 W. Washington Avenue In accord with ILHR 83.05 Wis. Adm. Code P O Box 7302 Department of Commerce Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, on paper not less County ,. than 8 112 x 11 inches in size. I :Z6 &)--0 i • See reverse side for instructions for completing this application State sanitary Pe N umber Personal information ou p rovide may be used for seconds � A J y p y second purposes ❑Check if revisi n to previous application [Privacy Law, s. 15.04 (1) (m)). same State Plan I.D. Number I. APPLICATION INFORMATION - `1 PLEASE PRINT ALL INF RMATI N Property Owner Name Property tion e 01 � 0 1 /a /W1/a, 5 ee T �o N, R�4E (o Property Owner's ailing Address Lot Number Block Number ,,[ City, r , Zip Code Phone Number Subdivision NamejwXSf"umber II. TYPE OF BU ILDING : (check one) ❑ State Owned ° C it e d'� Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms own 0 4 III. BUILDING USE (If building type is public, check a ll that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo / 4 - ch 3 0. /,?. a / e 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 1V. TYPE OF PERMIT (Check only one box on line A. Check box on line B, if applicable) A) 1 ❑ 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 CEf.Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ 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 �1 Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Q _ Elevation 6 � Feet v 7- Feet Ca clt VII TANK in allo s Total # of Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existing structed Tanks Tanks Septic Tank or Holding Tank O'a a Lr✓ G r f [3� ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ 1 ❑ 1 ❑ 1 ❑ 1 ❑ 1 ❑ VIII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumb 's Name: (Print) Plumb ignature: (No ps) MP /MPRSW No.: Business Phone Number: Plu er's Address (Street, City, Stat , Zip Code): IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater D ate I ssued Issuing A nt Sign roved Surcharge Fee) pp []Owner Given Initial ` p'i���� Adverse Determination O C/ . 1 X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.11/97) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber • ` � NLU I NL N /5 7a lcvcJ �� s PROJECT CS e{ G�`� ADDRESS �Gi 1 /4/f/f 1 /T�W N /R�rW TOWN .-1 COUNTY ,S7��Gro.X MPRS Byron Bird Jr. 3318 DATE –� BEDROOM CLASS PERC CONVENTIONK IN - ND PRESSURE CONVENTIONAL LIFT MOUND HOLDING TANK SEPTIC TANK SIZE ' /�� LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE _ ABSORPTION AREA �Z PERC RATE S' BED SIZE 116 Benchmark V.R.P. Assume Elevation 100' Location of Benchmark O Borehole Q Well Scale = Feet O Perc Hole System Elevation � - �C– Uent 12" Grftdp TYPAR COVERING 2" 12" 3' 4 g' O 3' 3' 0 3' I s " Sewer Rock 12' 18' ` ` LT yL d26 i t \ U 1n � d Q.►� 5 ��G� y /o OZA W isconsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page of Bureau of Integrated Services 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 percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # ©,R l0 4Z1 - -f'O 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)). r-- Property Owner Property Location fps e ��►� e Govt. Lot SG 1/4" 1 /4,S/ T d ,N,R 1 .81 E (o Property Owner's Mailing Address ! Lot # Block# Subd. Name or CSM 1 - 4 - 70 9 - Ci tate Zip Code Phone Number ❑City Villa e [� To Nearest Road /S'� l �fof�i /S ❑ New Construction Use: [Wesidential / Number of bedrooms Addition to existing building Replacement LJ Public or commercial - Describe: Code derived daily flow _g'� <5 gpd Recommended design loading rate bed, gpd /ft � c trench, gpd/ft Absorption area required bed, ft Z� trench, ft — Cam/ Maximum design loading rate _ bed, gpd/ft gpd /ft Recommended infiltration surface elevation(s) / " ft (as referred to site plan benchmark) Additional design /site considerations Parent material X. L Flood plain elevation, if applicable �/r��`�� ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system S❑ U i S ❑ U S El U S ❑ U ❑ SU E] S 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 elev e-W 62t. Depth to limiting factor J` in. Z ring # Remarks: Ground 9 D fe ft epth to limiting factor in. Remarks: CST Name (Please Print) Signature Telephone No. Addres Date CST Number PROPERTY OWNER ��� v y ' j� / /SOIL DESCRIPTION REPORT Page of PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 in. / Munsell Qu. Sz. Con Color /J Gr. Sz. Sh. Bed Trench _ r Ground 2 elev_ Depth to limiting factor Remarks: Boring # 13 Ground elev. ft. Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/fl? in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench Boring # E3 Ground elev. ft. Depth to limiting factor in. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBD -8330 (R. 07/96) Soil Test Plot Plan Project Name o5��1j L�"'�,`S � � Byro 'rd Jr. Address 1 5- - 7a o :�� I CS M #3479 Lot Subdivision Date � -- �i 14 1 /4S��T yip N /Rf� W -.- Township Boring GWell PL Property Line County BM or VRP Assume Elevation 100 ft r/G -Z System Elevation *HRP 0 2- f+ o� Scale 1/4" = 10 Ft. When Dimensions aren't stated y + r ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer t� e `r' , Sal Mailing Address Prqperty Address (Verification required from Planning Department for new construction) City /State Parcel Identification Number LE GAL DESCRIPTION Property Location _ 4, '/4, Sec. , T_ QN -RW, Town of 44 r Subdivision Lot # Certified Survey Map # , Volume — , Page # �^ Warranty Deed # `��S' —�` , Volume , Page # S �6 Spec house ❑ yes Wno 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. 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. GNA F APPLICANT MATE 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 perty describe above, by virtue of a warranty deed recorded in Register of Deeds Office. GNAT 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 DOCUMENT NO. i WARRAMY rNic 3111." Resenveo rope ReeowoiMa DATA i it �! STATE BAR OF WISCONSI j roam 2— Im 482596 -- - -- - vas. ��s�?�_�_ 0 Gale K. Knutson and Mary E. McDermott REGISTER'S ©FFICI S1rCM CO. N ... . � _ .... . _ ----- APR 291992 conveys and warrants Joseph P .. Grisell...and .Susan h_ ' . .. GriselI.,. husband -and wife, as survivorship..Writil... It 8;15 A. M _ property .............. _ how of Do* — .. .. .. ....... ....... ...... ........ .. .... ..._ .._. it RETUPR TO I ... .. ................. .... .. - .......... .......... -_... .... ... ..... .... ....... .... the following described real estate in .......... t • r0 X Y. Mate of Wisconsin- he 1 The North 208.8 feet of East 208.8 feet of at part Tax Parcel No: . ......--°------ ------•-- of Southeast Quarter of Northeast Quarter (SE! of NE#) of Section Fourteen (14), Township Thirty (30) North. Unm Eighteen (18) West, lying West and South of Town Roads. This is home-rsd pro pert }'. (is) (is not) Fxception to• %rarranties: uatvd H is "L day Of April 1992 �� 1r ' Gale a_ Knutson. (i�tc • /�[� -� 2� Mary E_ McDermott