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HomeMy WebLinkAbout026-1051-95-000 I � �-'7 � —�_ \ V ST. CROIX COUNTY ZONING DEPARTMENT/�'�,�` AS BUILT SANITARY REPORT Owner sr cRo;r. Address \;: ,;� COUNTY City /State \' ZONING OFF GE Legal Description: - -.- Lot. ' Block Subdivision/CSM # t �4 �4 -aJ Sec. 1% , T 30 N -RAW, Town of PIN # �a�- 1051 - JS' 06 0 SEPTIC TANK - DOSE CHAMBER - HOLDING TANK INFORMATION: x;a� - i ✓ry , Tank manufacturer J D " ; 9"VST/PC , / " / Setback from: House Well ,50 P/L 50 Pump manufacture_ r. 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: Width J,� Length 5 6 Number of Trendies Setback from: House Well 5 _ P/L 1 5 6 Vent to fresh air intake ELEVATIONS Description of benchmark i Elevation 10 U.0 Description of alternate benchmark Elevation 9 7 Building Sewert'i ST/HT Inlet ST Outlet PC Inlet lop PC Bottom Header/Manifold J Top of ST/PC Manhole Cover - Distribution Lines ( ) - ,9 `/ 0 () ( ) Bottom of System () 6 )3.0 () ( ) Final Grade ( ) 5 () ( ) Date of installation / /9YPermit number State plan number Plumber's signature g cease number 3 � Date Inspector Complete plot plan r 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 J� r ,0 3 r INDICATE NORTH ARROW Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM y= Safety and Buildings Division Count . CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) San itaryf(Y71 9'4: Personal information you provice may be used for secondary purposes [Privacy Lag, s.15.04 (1)(m)). R AEHSLERNamfiMOTHY ❑ Town of: State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description: Parcel TUN - 1051 -95 -000 6 0 10 0 r - t}a n.� o i— S TANK INFORMATION EL VATION DATA A9800173 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Benchm Dosing Aeration Bldg. Sewer Holding S Inlet TANK SETBACK INFORMATION S #r Outlet TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake NA Dt Bottom Dosing NA Header / Man. �� cjc�l 0-2 Aeratio NA Dist. Pipe R.g� $.�- $ga 4!'3.92 Holding , _ - -- 4 Bot. System 190' 22 -9Z PUMP / SIPHON INFORMATION Final Grade a 7;" q / Manufacturer emand Model Numb GPM TDH L' Friction S m TDH Ft L oss ead Forcemain Length Dia. Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH width , Length / No. O Trench PIT No. Of Pits Inside Dia. Liq Depth DIMENSIONS Ig �� DIMENSION SETBACK SYSTEM TO P / L I BLDG WELL LAKE/STREAM LEACHING INFORMATION Typeo i � CHAMBER Moe m er: System OR UNIT DISTRIBUTION SYSTEM Header /Manifold DistributionPipe(s) x Hole Size x Hole Spacing Vent To Air Fntake Length [Z Dia. Lengths Dia. Spacing /`�jTlv� 1+. Z'1 Z �S SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over �� Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Cente . ! v Bed /Trench il ❑ Yes ❑ No ❑ Ye COMMENTS (Include code discrepancies, persons present, etc.) LOCATION: RICHMOND 18.30.18.268C,NW,NW 903 160TH AVENUE � .> '; , tL \C� _-. - w. a h. -(- C. A � Z % X C 1) 4�Xr-4 An StAs jcwi rv. vt J't w > e- . Plan revision requi(e ❑ Yes '� No -'J' Use other side for additional inforr>Ifation. 9 '$ �.� F- fl i SBD -6710 (R.3/97) Date Inspector's Signature V SANITARY PERMIT APPLICATION `�'' 2ot Saf ety and Buildi Av E. 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 1/2 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Number 3c>r7 7 & The information you provide may be used by other government agency programs ❑ Check it revision toprevious applic tion [Privacy Law, s. 15.04 (1) (m)]. S State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION Property 0 Name Propert ocation /a 1 /4, S l� r N R Pr erty Owner's Mailing dress Lot Number Block Number 72P 3 7_ tit , tate Zip Code Phone Number Subdivision Name or CSM Number e L4 � 1,54 I' ll. TYPE OF BUILDING: (check one) ❑ State Owned ❑ C Nearest Road Public 1 or 2 Family Dwelling - No_ of bedrooms ❑ ow of "� ` �� Q fT 111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 19. 19.,R& ?C o4;zer 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. f7 3_ E] Replacement of 4. ❑ Reconnection of 5. E] Repair of an System em Tank Only Existing System ________ Existin ______ - _____� _�yst _____________ ______________ ---- -- 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 E] Holding Tank 1 { {❑ 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. 17 nalGrade /� S- Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation `1 19-ez,51 e ,�3 Feet I' Feet Cap acit y VII. TANK in Ca allon 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 el 1 elel;netia ik C r` S E R ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ 1 ❑ ❑ ❑ 1 ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plum s Name: (Pri t Plu s Signature: (No Stamps) MP /MPRSW No.: Business Phone Number: Plu 's A( dress (Street, City, State, Zip C de): IX. COUNTY/ DEPARTMENT USE ONLY E] Disapproved Sanitary Permit Fee (includes Groundwater Date Issued ISSU g g ntSigna ure(No Stamps) X Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination (� X. CONDITIONS OF APPROVAL / REASONS FOW DISAPPROVAL: M -6398 (R.11/96) -. DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber - 1 PLU I PLAN X03 /6of� f� PROJECT / o r ADDRESS `„r-�C. /nz o r S ©� / 1141 ,0 T� N/11/ 10f TOWN COUNTY G MPRS Byron Bird Jr. 3318 DATE ,_5' /7., BEDROOM CLASS PERC -, ?Z C ONVENTIONAL.IN -GROUN RESSURE CONVENTIONAL LIFT_ MOUND HOLDING TANK SEPTIC TANK SIZE /va'a LIFT TANK SIZE DOSE TANK SIZE OLDING TANK SIZE ABSORPTION AREA PERC RATE _ BED SIZE Benchmark V.R.P. Assume Elevation 100' X1-7 Location of Benchmark ' * H.R.P. - _ Cl Borehole Q Well Scale = Feet O Perc Hole System Elevation 9 Vent 12" Grndp TYPAR COVERING 2" 12" 3' 4 6' O 3' 3' 0 3' I 16" Sewer Flock i 12' 18' U e I to I, � � a Wisconsin 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 '64 G Y O! include, but not limited to: vertical and horizontal reference point (BM), direction and X percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # APPLICANT INFORMATION - Please print all information. T y . ed Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). 5 1 S h� Property Owner Property Location r �� Govt. Lot �� 1/4,W/4,S T O ,N,R l� E (oC9 Property Owner's Mailing ddress Lot # Block# Subd. Name or CSM# City State Zip Code Phone Number ❑ City ❑ Village Tow Nearest Road ❑ New Construction Use: Residential / Number of bedrooms __ Addition to existing building f9Replacement Public or commercial - Describe: .� Code derived daily flow 10 gpd Recommended design loading rate _ bed, gpd /fF trench, gpd/ft Absorption area required }o,0 bed, ft a.�l� trench, ft / Maximum design loading rate -, fli ed, gpd /ft gpd /ft Recommended infiltration surface elevation(s) � " y ft (as referred to site plan benchmark) Additional design /site considerations / /� Parent material G��'� ° — OG 242 c s / Flood plain elevation, if applicable /`y ft S = Suitable for system Conventional r MMo r und In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system I� S ❑ U i,c+S ❑ U IS S ❑ U KS ❑ U ❑ S [,2�' U ❑ S f? 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 /V , Ground l (ft ' Depth to limiting factor 4 in. ,> / Remarks: Boring # f- � 3 a Ground ee• ft. ' depth to limiting factor ,min. Remarks: KAddrs ase Print) Signature Telephone No. _ Date CST Number 54 4Z / �j / PROPERTY OWNER !lI'! �� "-�'� s ` �-,, SOIL DESCRIPTION REPORT ' Page of PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 in. Munsell Qu. Sz. Cont. Co Gr. Sz. Sh. Bed , Trench a zq .�;. Ground elev. T V P Depth to limiting factor Remarks: Boring # 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: SBD -8330 (R. 07/96) Soil Test Plot Plan Project Name Byron W Jr. Address 4 /60 7W,4 CSTM #3479 Lot i-- Subdivision Date 1 14AV y /4 S/ N /RA W -'- Township , Boring Q Welt PL Property Line County BN1 or VRP Assume Elevation 100 ft. 4 5� % 3 e `, System Elevation g3 *HRP � A V �6 ► ' 4 6ry �- ��i1i, h� f / 0 Scale 1/4" = 10 Ft. When Dimensions aren't stated i 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 7 z�Z . `j3 /tom- residence located at: Section , T N, R W, Town of Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. ff Last time service �/ Did flow back occur from absorption system?� Yes _Z No (If no, skip next line) Approximate volume or length of time: gallons minutes Capacity: Construction: Prefab Concret Steel Other Manufacturer: (If known) : �� �� �^ .S Age of Tank (If known): G L� 7 (Si ture) (Nam Please print (Title) (License Number) Date Form to be completed by licensed plumber (s.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, Wis. Adm. Code (except for inspection opening over outlet baffle). Name Y/ ,����- Signature P /MPRS ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailin Address �-�- -- g Property Address 6 l, (Verification required from Planning Department for new construction) City /State � c#1 �?��" / ' Parcel Identification Number e, LEGAL DESCRIPTION Property Location /A/ Sec. !K , TV N -RZ Town of ��o �' Subdivision , Lot # Certified Survey Map # , Volume , Page # Warranty Deed # 3o '?z , Volume �� , Page # d Spec house ❑ yes l R no Lot lines identifiable M 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 thiee year expiration date. SIGNA 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 property de ribe� e, by virtue of a warranty deed recorded in Register of Deeds Office. S GNATUfff 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