HomeMy WebLinkAbout026-1101-20-000 ST. CROIX COUNTY ZONING DEPARTMENT
AS BUILT SANITARY REPORT
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Owner c/c-�- :,$
ST CO UNT Y
Property Address
" . , courvty
ZONINGOf FICE
City /.State - U
Legal Description:- = -s--'
Lot Block Subdivision/CSM #
1 / a ' /4, Sec.,��, T3(.)-R�W, Town of PIN # ®d 6 ' //,0/ �d
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION:
Tank manufacturer Size ST/20 Y0 Setback from: House 65 - Well P/L /�O
Pump manufacturer Model
Alarm location ---
(HOLDING TANKS ONLY)
Setbacks: Service road o fresh 'r- 4'11t&6 _ Water Line
Meter location
Alarm location
SOIL ABSORPTION SYSTEM
Type of systed 1 f Width 3 Length 7O 6 _ Number of Trenches
Setback from: House / Well /$D PAL /So Vent to fresh air intake �7 a2-0a
ELEVATIONS
Description of benchmark Td� /✓ �� �- Elevation
Description of alternate benchmar s ; nh ^� Elevation 19
Building Sewer <x sue ' T/HW ?nVet �'J 3�'S T Outlet 20 - I PC Inlet
/n 1 96- 7
PC Bottom '` Header/Manifold Top of ST/PC Manhole Cover `
Distribution Lines ( ) () ( )
Bottom of System ( ) O 71
Final Grade
Date of installation/2/!Z/ 9 P mit number 3� State plan number
Plumber's si ture License number 4 100 Date / l/
Inspector
Complete plot plan �
t ,
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count
Safety and Buildings Divi sion 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.15.0 (1)(m)]. 324711
Permit Holder's Name: ❑ City ❑ Village K1 Town cam State Plan ID No.:
BERGSTROM, Julie RICHMOND
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
1 -a t `6 ! 026 -1 101 -20 -00
TANK INFORMATION ELEVATION DATA 4q'70011n
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic tA� 807 Benchmark --41
Dosing L I} q 6 gf
Aeration U 4WT er e F•Syl 70,T
Holding St /Ht Inlet $.Gy G JD
TANK SETBACK INFORMATION St /* Outlet 9a ti 7
TANK TO P/ L WELL BLDG. Airi to ntake ROAD Dt Inlet
irl
Septic NA Dt Bottom
Dosing Header / Man. 6a30 '99-
Aeration NA Dist. Pipe /0.30 / -W 10-46 99-& 8
Holding Bot. System 1).e1 // - 77 12 - P-0 P14 ?Z`j
PUMP/ SIPHON INFORMATION Final Grade 54 S• •g8 G I I
Manufacture and
Model Number GPM
TDH Lift Friction System H Ft L.l3
Forcemain Length Dist. To well
SOIL ABSORPTION SYSTEM
BED/TRENCH width L G8,7S No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIM EN DIMENSION
SETBACK
SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer:
INFORMATION Type / /C,\ C M T R Model Number:
Sys ! � V
DISTRIBUTION SYSTEM
Header / Mani old Distribution Pjpg(s) s , x Hol Size x Hole Spacing Vent To Air Intake
Length � Dia. Lengt .Dia' Spacing /� G
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over Depth Over xx Depth Of Kx Seeded /Sodded xx Mulched
Bed /Trench Ce nter Bed /Trench Ed es To soil
g p E] Yes No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: RICHMOND 36.30.18.552B,NE,NE 1479 130TH AVENUE
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I �z -9 e
Plan revision required? ❑ Yes ®-No
Use other side for additional information.
SBD -6710 (R.3/97) Date Inspector's Signature ert. No
% 6ons in Safety and Buildings Division
SANITARY PERMIT APPLICATION 201 E. Washington Ave.
In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
Department of Commerce Madison, WI 53707 -7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 81/2 x 11 inches in size.
• See reverse side for instructions for completing this application State Sanitary Permit_Number
071 /
1E
The information you provide may be used by other government agency programs ❑ Check if revision to previous application
J c
[Privacy Law, s. 15.04 (1) (m)].
t e_/ State Plan I.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATI N
Property Owner Name Property Location
-)Q_ "�, 1/4 N 1/4, 531, T 3 d , N, R r3 E (or)f V
Property Owner's Mailing Address 3 Lot Number Block Number
ALTYPE tate Zip d W l PhQn�Nuer Subdivision Name or CSM Number
/ (l r`
F B LDING: (check one) ❑ State Owned ❑ lt� Nearest Ro
Public 1 or 2 Family Dwelling - No_ of bedrooms ❑ Town of
111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
1 E] Apartment/ Condo �3 Q' 19. 55 P Oa
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 Replacement 3_ E] Replacement of 4_ E] Reconnection of 5. ❑ Repair of an
. _____Syfstem ________ _____________ ______________ 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) 31 - a
Non- Pressurized Distribution Pressurized Distribution Experimental ther
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12�eepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit .1 " GZ> 43 ❑ Vault Privy
14 ❑ System -In -Fill / 3 x
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 12. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
I Requi (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation
f7 o I la j 7 r .7.-6�Feet 1V Feet
VII. TANK Capacity
in gallons Total # of r Prefab. Site Fiber- Ex per-
IN MATION New Existing Gallons Tanks Manufacturers Name concrete Con- Steel glass Plastic xpe
structed
Tanks Tanks
Septic Tan rya (f ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber I ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plu]b r;s Name: (Print) Plumber' Plumber' i ure: (No S ps MP /MPRSW No.: Business Phone N u mber:
c O V r�V
Plumber's Address (Street, City, St e, Zi Code): r f`d1
L
IX. COUNTY / DEPARTMENT USE ONL
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps)
Rj Approved ❑ Owner Given Initial 1 C) •, Surcharge Fee)
Adverse Determination 4 to
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
s8p.6386 (p t f/B6) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
PLOT PLAN
PROJECT Julie Berastrom ADDRESS 1479 130th Ave New Richmond Wi 54017
NE 1/4 NE 1 /4S 36 /T 30 18 o N Richmond COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 12/3/98 BEDROOM 4
CONVENTIONAL )00C IN- ROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000/800 LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .6 ABSORPTION AREA 1017 # of chambers 32
BENCHMARK V.R.P. Top of Nail in Power Pole
ASSUME ELEVATION 100'
❑ BOREHOLE O WELL *H.R.P. Same as Benchmark
SYSTEM ELEVATION 87.
Alt. BM Base of Siding @ 99.0
Vent
>12" Sidewinder High
of Cover Capacity Leaching
Chamber with 31.8
'Long
16" ft ^2 per chamber
34" Grade at System Elevation
Existing 4
Bedroom
House Building Sewer Depth is >42" under driveway
120' 30' Alt
a
Driveway
0' S'
Existing 1000 Gallon Tank
B.M.
T
75' 2-3'X 70' and 1-3'X 65'
5 ' Trenches with 6' Spacing
between trenches
B -1
Overflow Vents '%-.7g-
20'
25 1
B -2
200 3% B -3
Slope
Property Line
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
This is to certif that I have inspected the septic tank presently
serving the reside located at:
, AJn , Section , T - 30 N, R / �5 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.
Last time serviced: �� ZI:
Did flow back occur from absorption system?
Yes No (If no, skip next line)
Approximate volume or length of time: gallons minutes
Capacity:
Construction: Prefab Concrete Steel Other
Manufacturer: (If known):: '-�
Age of Tank (If known).:
(S gnature) (Name) Please print
.109 1 (title) (License Number)
//- / �- 9
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 q baffle) .
Name, ; `;� /, �. Signature MP /MPRS
-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
include, but not limited to: vertical and horizontal reference point (BM), direction and S * C �fl f r x
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
02(v - /lot - Z a
APPLICANT INFORMATION - Please print all information. evievyed by _ bate ''] �p�p�
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). 11.� r p
Property Owner Property Location
Govt. Lot r- 1/4 1/4,S T3O,N,RI E (o09
Property Owner's Mailing Address Lot # Block# Sub d. Name or C M#
City State Zip Code Phone Number ❑ City ❑ Village own Nearest Road
1- I ( 6._�.� i��_ I e J, r" 0,-�j I / ---, C ,
New 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 - trench, gpd/ft
Absorption area required bed, ft ZeW Q ren ^ chh ft Maximum design loading rate s bed, gpd /ft , trench, gpd/ft
Recommended infiltration surface elevation(s) O ! �� ft (as referred to site plan benchmark)
Additional design /site considerations
Parent material CA -4 Flood plain elevation, if applicable ft
S = Suitable for system Conventional I Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
U = Unsuitable for syste OS ❑ U I V S ❑ U ,� S❑ U to S ❑ U ❑ S ,Z U El S 0 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
i /0 r 3/ Z YYl
02
d�
G
%° eft•
Depth to
limiting
factor
Remarks: -sa'"-�- d Q- a
Boring # a e S
3/z .S;
3 � ,6 �' /V,
Ground
y, d
Depth to
limiting
fa for
�o Remarks: A6
CST Name (Please Print) Sign e / Telephone No.
3
Address �d Date CST Numb r
Soil Test Plot Plan
Project Name Julie Bergstrom Shaun
Address 1479 130th Ave
New Richmond Wi 5 CSTM #226900
Lot -- - -- Subdivision - ---- -- Date 11/13/98
N E 1 /4 NE 1 /4S T 30 N/R 18 W
Township Richmond
Boring ()Well PL Property Line County ST. CROIX
BM or VRP Assume Elevation 100 ft. Top of Nail with Orange Ribbon in Power Pole
System Elevation 8 7. 05 * H R p Same as Benchmark
Alt, BM Base of Siding @ 99.0
Existing 4
Bedroom
House Building Sewer Depth is >42" under driveway
120' 30' R.M.
a
Driveway
0 ' 5'
Existing 1000 Gallon Tank
B.M.
5 '
35' B -1 35 '
Overflow
20' 3% 5,
B -2 ' Slope
200 B -3
Property Line
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner /Buyer (a_�
Mailing Address 1 - 71 a-,44 g'4z
Property Address ® 7
(Verification required from Planning Department for new constructi --�� �► /�]
City/State _ Parcel Identification Number
LE GAL DESCRIPTION
Property Locatiot774JZ'� ' /4, AIZ '/4, Sec. , J5V_N -R2W, Town of ' M=f znj
Subdivision , Lot #
Certified Survey Map # `— , Volume , Page #
Warranty Deed # ,/ j z , Volume ° , Page #
Spec house ❑ yes �io Lot lines identiflableAl 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
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. r�
/2 /,
ATURE OF APPLIC NT 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 described above, by virtue of a warranty deed recorded in Register of Deeds Office.
SIGNATURE OF APPLICANT DATE
* * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department.******
** Include Nvith 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