HomeMy WebLinkAbout030-1019-50-000 ST. CROIX COUNTY ZONING DEPARTMENT
AS BUILT SANITARY REPORT Erb,' „��� i
n
Owner rn Q N 12 --, M R )
Address I I5 ST CRICAx
C up t couNTv
AMMIN
City/State 504 S C CIE.
S
Legal Description: PA a q
IA
Lot Block N Subdivision/CSM # o�
t /4 5 F – % 4 N W , Sec. , T2IN -R j I W, Town of oSR P 1, PIN # 0
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION
Tank manufacturer _ Welk S Size ST/PC I (Ab `�%� – Setback from: House IL Well 0v4 P/L 7 $„
Pump manufacturer — Model —�
Alarm location
(HOLDING TANKS ONLY)
Setbacks: Service road Vent air in — •°Water --ine -- -•
Meter locatio
Alarm lt�cation
SOIL ABSORPTION SYSTEM
Type of system: � °f ` Width 3 Length a S Number of Trenches �
Setback from: House .:-)' I Well P/Lo 2- s' Vent to fresh air intake VV F 0, ) U
ELEVATIONS
Description of benchmark QoAo►'^ Elevation U u • U
Description of alternate benchmark Elevation
Building Sewer ST/HT Inlet 9 3 • ( ST Outlet � 3. 35 PC Inlet
PC Bottom Header/Manifol Top of ST/PC Manhole Cover �S 7
Distribution Lines
Bottom of System Q to p 0 � A� ��+• S �'Pk*
lt, p� vt ya�u�p
Final Grade ()) 19-
(� $ U () �V • V U
Date of installation /I U /9 8 Permit number a a State plan number
Plumber's signature `'' License number QED 9 Uy Date 1 /31 /
Inspector
Complete plot plan
i
Wisconsin Department of Commerce !CC) PWj
Safety and Buildings Division PRIVATE SEWAGE SYS EM County:
INSPECTION REPORT ST. CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar Permit No -:
Personal information you provice may be used for secondary purposes [Privacy L s.15.04 (1)(m)]. 1 20222
Permit Holder's Name: ❑ City Villa e Town of: State Plan ID No.:
GRUND, JIM ST. �OSEP
ki
CST BM Elev.: Insp. BM Elev.: BM Description: _
Parcel T x o.:
`r8. '/7 1 76 (#f =� { per � d3U 1019 -50 -000
TANK INFORMATION
L5
E LEVATION DATA A9800410
E MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic (� r d�� Bench r y ,,, d 7� �C /.3� 7 �• ��
Dosing AL4 BM
Aeratio Bldg. Sewer
Holding St /Ht Inlet
10/.3 7•C.3 q3. 47
TANK SETBACK INFORMATION St/ Ht Outlet ►ot.3
M N
TANK TO P/ L WELL BLDG. YO ROAD Dt Inlet
Airintake
NA Dt Bottom
Dosing A Header/ Man. / Al S �
ration �s 7�
NA Dist. Pipe T' '51—
Hol i Bot. System &.71 yy ,
y.os
PUMP/ SIPHON INFORMATION Final Grade -
/c ,� y� V-0 97 ��
Manufacturer A cV- wt q
's / °�• fs �lfo•
Model Nu er ae41'A ow
TDH Li Friction 5 ste S{, 2
wloH l�aC� / 0/ j �� 51^65 C L
Forcemain Length Dia.
SOIL ABSORPTION SYSTEM
BED / Width Length No. Of Trenches PIT \ No. Of Pits Inside �Liquid pth e
DIMENSIONS 1lZ DIMENSION
SETBACK SYSTEM TO P/L BLDG WELL LAKE /ST AM LEACHING Manufacturer:
INFORMATION Type / , CHAMBER Model Number:
J _ SystRAt 70 (7 17S OR UNIT
DISTRIBUTION SYSTEM
L ader / Manifold Distribution ' /' x Hole Size x Hole Spacing Vent To Air Ingth _T Dia. Length /��. Dia. 3'7 S acin ��
P 9 /A C
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
D Over xx Depth Of xx Seeded /Sodded xx M =Eo]No ed /Trench Edges Topsoil ❑Yes ❑ No Yes
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: ST. JOSEPH 5.29.19.81A,SE,NW 1157 42ND STREET – LOT 1
U 71-* (lom key--.
Hof Wti✓ befICh 44A4 e �pr
8r� 10l - 3 8�• � s� �.
lQ,va ( a r6 wt 4c k- v v't t,04 &&16t 4meteA r s 0 h . qo-F+
Plan e��l �
Pl See Flo' j
on require Yes No
Use other side for additional information. 3/
SBD -6710 (R.3/97) Date Inspe or's Signature ert. No
Vi scons i n Safety and Buildings Division
SANITARY PERMIT APPLICATION 2 01 E. Washington Ave.
Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
Madison, WI 53707 -7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 112 x 11 inches in size. 1 5 - wk
• See reverse side for instructions for completing this application State sanitary Permit Number
avua
The information you provide may be used by other government agency programs ❑C 3�
[Privacy Law, s. 15.04 (1) (m)]. heck if revision to previous application
State Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PR L INF RMATION
Pro Owner ame Property Location
0 1/4 / v4, T, 9 N,R /yE(or)W
Property Owner's Mailing Address Lot Number Block Number /
IIS N 'v
I City, State Zip Code hone Number Subdivis on Name or CS Number
ll. TYPE OF BUILDING: (check one) ❑ State Owned - ❑ itr Nearest Road
Public 1 or 2 Family Dwelling C3 Vil age - No. of bedrooms T�
Town OF
III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Numbers) O ,r
o�c-
1 ❑ Apartment/ Condo 030 /O/ -,SQ
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. E] New 2_ ,Replacement 3 [] Replacement of 4 E] Reconnection of 5_ ❑ Repair of an
- - - -- System ----- System Tank Only Existin 5 stem Existing System
----------------------- - - - - -- y------------- - - - - -- 9 -y ------ - - - - --
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 ❑ Specify Type 41 ❑ Holding Tank
12tgSeepage Trench US) N3 ir'�� ❑ In- Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit (.')N��r 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 I y 7. Final Grade
4 /� U
Required (s ft.) Propos'dol V (sq. ft.) (Gals/day /sq. ft.) (Min./inch) �, 143- Y ElevatiorrTk Jd
`� i N isFeet it @WV 9y Feet .�
VII. TANK Capacity
INFORMATION in gallons Total # of Manufacturer Prefab. Site Fiber- Ex p er
New Existin _
Gallons Tanks s Name Concrete Con- Steel glass Plastic App
strutted
Tanks Tanks 11 y
Septic Tank or Holding Tank /� ibou ( Wee ❑ ❑ El _ 0 1:1 Lift Pump Tank /Siphon Chamber ❑ El El E1 ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Print) Plumber's Signatu : (No amps) MP /MPRSW No.: Business Phone Number:
Plumber's Address ( treet, City, State, Z' Code):
IX. COUNTY/ DIEPARTMENT USE ONLY
[],Disapproved Sa �} tary Permit Fee (includes Groundwater ate I ssued Issuing Age t Sig
A roved /� /� Surcharge Fee)
p p roved Given Initial W O /
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL.
SBD -6398 (R.11/96) DISTRIBUTION: Original to County, One copy To: Safety 41 auildimp Division, Owner, Plumber
V o l T-
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tilled
8I 77' y
TP Of plug She ��,
p b x Vt c � y,-el 104��
I r 100- 0
p V d Spi 1.(1 , 1 N �p rr
S' ee d� 13' e,,k �) da Tire
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IAMI 0 5 :3 * I
Wisconsin a Industry
Labor and Hu man n Rel SOIL AND SITE EVALUATION REPORT Page of /
Rel
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
w • COUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but s�- o
not limited to vertical and horizontal reference point (BM), d° as ff slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to r sk„ t_I >; \� 030 ._ 161.9 — �O
APPLICANT INFORMATION— PLEASE PRINT °!~ NF 10
Y
R B D E
PROPERTY OWNER: RE
PR' O TY LOCATION
t r GO e .SOT _5:E 1/4 1 /4,S T 2 9 AR / 9 W
PROPERTY OWNER':S MAILING AD RESS Sr'° .m LOT #--- BLOCK # SUB D. NAME OR CSM #
s d7 ^ S . p --Ir
CITY, STATE ZIP CODE P NEiV G " f y ❑VILLAGE BrOWN REST ROAD
(j New Construction Use Residential / Number of S I � [ ] Addition to existing building
Replacement [ ] Public or commercial describe
Code derived daily flow X150 gpd Recommended design loading rate gi bed, gpd/ft? gpd/ft
Absorption area required ISGb bed, ft 2 11 s trench, ft Ma)dmum design loading rate ..3 bed, gpd /ft gpd/ft
Recommended infiltration surface elevations (TR I 3 �I qa,�2 �TR2.� �f JL �') ft (as referred to site plan benchmark)
Additional design / site considerations 'i nA r,-, sjA,_ 0 rerc�e_c� Cenc�roc� su r " o c/ry
Parent material �u 1 Flood plain elevation, if applicable N /,q It
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable fors stem ®S ❑U ®S ❑U IRS ❑U ®S ❑U ❑S ®U ❑S ®U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Structure GPD /ft
Boring # Horizon in Munsell Qu. Sz. Cont. Color Texture Consistence Bantry Roots
Gr. Sz. Sh. Bed rerx�
1
s 81 5b m A, ' s 2-, N P N P
Ground 13 2 3 7 S -2'16 /1 , 5
elev.
91� ft
Depth to _
limiting
factor I t r m r
nnrm
$o
Remarks:
Boring #
Ground 3 2- 2 6
elev. a ,S 6 J11/_
D rJ�• ' C' S- 3
qfo, ft.
Depth to � O —
limiting
factor
Remarks:
CST Name: Please Pr' Phone:
?/ c,? $
A ddress:
I N214 1 1 S ,4. � /�2o71fe lcl fL. 5�73
Signature: K . Date: , ` CST Number:
/ Q�
f
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer —r--
Mailing Address Ad
Properly Address ,q
(Verification required from Planning Department for new comstruction)
City /State
Parcel Identification Number 6 -31)
LEGAL DESCRIPTION
Property Location %., Y.. Sec. —�� T R �, Toy m of ..�
Subdivision
Lot #
Certified Survey Map # j Volume
page # S
Warranty Deed # 1 - p
Volume /,� page # 7�4
Spec horse O yes no Lot lines identifiable. ❑ yes ❑ no
'STEM °MAINTENANCE
consists of pc�g' � tank your sysp oonld result m its Pr=atmfiffum to handle wastes, pvVanmmt naaoe
can affecte frmctioa of septi tank every years or sooner, if needed by a licensed
septic tank a treaunc t stage in the waft �sd yc 1? . What you Pnt into the system
_ 110 property owioRx agrees to urbmit to St Croix zoning Departmat p ° ��nP rest<ictedplumber or a a certification form, signed by �e owner and by a
u m Proper Ming condition and/or (2) after . mat ( � on -cite Rrastewater di sposal
won and Pumpmg.(if necessary), the septic tankcis less .than 1/3 fhIl of sludge.
L*C• the mdersigned have read the above requirements and a gree
set forth. herein, as set by the Department of Commerce and @ie to maintain sire private sewage disposal system wig tku standards y o
d a tn W � � o d� Mimed must be completed wed to the St C[OixSCounty Zoning Office within 30
SI TURE OF APPLICANT 0'7 h2e
DATE
OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the best of my (our) larowl
the property described above, by virtue of a warranty deed recorded i R I (we) am (are) the owners) of
Re gister of Deeds Office.
SIG ATURE O��pp-ICANT d ? / .?,f /k?
DATE
« « « « «« Any informatio that is mis-
DATE may result in the sanitary pennit being revoked by the Zoning Department. «�••�
elude with this application: a stamped warranty deed from the Register of Dads office
a copy of the certified survey map if reference is made in the warranty deed
I
05 /ZS /98 FRI 12:32 FAX 1 715 388 8350 LILZ & ft-IIKE�N
582153 WARRANW DEED
Lei 13`16 Pau 493
Document Number
$T. CROIX CO., W!
Return Address Rso'd fw R"ofd
JUL U 11998
70 lo:ls A M
b 4Kd0o*&
Parcel I.D. Number: 030. 1019 -50
Stephen W. Shafer, a married qjs"-& Md Grata Y Shafts a ILI&p re 9s n.
_ conveys and warrants to dames A. Grund and Dawn hL Graad husband and wife as surylvers
marital property, the following described real estate in St. Croix County, State
of Wisconsin:
Part of SETA of NWl /4 of Section 5, Township 29 North Rangz 19 West, St. Croix County, Wisconsin,
described as follows: Lot 1 of Certified Survey Map field June 17, 1976, in Vol. 1, page 2sb, Doc. No.
333660.
This is homestead ro TRA � FER
p perry as to Greta Y. Shafer. S d o,
This is not homestead propert; as to Stephen W. Shafer. FEE
Exception to warranties: Easements, restrictions and rights -of -way of record, if any.
Dated this ;Z& * day of June, 1998,
AQ (SEAL)
tephen 1 W. Shafer Y_ S
AUTHENTICATION
Signatures) Stephen W. Shafer, a married person, and
Greta Y. Shafer, a single person, authenticated this
day of June, 1998.
Kristin Ogladd
TITLE: MEMBER STATE BAR OF WISCONSIN
THIS INSTRUMENT WAS DRAFTED BY:
Attorney Kristina Ogland
Hudson, WI 54016
Y
r •
y APPROVAL OF TI-11' OR SUBDIVISION
A � DOES NOT MEAiA A--- rk"0VAL FJ : SEPTIC
A �� SYSTEM. P,rFcR TO H62.20
7
l9 6
o' C i
APPROVED
ST. CROIX COUNTY
CERTIFIED SURVEY MAP
COMPREHENSIVE PARKS PLANNING
DAVID ANDERSCN AND ZONING COMMITTEE
JUN 1 6 1,976
The SE 1/4 of the NW 1/4 of Section 5, Township 29 North, Range 19 West,
Town of St. Joseph, St. Croix County, Wisconsin
N I/4 COR SEC, 5 -29 -19
N
M
I
S 83042'40 ' E
r
3s, N
I 0 N - S CALE
Lot 3 I
In 1 7.9 Acres m
0• I 0
0 I
0
0 cuE N
O u 595.93' 720. p7 O Bearings based on
I East /West 1/4 line
�g e
z I being due West.
Y 3 O Indicates 1
F I $ Lot 1 p Lot 2 iron pipe stake
weighing 1.13 # /ft.
In IM 10.0 Acres o 0 12.0 Acres R
N
1') M
I 0 0
0
z 9
• I FARM D �
STEAD p,
C;% 60 �OIhIT FIELD o
1 M '395.9'8+ T 14 . 30 70 li HAtiiMentT ,
�3+ _ _ 1 1 __
x ' 35,
-- — _ — pub w SST _ 131fl • 2 _
RIVER ROAD (TOWN ROAD
CEAST /WEG- 1/4 LINE
Description:
The SE 1/4 of the NW 1/4 of Section 5, Township 29 North, Range 19 West,
Town of St. Joseph, St. Croix County, Wisconsin described as being the
following parcel; Commencing at the North 1/4 corner of said Section 5, thence
go S 00 20 08f W along the North /South 1/4 line a distance of 1319.27 feet;
to the Point of Beginning of the parcel to be herein described and bein� also
the Northeast corner of said SE 1/4 of the NW 1/4; thence continue S 00 08 W
a distance of 1319.27 feet to the East /West 1/4 line of said Section ,
th ence
Due West along said East /West 1/4 line a distance of 1310.23 feet; thence
N 00 07' 00" W a distance of 1325.91 feet; thence S 89 42 401 F
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