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Home My WebLink About030-2106-30-000 ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT�� \' Owner Address City /State h�u.lSa� Corn ry Legal Description: Lot �_ Block Subdivision/CSM # '/, , '/4 iUG Sec. �L , TAN -R /� W, Town of a L PIN # IF SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer Size ST/PC /;2�/gam Setback from: House ay , Well ,/ -'f P/L Pump manufacturer AQU i,w s Model _ fv 1 y// Alarm location a e (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM Type of system: Width Length Z_ Number of Trenches - Setback from: House Well r /r✓ P/L ,2.5' Vent to fresh air intake _ a S '�- ELEVATIONS Description of benchmark Elevatio Description of alternate benchmark _:2ap Elevation Building Sewer ST/HT Inlet tTd ST Outlet- PC Inlet PC Bottom Header/Manifold r Top of ST/PC Manhole Cover _ ?/ ;7,5 Distribution Lines Bottom of System () Final Grade Date of installation /l / f ermit number State plan number Plumber's signature , - -, ! License number �7 ��0 Date Inspector ,1VIQ complete plot plan Wisconsin Department of Commerce PRIVATE SEWA SYSTEM y: Safety and Buildings Division GE Count 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.15.04 (1)(m)]. 315995 Permit Holder's Name: ❑ Cit . ❑ Villa e Town of: State Plan ID No.: S KING, DAVID T JOSP CST BM Elev. Insp. BM Elev.: BM Description: Parcel Tax No.: 100 I� 5 - 030 - 2106 -30 -000 TANK INFORMATION ELEVATION DATA A9800383 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. eptic - r2ty Bench -1.0 01 ( D D Dosing —� l0D 2. o Gf7 Aeration Bldg. Sewer loo ?.0 G/ f -Gp Holding ( P4 Inlet j pp �j. Cf p. S TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. A I to ntake ROAD Dt Inlet / Septic So f- ►V ` �� NA Dt Bottom f b0 Dosing '" �' �' NA Header/ Man. Cl 00 Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION q � �, � Final Grade Manufacturer Demand S f, 01 ZS °f 7 Model Number , p 411 It, �6 GPM 6/v( j co , SS` � (� -9(� TD H Lift ,thy Friction Syestem TDH?.e�ZR Forcemain Length 30 Dia. '' Dist. To Well SOIL AB ORPTION SYSTEM BED TREN Width Length _ < No. Of Trenches PIT No. Of Pits Inside Di Liquid Depth DIMENSIONS 5 c� DIMENSION SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEAeCIIING Manufacturer: INFORMATION Type CH I Number: cyst y8 Yo ti "�� OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing � /t'�jTl t 4-2 �Q SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over 9 �� Depth Over xx Depth Of wy Bed /Trench Center �!� Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS (Include code discrepancies, persons present, etc.) LOCATION: ST. JOSEPH 6.29.19,SW,NE 370 117TH AVE EVERGREEN RDG LOT 3 Plan revision required? ❑ Yes ® No Use other side for additional information. 2 2 SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. Vi sconsin Safety and Buildings Division SANITARY PERMIT APPLICATION 2 W. W in Avenue • Departmdnt of Commerce In accord with ILHR 83.05, Wis. Adm. Code 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. 7 r • See reverse side for instructions for completing this application State Sanitary Permit Number Personal information you provide may be used for secondary purposes�► V �o ® Check if 315 revision to previous application [Privacy Law, s. 15.04 (1) (m)]. 3 `/ 7fh /� State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Owner Name t P operty Location Q �Q 501 /4 ,�l t r4, S T � 7 , N• R /4 E (or) W Property Owner's Mailing Ad ess Lot Number 7� umber 0 o�d t crr T 3 City, State Zip Code Phone Number Subdivision Name or CSM Number r e of Z 1 ( ) L 11. TYPE F BUILDING: (check one) E] State Owned ❑ !tyy Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms ° Tow OF sc G 111 BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 030 - A/04 -- 3 o - oo o 1 ❑ Apartment/ Condo — SP , I t?. /9.88 jr 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. V New 2 ❑ Replacement 3. ❑ Replacement of 4 ❑ Reconnection of 5. ❑ Repair of an ________ 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 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 aSeepage Trench 22 ❑ In- Ground Pressure r r i 42 ❑ Pit Privy 13 E] Seepage Pit J X�5 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 Required (sq_ ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation 75 ,�/W Feet I Feet VII. TANK Capacity in gallons Total # of Prefab. Site Fiber- Ex er INFORMATION Gallons Tanks Manufacturers Name Concrete Con Steel Plastic p New Existing strutted glass App. Tanks Tanks Tart or- k[otditTg�arrk— D El El El El El Septic Lift Pump Tank l c [a I ❑ 1 ❑ 1 ❑ I ❑ ❑ NSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite se age system shown on the attached plans. Plumber's Name: (Print) L Plumb�Signatur No St amps) P ^ / MPRSW Q N Q o.: Business Phone Number: n Plumber's Address (Street, City, State, Zip Cod ): c s IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary mit Fee (IncludesGroundwater a ssu� Issuin a Si natu a (No Stamps) Approved ❑ Surcharge Fee) H o f ht 0 Owner Given Initial Adverse Determination X. CONDITIONS OF APPROVAL / REASON FOR DISAPPROVAL: SBD- 6398 (R.11 /97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber Visconsin Safety and Buildings Division SANITARY PERMIT APPLICATION 201 Box Washington Avenue Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 -7302 • 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 Personal information you provide may be used for secondary purposes j'✓ R 9.S [Privacy Law, s. 15.04 (1) (m)]. ❑ Check if revision to previous application State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT AL INF RMATION Property Owner Name Property Location ,- 1 /4W`G 114, S 4 !; T f' , N, R/' (orto Property Owner's Mailing 4ddress Lot Number Block Number ead 'eat 3 City, State Zip Code Phone Number Subdivision Name or CSM Number II. E F BUILDING: (check one) ❑ State Owned E] Cit ea rest Road E] Village Public 1 or 2 Family Dwelling - No. of bedro TLo own OF III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 050 - a 16 to - 30 1 ❑ Apartment/ Condo ' — 9 " 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. j. New 2 ❑ Replacement 3 ❑ Replacement of 4_ ❑ Reconnection of 5 ❑ Repair of an _____ ________ _____________ _ System System Tank Only __ Existing System stem ExistingSystem B) 11 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 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 Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) 9r YQ Elevation oe 7 5 - 41 '41 Feet 2 f 1 d Feet Capacity VII. TANK in Ca gallons Total # Of r Prefab. Site Fiber- Exper. INFORMATION Gall Tanks Manufacturers Name Concrete Con Steel lass New Existing Gallons an structed g plastic A PP' Tanks Tanks Septic Tank or Holding Tank A, G Lift Pump Tank /Siphon Chamber ❑ I E] I ❑ ❑ 1 1:1 ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite se ge system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (No Stamps) rm PRSW No.: Business Phone Number: r 79 70 Plumb s Address (Street, City, State, Zip Code): / IX. COUNTY / DEPARTMENT USE ONLY X Approved ❑Owner Given Initial (. r [] Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued I g Agent Signature (No Stamps) A Jl surchar Fee) Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.11/97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber �Y v I�ropa's� cl m a n' bpi 4 re PA(,t -? G Puff& CHAMBER CROSS SEC T IOIJ AND SPECIFlCAFI0K1j l VCM7 CAP `1 "C.I. VENT PIPE WEATHERPROOF APPROVED LOCKIAIG 25' FROM DOOR, JUNCTION BOX MAIJHOLE COVET WINDOW OR FRESH 12 "MIU. AIR INTAKE I GRADE I Y" MIN. 18" MIIJ. COIJDUIT -- _ 18 "MIN. \ ---- - - - - -- 11� INLET PROVIDE ( - - - -- AIRTIGHT SEAL _T I A - i Ilj I I ALARM 5 I II I I *APPROVED I ON JOINTS WITH I i ELEV. FT. APPROVED PIPE 3' ONTO P UMP , OFF D SOLID SOIL COKICRETE BLOCK RISER EXIT PERMITTED ONLY IF TANK MANUFACTURER HAS SUCH APPROVAL SEPTIC E SPECIFI CAT IOA.IS DOSE TANKS MAN UFACTURER: A `JWe5 7L-elf--e-1 (JUMBER OF DOSES: PER DAS TANK SIZE: 'G9G GALLONS DOSE VOLUME ALARM MAMUFACTURi<R: e°Zl INCLUDING BACKFLOW: !7 GALLONS MODEL NUMBER: D.4 zJ CAPACITIES: A INCHES OK l GALLOWS SWITCH TSPE: "&2 e yL 5= oZ INCHES OR GALLONS PUMP MANUFACTURER: C5 00 /Gt S' ,,hh 3 21 7 C = �Ll� - — INCHES OR 7 GALLONS MODEL KIUMBER: ��a' y j D- —INCHES OR 1 426 GALLONS SWITCH TYPE: /`��t'rC NOTE: PUMP AND ALARM ARE TO BE MINIMUM DISCHARGE RATE _ yj GPM INSTALLED ON SEPARATE CIRCUITS VERTICAL DIFFERENCE DETWEEKI PUMP OFF ARID DISTRIBUTION PIPE.. FEET + MIAIIMUM NETWORK SUPPLY PRESSURE + 0 FEET OF FORCE MAIN X GZ F /IOOFLFRICTION FACTOK._ FEET = TOTAL DYNAMIC HEAD = Ga FEET I 1UTERNAL DIMEMSIONt OF TANK: LENGTH ;WIDTH ;LIQUID DEPTH 2, 51GIUED: -_l� LICENSE NUMBER: 2 - ?FF lJ DATE:1� P Goulds } Submersible rn Effluent Pump ter. 3871 EPO4 EP05 I APPLICATIONS • Fasteners: 300 series • Fully submerged in high ■ Motor Housing: Cast iron Specifically designed for the stainless steel. grade turbine oil for for efficient heat transfer, following uses: • Capable of running lubrication and efficient strength, and durability. dry without damage to heat transfer. ■ Motor Cover: Thermo las- • Homes Available for automatic and g • Effluent systems components. tic cover with integral handle • Farms Motor: manual operation. Automatic and float switch attachment • Heavy duty sump • EPO4 Single phase: 0.4 HP, models include Mechanical points. • Water transfer 115 or 230 V, 60 Hz, 1550 Float Switch assembled and ■ Power Cable: Severe duty • Dewatering RPM, built in overload with preset at the factory. rated oil and water resistant. automatic reset. ■ Bearings: Upper and lower SPECIFICATIONS • EP05 Single phase: 0.5 HP, FEATURES heavy duty ball bearing 115 V, 60 Hz, 1550 RPM, construction. Pump: EPO4 built in overload with ■ EPO4 Impeller: Thermo- Solids handling capability: automatic reset. plastic Semi -open design 3 /4 " maximum. • Power cord: 10 foot with pump out vanes for AGENCY LISTING • Capacities: up to 55 GPM. standard length, 16/3 SJTO mechanical seal protection. Co. CanadianstanaartlsAssociation • Total heads: up to 24 feet. with three prong grounding _ • Discharge size: 1'/2 " NPT. plug. Optional 20 foot ■ EP05 Impeller: Thermo- (CSA listed model numbers Mechanical seal: carbon- length, 16/3 SJTW with plastic enclosed design for end in "F" or "AC ".) • rotary/ceramic- stationary, three prong grounding plug improved performance. BUNA -N elastomers. (standard on EP05). ■ Casing and Base: Rugged • Temperature: thermoplastic design provides 104 °F (40 °C) continuous superior strength and 140 °F (60 °C) intermittent. corrosion resistance. • Fasteners: 300 series METERS FEET stainless steel. 10 i l • Capable of running dry without damage to s 30 Scan' components. Pump: EP05 $ • Solids handling capability: 0 7 25 i maximum. W • Capacities: up to 60 GPM. o s 20 • Total heads: up to 31 feet. • Discharge size: 1V NPT. Z 5 • Mechanical seal: carbon- 0 15 rotary/ceramic - stationary, a 4 BUNA -N elastomers. o s • Temperature: ~ 3 10 104 °F (40 °C) continuous 140 °F (60°C) intermittent. 2 • 5 t LIZ. OL 0 0 10 { 20 30 40 50 GPM L L 0 2 4 6 8 10 12 m�lh CAPACITY 0 1995 Goulds Pumps, Inc. I J Effective May, 1995 Wisconsin Department of Commerce SOIL AND SITE EVALUATION Pa ge Division of Safety and Buildings P Bureau of Integrated Services s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less `02 x 1 nts i ze: `Matt ust County include, but not limited to: vertical and horiz t8eferen directjgp C ro percent slope, scale or dimensions, north a ow; and location and distance to t road. Parcel I.D. # I s a r I R 1998 APPLICANT INFORMATION - P/ _ rint allfifitdefil> don. Reviewed by Date Personal information you provide may He used for pu W s./f Property Owner roperty Location �� Govt. Lot s (,U 1/4�/�1/4,S T �N, �p E (or)� Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# City State Zip Code Phone Number ❑ City ❑ village Cy Town Nearest Road d o 1 w l I 35/cY ( ?1S 6 16Y _S4'. e P ti e d u b r (X New Construction Use: Residential /Number of bedrooms 3' / Addition to existing building ❑ Replacement ❑ Public or commercial Describe: Code derived daily flow o gpd Recommended design loading rate bed, gpd gpd* Absorption area required SS7 bed, ft 7S trench, ft2 Maximum design loading rate!.t--bed, gpd/fl trench, gpd/f? Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design/site considerations Parent material (} �4C " a ( Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U= Unsuitable for system S❑ U S❑ U � S El S❑ U ❑ S 5a U ❑ S RJ U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD lft2 in. Munsell Qu. Sz. Cont. Color / Gr. Sz. Sh. Bed , Trench Q Z 6- is .5/( -5",/ a MX CS Depth to limiting factor Remarks: Boring # a tv o .. ............. / l CS 7 Ground elev. Depth to limiting factor in. Remarks: CST Name (Please Print) Signature Telephone No. Address Data CST Number S c-ce e r - 4- 1 me a f �i/ ( Ll z G -�7 -9 '�� 3 >c Ol« n a k •e--e l r r = e-10 3 3 G ti . � Y3U lY2o 4! L / e %2v QG, Q /1 •, , JC�r / f -Q F, C � IS 05 c ore--,, p- ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer .7 -d3'd Mailing Address )7,11 ep W .'A ✓1" ) Cr -� :�,E r ,r• r t A k yv� 3 5 37 Property Address 370 I l - C4— 190t 4 LAA, 5c' (Verification requited from Planning Department for new construction) City/State t#ud: t Parcel Identification Number _6 30 - fD-1 - 9w LEGAL DESCRIPTION Property Location dW ' /,,r y,, Sec. �, T Z-1 N -R-d—W, Town of Subdivision Et1 c- �,r- e,C�4- 2 e, Lot # � OF Certified Survey Map # . Volume , Page # Warranty Deed # Volume , Page # Spec house ❑ yes Rrl�o Lot lines identifiable Gk 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 masterplumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal 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. 71��e � ' I 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 property described above, by virtue of a warranty deed recorded in Register of Deeds Office. 71" 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 • 1; CN -► •� 3 < C \\ l cn Ij • ,��0 _- r .i egg INS • f: \�`�� \�� \�\�� \� i I I� i ii` \� \ �� ) � � �� fro ` ; •, �r!�!�++ +�♦ O o oo RA W NFA \� \' �• � _- - - -- - -- - L+r� mot. •� — � s s< <.�s� -��:i