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Home My WebLink About030-2106-50-000 ST. CROIX COUNTY ZONING DEPARTME.. p 4. AS BUILT SANITARY REPORT I `;`' r`e'., !V[D Owner ?` F Property Address J ! / � y G OU P rtY � 7 l/7 City /State zINGOFFicl Legal Description: ' Lot 6 Block Subdivision/CSM # Of � r A) sr .. SGW '/4 � '/4, Sec. , T y N -R,W, Town of s7 -/o4 PIN # B3Q SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer Size ST/PC /ad /8o Setback from: House ;? dd r Well Vj P/L Pump manufacturer Model fZe y �l Alarm location cc - (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM Type of system: ea -N Width s Length �2 Number of Trenches 2 Setback from: House S Well x.),-C P/L / Vent to fresh air intake 2SL ELEVATIONS Description of benchmark Elevation Description of alternate benchmark A-07 0 'P Elevation od_ Building Sewer ST/HT Inlet ST Outlet PC Inlet PC Bottom Header/Manifold Top of ST/PC Manhole Cover Distribution Lines () () ( ) Bottom of System () () ( ) Final Grade () () ( ) Date of installation //a //r Permit number State plan number Plumber's signature License number a29d Dat Inspector Complete plot plan � ainDepartment Commerce Safety a : Safety and Buildings Division PRIVATE SEWAGE SYSTEM Co unty sion ST . CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary PermitNo.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)j. 315948 Permit Holder's Name: ❑ City ❑ V Town of: State Plan ID No.: SMITH, MIKE S J E CST BM Elev..- Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA A9800341 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic �C Benchm r , Dosing' CI-0 Aeration Bldg. Sewer /0.1 Holding L t/ Inlet //,3 TANK SETBACK INFORMATION St/ btf Outlet TANK TO P/ L WELL BLDG. Air I to ntake ROAD Dt Inlet ir Septic w N �. NA Dt Bottom !30 Dosing a-7 NA Header / Man. g,tZ- Aeration � I NA Dist. Pipe •� .2 °I.3� Holding--- B System Cif 9.32_ PUMP/ SIPHON INFORMATION >✓1 Final Grade Ti S: 3 Manufacturer Demand Model Number d 7 GPM T 3)- J TDH Lift 7,0D I Lrictio System TDH/ f � �, �, r 2 - i� [ 7Forcemain Length/82- Dia. L Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width / Lengt No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSION SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING n r: INFORMATION Typ I f �_ CHAMBE Model Nu r. i�, Sy e �-fv OR UNIT - DISTRIBUTION SYSTEM Header /Manifold I I Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length L2_ Dia. Length ! Dia. Spacing / 5r m - 7 Z. SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded i xx Mulched Bed /Trench Center Bed/ Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) /00 LOCATION: ST. JOSEPH 6.29.19,SW,NE 371 117TH AVE- EVERGREEN RDG LOT 5 kA� Cv,11, k" a Plan revision required? ❑ Yes 16 No Use other side for additional inform El I I I SBD -6710 (R.3/97) Date Inspector's Signature Cert. No Safety and Buildings Division " SANITARY PERMIT APPLICATION 201 B Washington Avenue Visconsin 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. C • See reverse side for instructions for completing this application State sanitary Permit Number Personal information you provide may be used for secondary purposes heck if re �lO vi s �p6,on [Privacy Law, s. 15.04 (1) (m)]. 3 7 / ''i State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION �— Property Owner Name Property Location /1i; e s'j ,r�'� tJ 114 �c 1/4, S T , N, R E (or) W Property Owner's Mailing Address Lot Number Block Number d` c e? 10-4 X-a r e -5 City, State Zip Code Phone Number Subdivision Name or CSM Number s/ 44d O - I DOD y I ( ) 'e-V gay g e , II. TYPEOF BUILDING: (check one) ❑ State Owned o it Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms ° Tow OF III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 09 ZO& + sO _ ODO 1 E] Apartment/ Condo . /F. 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 online B, if applicable) A) 1. pa 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 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In- Ground Pressure f 42 ❑ Pit Privy 13 []Seepage Pit Y7 S 43 ❑ v ault 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/da /sq. ft.) (Min. /inch) �,?S «�a�`" r l,Cr Feet Feet Capacit VII. I NFORMATION in gallo Total # of Manufacturer's Name Prefab. Con Steel Fiber- Exper Gallons Tanks Concrete glass. Plastic App New Existin strutted T nks Tanks En or Holding Tank / 1 ,'(wG 7`'� El El El ❑ El Tank iphon Chamber 11 ❑ El El E] NSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: o Stamps) PRSW No.: Business Phone Number: 11Z 1Z 1 2 ?Fa Plumber's Address (Street, City, State, Zip Code): d Ito gg a = g ju x IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issui g gent gnature (No Stamps) V A roved Surcharge Fee) j 4 pp ❑Owner Given Initial a l l -L), 16 , 1 A&�� 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 ' *L fir Safety and Buildings Division consin SANITARY PERMIT APPLICATION 2200 W. Wash in Avenue Department of Commerce In accord with tLHR 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. S C y .„"x • See reverse side for instructions for completing this application State Sanitary Permit Number 915gLX Personal information you provide may be used for secondary purposes ❑ Check if revision to previous application (Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INF ATI N -PLEASE PRINT ALL INF RMATION Property Owner Name Property Location e 5'/_-V '-a`h al /4A/4 114, S T , N, Rl (or Property Owner's Mailing Address Lot Number Block er //$ r'/ Was T G 77 c e City, State I Zip Code Phone Number Subdivision Name or CSM Numb r4Y O QD ( ^) — ev rs , �d II. PE F BUILDING: (check one) ❑ to Owned ❑ it yy Nearest Road ❑ Village Public 1 or 2 Family Dwelling - No_ of Brooms Town OF aSa 1 CQr e III BUILDING USE (If building type is public, check all t t apply) Parcel Tax N ber(s) 1 C] Apartment/ Condo B 3 01 2 ❑ Assembly Hall 6 ❑ Medical Facility/ N sing Ho a 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ pai 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 li/A. ck box n line B, if applicable) A) 1. R New 2_ ❑ Replacement 3, cement o 4. E] Reconnection of S_ ❑ Repair of an - _____System ________ System __________Only_____ ________ Existing System _________Existing System B) ❑ A Sanitary Permit was previously issued Number Date Issued V. TYPE OF SYSTEM: (Check only on Y221n-Grouncl Non - Pressurized Distribution d Distribution E erimental Other 11 El Seepage Bed nd 30 Specify Type 41 ❑ Holding Tank 12,E Seepage Trench Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFO ATION: 1. Gallons Per Day 2. Absorp. Ara 3. Absorp. Area 4. Loading Rate 5. P c. Rate 6. System Elev. 7. Final Grade G Required ( s . ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. if rl g7.odr Elevation 9S0 95�Od Feet Feet VII. TANK Cap city in g (Ions Total # of Pr lab. Site Fiber- plastic Exper. INFORMATION New Existin Gallons Tanks Manufacturers Name Con ete Con- Steel glass App. strutted Tank Tanki Tanks Septic Tank or Holding Tank r 9 ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ 1 ❑ 1 ❑ 1 ❑ ❑ VI11. RESPONSIBILITY ST TEMENT I, the undersigned, assum responsibility for installation of the onsite se age system show on the attached plans. Plumber's Name: (Print) Plumber's Signature: (No Stamps) P PRSW No.: Business Phone Number: Gv; it 4 ,> aa99Q d ea Plumber's Address (Street, City, St te, Zip Code): SQ L9l IX. COUNTY/ DEPART ENT USE ONLY Disapproved anitary Permit Fee (Includes Groundwater ate Issued Issuing Age" T Signature (No Stamps) Approved [:]Owner Given Initial / �71 S u rcharge F ee) ` Adverse Determination U X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.11/97) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber C o ✓�� ,vr � N Vi V � �dr� PLJPf�P CHAMt;ER CROSS SECT IOIJ AK1G SPECIFIC! I "IO�J.`. VC UT CAP `1 "C.I. VENT PIPE WEATHERPROOF APPROVED LOCKIMC, 25' FROM DOOR, JUAICTION BOX MAIJHOLE COVEF. WIIJDOW OR FRESH 12 "MIU. AIR IAITAKE GRADE ml I / CONDUIT 11� INLET PROVIDE _T AIRTIGHT SEAL I / * l Iii I I I l ALARM B I II I I *APPROVED l I ON JOINTS WITH l I ELEV. FT. APPROVED PIPE 3' ONTO PUMP —� OFF o SOLID SOIL CONCRETE BLOGK RISER EXIT PERMITTED ONLY IF TANK MANUFACTURER HAS SUCH APPROVAL SEPTIC E SPECIFICATIOAIS DOSE TANKS MANUFACTURER: NUMBER OF DOSES: _C, d TANK SIZE: ,ADD GALLONS DOSE VOLUME ®6SZ�)N& Q` ALARM MANUFACTURER: �k.- U�/"q ->' "-i INCLUDING BACKFLOW: / /GALLONS MODEL NUMBER: b/_ y CAPACITIES: A= .2.2 INCAES OR 'I;Zd_ GALLON5 SWITCH TYPE: er/ G g INCHES OR '? _ G IL S PUMP MANUFACTURER: C = g'•3/ INCHES OR I �G MODEL NUMBER: At&'o /, D - 2c,Z1 INCHES OR A lk-F GALLONS SWITCH TYPE: _ Z°c L NOTE: PUMP AMD ALARM ARE TO BE MINI DISCHARGE RATES =GPM INSTALLED ON SEPARATE CIRCUITS . VERTICAL DIFFERE BETWEEN PUMP OFF AND DISTRIBUTION PIPE.. FEET � + MINIMUM NETWORK SUPPLY PRESSURE FEET + 15 FEET OF FORCE MAIN X � f /oorLFKICTION FACTOR.. r l7 3 93 FEET TOTAL DYNAMIC HEAD = Y ' �3 FEET I INTERKIAL DIMENSIONC Of TANK: LENGTH ;WIDTH ;LIQUID DEPTH SIG NED: T LICEoSE NUMBER: a!Z7Vr4:; DAT E: � rd Goulds Submersible Effluent Pump 3871 EPO4 EP05 APPLICATIONS •Fasteners: 300 series •Fully submerged in high E Motor Housing: Castron Specifically designed forth stainless steel. grade turbine oil for for efficient heat transfer, following uses: • Capable of running lubrication and efficient strength, and durability. • Effluent systems dry without damage to heat transfer. ■ Motor Cover. Thermoplas - • Homes components. Available for auto matic and tic cover with integral handle • Farms Motor: and float switch attachment • EPO4 Single phase: 0.4 HP, manual operation. Automatic points. • Heavy duty sump p 1550 models include Mechanical 115 , Float Switch assembled and 230 V, 60 Hz, • Water transfer RPM, built in overload with ■ Power Cable: Severe d uty • Dewatering t t th preset ae acory. rated oil and water resistant automatic reset. ft ■Bearings: Upper and lower 115 V, 60 Hz, 1550 SPECIFICATIONS • EP05 Single phase: RPM, FEATURES heavy duty ball bearing RP, � 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 rotection. � • Total heads: up to 24 feet. with three prong grounding p SP• 'a"01 • Discharge size: 1 NPT. plug. Optional 20 foot plastic l Impeller Thermo- (GSA 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. 1 ( 9� • Fasteners: 300 series MEreRS FEET cu�v,c, stainless steel. 10 • Capable of running -44 dry without damage to s 30 ' components. _ Pump: EP05 s • Solids handling capability: 0 25 , %" maximum. a ' 7 W • Capacities: up to 60 GPM. x s 20 • Total heads: up to 31 feet. • Discharge size: 1IR NPT. z s • Mechanical seal: carbon- o 5 rotary/ceramic - stationary, _j 4 BUNA -N elastomers. o • Temperature: 3 10 104°F(40°C)continuous 140 °F (6K) intermittent 2 3 , s i 0 00 10 20 7 50 CFV 12 m'Yh CAPAarr r =< 019% Gaft ftTV, lnc : � �' • May, 19% 83871 • Wisconsin Department of commerce C OIL AND SITE EVALUATION Pa ge 3 Division of Safety and Buildings Pa Bureau of Integrated Services gn aoM C h s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper nhan 8 1 1 h n Ian must County include, but not limited to: vertical antal ref (BM), iMc> on and percent slope, scale or dimensions, w, and location and di ' stande.to Barest road. R • P,, ' 7 Parcel I.D. # �zf 1498 APPLICANT INFORMATION - /ease prij i�ormatipq; Reviewed by Data Personal infonnatan you provide may be usedi seopnd Lvr; 5. 5.04 (t) Property Owner -: Property Location r1cr C.Af Ck r.. ` ' 1 \ Govt. Lot 1/4 1/4,S T N,R j Z E (or) Property Owner's Mailing Address Lot # I Block# Subd. Name or CSM# �3 mc- 4, "-" S .e rt , rP City State Zip Code Phone Number ❑ city ® Village Town Nearest Road yd so n I &,/( Co -e fir' V3 New Construction Use: EgResidential /Number of bedrooms 3 — � Addition to existing building ❑ Replacement F1 Public or commercial - Describe: Code derived daily flow 4 / 0U gpd Recommended design loading rate ! � bed, gpdit? gp t* Absorption area required $ —r7 bed, ft 7s'_O trench, ft2 Maximum design loading rat - 9 9 bed. 9t — ,, :?--Nench.91de Recommended infiltration surface elevation(s) 46 D�rencbi Y7 Z!r_ 40VeY' ft (as referred to site plan benchmark) Additional design/site considera Parent material /1 7 aC7, .t tl U S L( 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 R s❑ u lk S❑ u Ns 0 u I ❑ s O u ❑ s® u SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft2 in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench 3 6 — /6" 3 Z S; / 464 -fir' G S 1 z l / .- /G Si 6 WX" cs Ground S''Y /G r 4111 & G Y 6 . 7 , . lev. Depth to limiting factor Remarks: Boring # g " (� / � . -ZZ /� /3��0 S� l rna bl r 'S (O 3 Zz io i�l /G v`r s 7 Ground elev. Depth to limiting factor 93 in. Remarks: CST Name (Please Print) Signature Telephone No. Address Date CST Number 441 5 e G /7 -yam �5�3�9 -4 o �.S'33� ey rh (� �Sm Z cIe /Wes -eel 11 d w�c Cor X L ► i 'fit 3 yU` � I � a i k ail ,. 1 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer v 1)4,y- f� .J- h-j Mailing Address f 68 y t,- )-cn4- 1'. - 7 g *1" Q 1,- Ac &cL Co 2 QO Oil Property Address 3 117 V2, 444 So yj (Verification required from Planning Department for new construction) City/State Parcel Identification Number e&0 LEGAL DESCRIPTION Property Location -S w y,, /V c /,, Sec. (, . T g N -R Town of 5 L St PG. Subdivision 9'J k.,v q ads, .� , Lot # Certified Survey Map # , Volume ' , Page # Z / &J7 Warranty Deed # .5 3 7 7 ____ , Volume /S `/3 , Page # Spec house 0 yes 11no Lot lines identifiable Q( yes 0 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 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. 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 th threq year expiration date. SIGNATURE OF APPLICANT J 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 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 I1111111�� I` `� • � ;:•�� it I I I �t� \\` \��ti `� , - , �- �� ° \O� ��, ♦ O ♦ �� : - � \ wx ggyg Nk INN `