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HomeMy WebLinkAbout030-1079-30-000 J� ST. CROIX COUNTY ZON \i- " E T AS B X EI UILT SANIT �I REI.�'1'�i�� Owner Address `5758 �E21 L �fL sT ac C City /State , — i , s UQ.fl9/1/ �e� �/ �/ �� �oF� c Legal Description: Lot q_ Block Subdivision/CSM # _ '/. ► '/. PL, Sec. A, T30N -R jW, Town of S , PIN # 0-76 SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer Size ST/PC /w/ Setback from: House 20 Well ,j/d� P/L Pump manufacturer. _!_ Model Alarm location A (HOLDING TANKS ONLY) Setbacks: Service road V t intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM 1N/ LT/1 -+lox Type of system: TiPe &,QA� Width J Length _ j7 2 Number of Trenches Setback from: douse jk.L Well Vent to fresh air intake /do f ELEVATIONS Description of benchmark — To p " j eV C_ Elevation Z04,0 Description of alternate benchmark �o_ZLW2 or Elevation ZAP, Building Sewer , . ST/HT Inlet Lj ST Outlet PC Inlet /.I PC Bottom M,4 Header/Manifold Top of ST/PC Manhole Cover Bottom of System Final Grade Date of installation 4 11V Permit number State plan number Plumber's si n License number ,2 /7y / Date / / Inspector i /r1 er Complete plot plan R (Visconski. Department ofCommerce PRIVATE SEWAGE SYSTEM County: Safety and Buildings Division 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)]. 315841 Permit Holder's Name: ❑ City ❑ Villa e Town of: State Plan ID No.: PICOTTE, JANE ST. JOSM CST BM Elev.:. Insp. BM Elev.: BM Description: Parcel Tax No.: 4 1 6D 1 1 12 bf 1 030 - 1079 -30 -000 TANK INFORMATION I il_ VATION DATA A9800230 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic �6 //��Benchmar c )-?y W_ Dosing A0. /Of 7 Aeration Bldg. Sewer ,721 +� 7 Holding St/ Ht Inlet TANK SETBACK INFORMATION Outlet TANK TO P/ L WELL BLDG. Air Intake ROAD Dt Inlet eptic l op lo0� q Sl NA Dt Bottom Dosing NA Header /Man. Aeration NA Dist. Pipe g ' 3 q.sa qs L Holding Bot. System 3 PUMP/ SIPHON INFORMATION Final Grade s. (o 7 _ Manufacturer and Mod umber GPM TDH ' Lift­ Fri Syetem LT DH Ft Forcemain Length Dia. HH Dist. To Well SOIL ABSORPTION SYSTEM BEII)e,jn W Width r( Length No. Of Trenches PIT No. Of Pits Inside Dia., Liquid Depth DIM N 3 .Z -a 4 a- I DIMENSION SETBACK SYSTEM TO P/ L BLDG WELL LAKE / STREAM LEAC ING Manu INFORMATION Type O CHA ER Model Syste :ay �1� R � �7 OR UNI DISTRIBUTION SYSTEM Header/Manifold rr Distribution Pipes) ) t r x Hole Size x Hole Spacing Vent To Air ntake Length _LSD Dia Length _ Spacing �� (, �rCa uu Si e`2wi �,rN 76C 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 Center Bed/ Trench Edges opsoi ❑ Yes ❑ No ❑ Yes ❑ No — COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: ST. JOSEPH 28.30.19.285,SW,SE 558 PERCH LAKE ROAD 1 t'I hu (. �'� �1 ��7 Plan revision equ ❑ Yes No M1 Use other side for additional information. (0 1 C 11 3 I qS SBD -6710 (R.3/97) Date Inspectog Signature . No. Mi scons i ITARY PERMIT APPLICATION 2 01 e E.W and shn SAN n In accord with ILHR 83.05 Wis. Adm. Code P.O. Box 7969 Department of Commerce Madison, WI 53707 -7969 0 Attach complete plans (to the county copy only) for the system, on paper not less County S r than 8 1/2 x 11 inches in size. • See reverse side for instructions for completing this application State sanitary Permit Number The information you provide may be used by other government agency programs heck it revisi 1 [Privacy Law, s. 15.04 (1) (m)]. sojrv` State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE x � ASE PRINT ALL INF R ATIO Property Owngr Name VV Prope ation J �F Ofi� 1/4 1/4 7 T30 ,N,R�9 E(or� Property Owner's Mail g Address Lot Number Block Number s B VEEL4 Z .4K - c P.0. City, St to Zip Code Phone Number Subdivision Name or CSM Number I ,W W L -1-69 a 3 0 1 II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ it Nearest Road 3 ❑ vll age s % 505� P6eC &A- K Public 1 or 2 Family Dwelling - No. of bedrooms Town OF III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1❑ Apartment/ Condo C 8 ' 3 Q 1 1 . : 85 q 7 -30 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. ❑ 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 30'7 1 Date Issued -3 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 0Seepage Trench 22 ❑ In- Ground Pressure a— 3 r X j - 6,ZS � 4 E] Pit Privy 13 E] Seepage Pit ❑ Vault Privy 14 ❑ System -In -Fill _ i`� ft 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 Z15 -0 -5 S 7 , 8 � 3.5 Feet 1 Feet Capacity VII. TANK in llos Total # of r Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturer Name Concrete Con- Steel glass Plastic App_ New Existin strutted Tanks Tanks Se tic Tank r Holding Tank X I co O lAY 66,<7 ® ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ I ❑ 1 ❑ 1 ❑ 1 ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plu be 's Signature: (No Stam PRSW No.: Business Phone Number: Aw* vl�J Scam err s Plumber's A( dres f Street, City, St at , Zip Code): S"8 6 V A L L 6 (�i � w e. So 01 eQ S,6 7 Gt1 L s `�O Z.5 IX. COUNTY / DEPARTM USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued Iss g t Signature (No Stamps) Su char Fee) I `Approved El Owner Given Initial Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD•6398 (R.11/96) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber , 3.S 1 64 , }- > 6 -- - - - - -- W ALL i 1 , : i f j I : BI i 3 I OEUJ/ �o�� ;r�?Hs / ALT.._ - - -- } }�. - - -• [ 3a -- - a — — - , E i ( r / i , � l � i o �' o � � �G ADO �DQY_ �Ct` B►1 rre� dx i I ll , t 1 ' E C Try. I. r 110 , Wisconsin Department of Industry SOIL AND SITE EVALUATION Labor and Human Relations Page / of 3 Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. 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 / percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # 03 -107 -30 APPLICANT INFORMATION - Please print all information. d Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). il Property Ow er A'e- Property Location GL G Govt. Lot SC/4 /&j 1/4,S ay T ,N,R / 1W W Property Owner's Mailin Lot # Block# Subd. Name or CSM# S 77 City State Zip Code Phone Number Nearest Road A lt SO �� ((�/ ) �/��_ 6 ��, ❑ City ❑ Village Town aNew Construction Use: Residential / Number of bedrooms 3 Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow gpd Recommended design loading rate . 7 bed, gpd/ft trench, gpd /ft Absorption area required ie�) bed, f: ^, �� trench, ft Maximum design loading rate ° 7 bed, gpd/ft trench, gpd/ft Recommended infiltration surface elevation(s) 93- �� / ft ( referred to site plan benchmark) Additional design /site considerations ( NC �r�f� A g & - C � Parent material Flood plain elevation, if applicable /W ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system R S ❑ U 9 S ❑ U 0 S ❑ U I RS ❑ U I NS ❑ U I ❑ S Wu 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 e Ground Depth to limiting factor Remarks: Boring # Ground elev. Depth to limiting factor 7 - Remarks: CST Name (Please Print) Signature Tele hone No. Address Date CST Number 641441 Pad e /// o BM= rr �l� /oo, Q o i0, y� p �y /6)8'' yy' I► s Z 5 Ot4.- * I r od em �y Ztll t es f c� .Sys e .� pnr' �4 u, 9 3, rp ��. 5L /�l� S.2�'73oNe/ C S7 k n a�7yl9 lecl- 1-14 clson 4 11.1. 5 S% /61 Vi ITARY PERMIT APPLICATION 201 Saf and shnilgtonAve sion SAN sconsi 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 � CI�G !k than 8 112 x 11 inches in size. • See reverse side for instructions for completing this application State sanitary Permit Number 3o 6 ?9 The information you provide may be used by other government agency programs ❑ Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATION Property Owner Name Property Location /a , 1 /4, S 8 T3 N, R E (o ge Property Owner's Mailing Address Lot Number Block Number 6 City, State I Zip Code . Phone Number Subdivision N me or CSM Number 4 r d le. 1 ( 7/6 -) - -5614 7 H. TYPE OF BUILDING: (check one) E] State Owned E] Cit Nearest Road ❑ Village Public 25 1 or 2 Family Dwelling - No. of bedrooms_ Town OF o LJ- C 4_� 40 111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo — 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_ ❑ 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 42 E] 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. 1 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) 9y,S Elevation Feet 9 . / Feet Capacit VII. TANK in Ca allo s Total # of Prefab. Site Fiber- Exper. INFORMATION, g Gallons Tanks Manufacturers Name Concrete con- steel glass Plastic APP New Existin structed Tanks Tanks eptic Ta pr unl i. y,j =� r 19 1:1 1:1 El 1:1 1-1 Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VI11. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) P 32.0 s Signature: (No t ps I M MPRSW No. Business Phone Number: / 7 4S _ l Pum dress (Street, City, State, Zip Code). IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit F e (includes Groundwater ate Issued Issuing Agent Signature (No Stamps) KA roved 0 vO aV rcharge Fee) I pp ❑ Owner Given Initial Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD -8398 (R.11/96) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber AGT 13/"1 7o%o /" SPEEL Lo T . OG ®a moo &Z. CP "U m ca 0 ¢ RN B � I 8 � I I i Z - 5X 5 I i I � I I t� p8 11 3 2 LoT GdQ/�l�� rE LINE e,c i AGT 9 GC uV�/1 ,ORAW"wc- 'Cop. 3 -Z3 s'8 DRA c11 N6- d y c7A Pi c © 77e zo ,S'6 PERc�l c.4 /10. 5 alluey T.P. 1141, 0501V eZ)I' S 501`7,�FRS ,67 y f (/ i TO .1 30 ,�4�pRad� cave2 v ANY t7bcrC (o T/?FAI-CH i /�iPA a l 3 z w %�v� .3 - �8 !-)I?AW 6.- CfAl l� Pi c a T TG - - - CSS8, S 0 PER // 1-,4R'C- AO SSG VA "L y W&Uu T 2 ffur�s.�nc Gl�i' S ya/'G So/'�E2s�T GIJi' 3 yak s . Wisconsip. Department of Industry SOIL AND SITE EVALUATION tabor and•Human Relations Page—/ of Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. s' Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. FPfti m y / include, but not limited to: vertical and horizontal reference point (BM), doNkrid Ccaix percent slope, scale or dimensions, north arrow, and location and dista earest ro parce I. . # 01V- Ijg9 - 30 -000 APPLICANT INFORMATION - Please print all inform . T a , Re wed by _ D Personal information you provide may be used for secondary purposes (Privacy w, ,Ira .^ .- Prop Owner �, Pr calf i p Govt. L'�t 1[4 �- 1/4, � T ,N,R l/ 4M W ) Property Owner's Mailing Address / - # BIocK# Sf�tid. Name or CAM# �l City State Zip Code Phone Number Nearest Road /_T r f / �,�p s — y ��`/ ❑City El � Town / fG / L New Construction use: JK 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 e-le—trench, gpd/ft Absorption area required bed, ft2 �/ trench, ft Maximum design I ding rate . 7 bed, gpd/ft gpd/ft Recommended infiltration surface elevatioTn(s 4,, i► .S V 1 . O (as referred to site plan benchmark) Additional design/site considerations n f Tit STt?�d i;enC A&S &W R Cr• Parent material Ou T G✓QS 4 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 XS ❑ u krs ❑ U I li�S ❑ U I 9'S ❑ u ❑ S S� 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 11 bn Ground J _ �--- elev. Depth to limiting factor Remarks: Boring # 6 -1.2 /0 "/ s/ --- C .?m r- 'r- Ground Qa e G le , v. /-f� �—ft Depth to limiting factor 'iQin. Remarks: CST Name (Please Print) Signature Telephone No. - 7/;& - Address Date CST Number Pay, 3�� 3 N Rol = T `2 1, Pic P; FC, 100. 00 ` 13, B 1414, oQ Sysf --m 60&— t NIJ �S �• 170 lope u 177 lag isl3' a ner 02 Z otj re -fence l ine [�w Cor „ei (/' M ''�' a -' Q / � � [ e Qr;�� �►.y `/ •. Tlra,,.o.s J , S Gfirv►i D r�..,�'�1 C ST M O yo L o i�L Aloi, j ,( 5/ , Sose 4, $ (o Ile” l /ey ,I . ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer 'T��� ANb GAR v - / j Tom' M011ug Addrnaa Property Address _55A JPP_ L A/rE ' / (Verification required from Planning Department for new construction) City/State N UD SDn/ Wi` SUO d Parcel Identification Number 030-1,6.79-30 LEGAL DESCRIPTION Property Location SW ' /a, , St '/4, Sec. T_jp_N -R_4LW, Town of _s7, 9,014QA Subdivision Pico 7 , Lot #. 33 Certified Survey Map # 56 9 7 ! , Volume , Page # Y? 906 930 6 36 Warranty Deed # 5,1 / A 9 ? , Volume i a 96" , Page # a 6 If Ss' oea o / lav Spec house ❑ yes ® no Lot lines identifiable ® yes ❑ no SYSTEM bAINTENANCE 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 j stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days o e three year exp' te. QxJ l� IGNA OF AP LICANT 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 pr rty described abov virtue of a warranty deed recorded in Register of Deeds Office. SIGNA F 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 2 (X 94 or ip 2 ry -C c ' I H l 1997 569771 Cr oix , Co. Co, Wi 23 T L) BEARINGS ARE REFERENCED TO THE c: I < SOUTH' LINE OF THE SEI/4 OF- ON 28, ASSUMED TO BEAR M 41 M z z co M pi ;u J M co CD PG. 2413 LOT 1 OF C.S.M. IN - VOL. --------- ----------------------- < 0 00 ir- 10 -ul �: S00*45'34"W 1306.08' — z 31.46' n 3 612.58' 662.04' I 10) A CESS EASEMENT, V) �OD I 4h. 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