HomeMy WebLinkAbout030-2101-70-000 ST. CROIX COUNTY ZONING DEPARTMEN ,� ,,
AS QUILT SANITARY REPORT � _ f
Owner ``' ��c
Address �O f�iG�/ Q &a-) !�`
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City /State - qul sdN 0 1 `y v/C i =' a sr C .
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Legal Description: coF�'w i
Lot . Block A(A Subdivision/CSM #
%+ AE %, S�f Sec-,jX, TAN -R - &W, Town of SST, � eu &= W PIN # 40 T-2o
0-70-,,093 — SO
SEPTIC TANK — DOSE CHAMBER — HOLDING TANK INFORMATION:
Tank manufacturer _ I,l1� ,Efi -S Size ST/PC WALIyoo Setback from: House gL Well Z&2_ P/L &)
Pump manufacturer _ ; � �q -Model 137
Alarm location
ONLY)
Setbacks: Service ro air intake Water Line
Meter location
Alarm location
SOIL ABSORPTION SYSTEM:
TWO of system: T&i & Y Width 3 '2 S Number of Trenches I_
Setback from: House Ado Well 3pD P/L 11q Vent to fresh air intake tea t
ELEVATIONS
Description of benchmark vex r, M 1p c, ,- VC1k& - -57A r — Elevation - loo, o
Description of alternate benchmark n4 daa,e r Elevation
Building Sewer , ST/HT Inlet , v ST Outlet PC Inlet 0.6 L
PC Bottom _ Header'/Manifold 9'S, p G Top of ST/PC Manhole Cover 9� , 3'/
Distribution Lines (I) 2 3,3 9 (Z) _ 9 4 1/ ( )
Bottom of System (1) 3 (z) i t l, b V ( )
Final Grade ()) - 7. q ( �• J y ( )
Date of installation / Permit number 30 ?'2 3 State plan number Vii¢
Plumber's signature 'License number 7111 Date 1 By
Inspector
complctc plot plan or
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Y'
Safety and Buildings Division Count ST . CROIX
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitarzf"ty.:
Personal information you provice may be used for secondary purposes [Privacy L J T , s.15.04 (1)(m)].
H
DAVIDe: 1�, Ejagl Town of: State Plan ID No.:
CST BM Elev.: 1 6 0 Insp. BM Elev.: BM Description: Parcel tMWU 1083-20-000
TANK INFORMATION ELEVATION DATA A9800126
TYP MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic g � Obi Bench 2.34 IiV-3 oC�
I
Dosing 4,/ 9 g . 5 q71
Aeration Bldg. Sewer
Holding (St qt Inlet GI 3. Da-
TANK SETBACK INFORMATION St/ Outlet � -7
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet ((.
Air Intake
Se N NA Dt Bottom /ro 7. 2 >
Dosing 7 NA Header / Man. - - 7-25 - �7
Aeration -------- Dist. Pipe
7• V-g-
ff
Holding Bot. System � f✓ $, -� � � 39
PUMP/ SIPHON IN RMATION Final Grade
Manufacturer �o Demand /- fWC;V� ..tG �� �' 7 95/.�
Model Number `i FPM �� D
TDH Lift g7 Frictiort7 System TDH // 3j t
Loss Forcemain Length /0 o 1 Dia. ;L Dist. To Well
SOIL A RPTION SYSTEM a ��—
BEDVTKENCW Width r Length r No. Of Trenches PIT No. Of Pits Inside Dia. Liqui epth
DIM N 3 7 PIT DI MENSION S
SYSTEM TO P/ L BLDG WELL LAKE / STREAM LEACHING anu acturer.
SETBACK
INFORMATION Type Of it CHAMBER Mo a Nu er:
Syste. Q J OR UNIT
DISTRIBUTION SYSTEM
Header/ Manifold u i old Distribution Pipe(s .� x Hole Size x Hole Spacing Vent To Air Intake
Length 121 Dia. � Length Spacing
kACKI-
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 Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: ST. JOSEPH 29.30.19.300,NE,SW 460 HIGHLAND VIEW
z5�4. �C( �C, wir
//
Plan revlslon e requli•e ❑Yes K[ No
Use other side for additional information. $r
SBD -6710 (R.3/97) Date Inspect Signature Cert. No.
Vi sconsi n SANITARY PERMIT APPLICATION 0 E Washingtonn A evision
In accord with ILHR 83 - 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 cc++
than 8 1/2 x 11 inches in size. v4• C x
• See reverse side for instructions for completing this application State Sanitary Permit Number
30 -
The information you provide maybe used by other governmms r ❑ Check it revision to previous pplication
[Privacy Law, s. 15.04 (1) (m)]. A/_ O C e �I V State Plan I.D. Number
I. APPLICATION INFORMATION -PLEA R MATION
Property Owner Name Prq rty Location ��;�
At 1 � 1 i4, S T ,3Q , N, R/ E (" "
Pro Owner's ailing Address Lot Number Block Number
City, State I Zip Code Phone Number Subdivision Name or CSM Number d
II. TYPE OF BUILDING: (check one) ❑ State Owned H It Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms _ ° -Town OF S L O & G 6- Villae
III. BUILDIN USE: (If building type is public, check all that apply) Parcel Tax Numbe (s) � / 70 — 000
n 9 M. Say °Of
1 E] Apartment/ Condo a 3 o.
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. A New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of S. ❑ 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 IN Seepage Trench 22 ❑ In- Ground Pressure �1\ t 1 42 ❑ Pit Privy
13 ❑ Seepage Pit (a J 3 X 7� 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) r Elevation
V S-0 93. S5
Feet 12. _ Feet
VII. TANK Capaclt in altos Total # of Prefab. Site Fiber- Exper.
INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con steel glass Plastic App
New Existing structed
Tanks Tanks
Septic Ta r an Q�d ` 0 ❑ ❑ ❑ ❑ ❑
Lift Pum Tank er '� Q — — ` ® ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print PI b is Signature: (N S m ) /MPRS No.:�l, Business Phone Number:
Plum er s Address (Street, City, State, Zip Code):
lE
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue ] ISSui gent Signature (No Stamps)
IZApproved E] Owner Given Initial Q'�1 f Surcharge Pee)
Adverse Determination 60 co ► 10(9 q I k wj S6 /I
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
OU ISM DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, plumber
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• PAGE OF
PUMP CHAMBER CROSS SECTION ARID SPECIFICATIONS
VEWT CAP
i VENT PIPC WEATHER PROOF APPROVED LOCKING
JUAJCTION BOX - MANHOLE COVICK.
2: 2.3' FROM DOOR, I2•MIU.
wINDOW OR FRESH I
AIR INTAKE I
GRADE I 4 MIL.
I
IB'MIIJ.
COWDUIT -- ---- - - - - --
10 \
I PROVIDE --
MILE T -7 AIRTIGHT SCAL
( I v
APPROVED JOIAIT A I I ( APPROVED .101WT
W /C.I. PIPE I III, W /C.I. PIPC
EXTENDING N
G 3' I 11 ALARM T 3'
OWTO 50610 WIL I I I ONTO O 3 S0LI OLID 1011
d I I
I I oN
c
I
LLCV. FL PUMP -, --�
OFF
O
CONCRETE BLOCK
AvP K15CK EXIT PERMITTED GNLy IF TAAJK MANUFACTURCR HAS SUCH APPROVAL 1 38-
g�ppl
SEPTIC E SPEC.IFICATIOLIS
DOSE /� )�� WUMBER OF DOSES: _ —PER DAU
TANK MANUFACTURER: bf.
TANK SIZE: 60,0 - GALLOWS DOSE VOLUME / /,2 ,
ALARM MANUFACTURCR: � AwK AGf -2!_- _ INCLUDING DACKPLOW: �� c GALLONS
MODEL ►DUMBER: - &A CAPACITIES: A= If INCHC5 OR . '305 -,, GALLONS
SWITCH TYPE' _�MM AiC I// g = A/INCMES OR 92 , q 4LLOUS
PUMP MANUFACTURCR: ZDcLLEP C -_�2 INCHES OR j 5,19 GALLOWS
MODEL WUMBCR: __L32 D- 1?�, INCHES OR GALLONS
SWITCH TYPE: _L= �� MOTE: PUMP AND ALARM ARE TO DE Sys
MIWIMUM DISCHARGE RATE .32, `/Y GPM IN5TALLED OW 5EPARATC CIRCUITS
VERTICAL DIFFERENCE OETWCCAJ PUMP OFF AAJD.DISTRIBUTION PIPC.. LT FEET �L/JT 6 lAfCO
+ MINIMUM NETWORK SUPPLY Pr -°'2
E , . , , . . . . . . . •- � �FLET
+ 1 � FEET OF FORCE MIN X �C✓ F Yo pl. FRICTIOM FACTOR.. _ FEET
TOTAL. OtIMAMIC, HLAD = 9 FEET
� o<
IWTERAJAL D EWSIOW� OF TAWK: INSI Q�; 01A 80 - ;LIQUID DEPTH
SIGNED LICEIJSE AJUMBER: .i.2 DATE -lL 8
c
Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page I of 3
Labor and Human Relations
Division of Safety 8 Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or P # %'
dimensioned, north arrow, and location and distance to nearest road. 1P r
APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION WED B D
DEC Q 19n,
PROPERTY OWNER: PROPERTY LOCATION V ljwj �;
Joanne Persico GOVT. LOT NE 1/4 SW /A 29 T ST C ,f�,R 19 ) W
PROPERTY OWNERS MAILING ADDRESS LOT # I BLOCK # S� E
400 S. Ser ST. 2 Hi hl ddn.
CITY, STATE ZIP CODE PHONE NUMBER [ [:]VILLAGE }TOWN D
Hudson, WI. 54016 715) 386 -9060 St. Joseph *Ell
] New Construction Use jx] Residential ! Number of bedrooms 3 [ ] Addition to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow 450 gpd Recommended design loading rate _gy bed, gpd /ft trench, gpd /ft
Absorption area required 900 bed, ft 750 trench, ft Maximum design loading rate —_ bed, gpd /ft gpd /ft
Recommended infiltration surface elevation(s) 93.55 ft (as referred to site plan benchmark)
Additional design / site considerations na
Parent material pitted qlacial drift Flood plain elevation, if applicable na ft
S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable fors stem ®S ❑U ®S ❑U ®S ❑U ®S ❑U ❑S $7U ❑S]U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft
..................
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
.................
..................
.................
..................
.................
..................
1 1 0 - 12 10 r3/3 none sil 2msbk mfr CS 2
2 12 - 10yr4 /4 none sicl 2csbk mfr qW if .4 .5
Ground 3 26 -84 7.5 r4 4 none sl 2msbk mfr n
elev.
97 ft.
Depth to
limiting
factor
+84
Remarks:
Boring #
1 0 -10 10 r3 3 none sil 2msb
2 2 10 - 10yr4 /4 none sicl 2msbk mfr gy if .4 .5
3 22 -38 7.5 r4/4 none scl 2csbk mfr C1W na .5 .6
Ground
elev. 4 38 -84 7.5 r4/4 none sl 2m r mvfr na na .5 . .6
97.5 ffi
Depth to
limiting
factor
+84
Remarks:
CST Name: -- Please Print Gary L. Steel Phone: 715- 246 -6200
Address: 1554 200 New Rich and WI 54017
Signature: Date: 11 - - CST Number: m02298
A
STEEL'S SOIL SERVICE
Gary L. Steel Joanne Persico 1554 200th Ave.
CSTM2298 NE4SW4 S29- T30N -R19W New Richmond, WI 54017
MPRSW 3254 town of St. Joseph (715) 246 -6200
lot #26- Highland HIlls Second Addn.
N
1 =40
BM.= top of mid lot survey stake C el. 100' J C
9 6
ti
2.0 � ►� o'
Gary L. Steel
11 -12 -96
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer nA/ria LU nIX
Mailing Address /Sa hFIPdAI'
Property Address _ LY�6 L ' &4 ' 4 A
(Verification required from Planning Department for new construction)
City/State Au'_s 'I'V ZV Parcel Identification Number o 3o - /o 83- so
LEGAL DESCRIPTION
Property Location AC %., W_ y., Sec, T N - R�_W, Town of Si.7.r
Subdivision 11&Q - h1,Q Lot #
Certified Survey Map # Volume . Page #
Warranty Deed # 74 S 70 Volume Page # el, 5"A_
Spec house ❑ yes G no Lot lines identifiable M yes ❑ no
SYSTEM MAINTENANCE
ImPrw use and Hof your septic system could result in its premature-failure to Dandle artistes. Propermamtenance
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 p lumber joumeymanplumber, restxictedplumberoraIicensedpumperverifyingthat (1)theon -site a rastewaterdisposal"stem
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
that
stating 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.
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.
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
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