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Home My WebLink About030-2003-10-000 • ST. CROIX COUNTY ZONING DEPARTMENT'.. • AS BUILT SANITARY REPORT J Owner Property Address _ .3.36 C. '„/ t 7 , City /State �/�./. �� coax Legal Description: Lot /1 � Block kh Subdivision/CSM # ,2L %4 /Y 4) %4, Sec. 3J, T- N -RAW, Town of iS�z PIN # /4_ SEPTIC TANK -- DOSE CHAMBER -- BOLDING TANK INFORMATION: Tank manufacturer Aky 4 & A5 Size ST/PC A01 Setback from: House Well PAL Pump manufacturer 11-,4 Model Alarm location (HOLDING TANKS ONLY) Setbacks: Service road 4 Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM C A-2, Type of system: 1, tr Width 3 � Length 76 Number of Trenches z Setback from: House Well P/L Vent to fresh air intake ELEVATIONS Description of benchmark _ 1 � X air kr ,,�' Elevation iao Description of alternate benchmark Elevation Building Sewer ST/HT Inlet � 7, a d ST Outlet y/,, , 7 9 PC Inlet PC Bottom Header/Manifold 9.�t b� 3 Top of ST/PC Manhole Cover f 3- Distribution Lines ( i) Va. f7 ( z) 9 1 , -'C7 ( ) Bottom of System (j) �b 9V 9i -�"i. ( %1, --/,6 ( ) Final Grade (/) V( o , 3 - 7 (Z) 9Y, 3 3 ( ) Date of installatiw /7 /Y'B Permit number 3--7 State plan number Plumber's signature License number /! ,& Date Inspector � Complete plot plan Wisconsin Department of Commerce Safetysand Buildings Division PRIVATE SEWAGE SYSTEM County: 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)]. 324707 Permit Holder's Name: Li City g y ❑ village Town of: State Plan ID No.: OSTENDORF, Richard ST. JOSEPH CST BM Dev.: Insp. BM Elev.: BM Description: Parcel Tax No.: OD 1 030-2003-10-000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV. Septic Be c r ,2' /i 102.3 100 Dosing Aeration Bldg. Sewer Holding S Fit Inlet 5¢f(3 5 -. 3 7 TANK SETBACK INFORMATION S kf Outlet s'?" Cl'G • 7q TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet �—.- Air Intake Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe q 1 , Holding Bot. System 'd 0 % ; �o•�S 9' Su PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand f - �� C 3 �t�y� ��-f �q• 33 Model Number GPM TDH Lift L ys em DH Ft ad Forcemain Len hi Dist. To well SOIL ABSORPTION SYSTEM D/ C Width / Length No. O fiches PIT No. Of Pits Inside Dia. L DIM DIMENSION SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type CHAMBER Mod Number: Syst� 3 --- OR UNIT DISTRIBUTION SYSTEM Header /lylan old Distribution Pi es (/ II P ( I+a�ti � x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length 7 Bra. 54 Spacing 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, perso s present, etc.) LOCATION: ST. JOS // EPIC 3.30.19.36E,SE,NW 536 COUNTY ROAD E Plan revision require ? ❑ Yes �o Use other side for additional information. SBD -6710 (R.3/97) Date Inspect s Signature Cert. No. I V1 .91consin Safety and Buildings Division SANITARY PERMIT APPLICATION Po B ox shiingtonAvenue 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. S-{': Ceas K • See reverse side for instructions for completing this application State Sanitary Permit Number Personal information you provide may be used for secondary pur purposes /� it 43�� " D-1 (Privacy Law, s. 15.04 (1) (m)]. ��' / �/ ❑ Check revision to previous application State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION Prope y Owner Name Property Lo ation /..C�2L& leo" 1/4 A4) 1/4, S 33 T �d , N, R J (or Property Owner's Mal ng Addr Lot Number g BloSk lu ber �3 C �A /d� City, sta Y IF , ! Zip Code Phone Num Subdivision Name or CSM Number �/ /,(-� ( ) yr' 6 W. 1 4 Ae'. II. T YPE OF BUILDING: (check one) ❑ State Owned o v W age Nearest Road Lj Public 1 or 2 Family Dwelling - No. of bedrooms Town OF S� '0 111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Numbe s) 1❑ Apartment /Condo 33. 1q. WE d -3G acx+3- lQ Ono 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 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 12fijo Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit �r .1 /, 4C z'./,' t� 6X IA ,se's 3 ID Vault Privy 14 ❑System -In -Fill l j & k (A Pit vl S ot,w/ C31• . S y 7S VI. ABSORPTIONS ' STEM 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/daa sq. ft.) (Min. /inch) /y/ 6 E eyation CO 7 3• - Z qo Feet / Feet VII. TANK Capacity in gallons Total # of Prefab. Site Fiber- Ex p er. INFORMATION New Existin Gallons Tanks Manufacturers Name concrete con steel glass Plastic A p p strutted T Tanks Septic Tank or Holding Tank &0 /,0-0 16W Z ❑ ❑ Lift Pump Tank /Siphon Chamber – - ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumb 's Name: (Print) Plumb 's Signature: ( Stamps) MP / k&W N o.: Business Phone Number: 77.4� 77z - -,32/ / Plumber' Address (Street ity, State, Zip Code 1 / . IX. COUNTY/ DEPARTMENT USE ONLY []Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuin gent Signature (No Stamps) Approved El Given Initial Surcharge Fee) / 1 3 1 1 Q0 Adverse Determination [ / [ X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: 0 Uhh)A_1'h fWVA SBD- 6398 (R.11/97) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, plumber • JOB TIMM EXCAVATING SHEET NO. OF Route 1 Box 192 WILSON, WISCONSIN 54027 CALCULATED BY dt� DATE (715) 772-3214 (715) 386-5443 MPRS #3224 WI MPCA #696 MN CHECKED BY DATE SCALE .......... .......... ........... ......... .......... ........... .......... . .... .......... ........... ........... ........... ....... ........... ; I .......... .......... ........... ........... .......... ............ .... .......... ..................... .......... .................... ---------- .................. - ........ ... .......... ........... ........... ........... ........... .......... �eA ........... ........... ..... ...... .... ........... ........... ........... ........... ...... .......... ........... ........... ........... ... ...... r .. .......... .......... ........... .......... ......... . ........... ........... ................... .... ........... ........... ........... ........... . . ......... . .......... ....... ... ... ....... ........... ........... .... ...... .......... ........... ...... .. . ...... .. . .......... ........... . ......... ..................... ........... ........... ........... ........... ........... .......... .......... .. ........... ........... .......... ............ f ... ........... ........... ........... ........... .......... ........... ........... ........... ...... ..... . ............ ........... ........... .......... ........... ........... .......... ........... ......... . ........... ........... ........... ........................... ........... ........... ........... ........... . .......... ........... ----------- ........... ....... ......... c 1 90 ............ ............. ...... ............... ....................... .......... .. ........ .......... ........... ........... ..... ........ .......... . .......... .... ........... . ........... ........... ........... ........ .. ............... .......... ........... ........... i ........... ........ ........ ........... ........... ............ ............................. ...... ........... ....... ...... .......... ........... .................. ..... ........... .......... . .......... .......... . .......... ............... .......... ........... ....... ...... ............... ...... - .......... ........... ........... . ............ ..... . .. ........... .. .... ............. . .......... ........... ........... ........... . . . . .......... .......... ............ ........... .......... ........... . ........ .......... ...... . ....... . . .......... .......... .. ................. ........... ........... .... ...... 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PRODUCT 205-i� Inc., Groton, Man 01471 To Order PHONE TOLL FREE I-BW225-M JOB TIMM EXCAVATING SHEET NO. OF Route 1 Box 192 fJ WILSON, WISCONSIN 54027 • (715) 772-3214 (715) 386-5443 CALCULATED BY DATE Z- _2 MPRS #3224 WI MPCA #696 IVIN CHECKED BY DATE SCAL .......... ........... A ........... ................... .... ........... ........... .......... .................................. ...................... ................. .. ........ ......... ......... ........... .......... .. ...... ... .. ........... ......... ........... ........... ........... .......... ............ ........... .. ........... .......... .......... ........... ........... ........... .......... ....................... ........... ........... ........... .... .......... .......... ......... ........ ..... ..... .......... .......... .......... .......... .......... .. .... ...... ........... ...... ........... ........... ........... .... ..... ........... .......... ... ....... ........... A ........... ........... ........... ........... .......... I .......... .......... ........... ........ ... ........... . ...... ........... ........... ........... ........... . .......... .......... . . . .. .. .... .... .. .......... .......... ..... .......... .. ..................... .......... ....... .... ........... ......... .... ..................... ............ ........... ........... ........... 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PRODUCT 2051® Inc., Groton, Man, 01471 To Order PHONE TOLL FREE 1-800-225-M Wiscorrain Department of Commerce SOIL AND SITE EVALUATION page _ 1 of 3 _ Division of Safety and Buildings in' aixord with Comm 83.05, Wis. Adm. Code Certified Soil Testing Attach complete site plan on paper not less `thaAL' bS x ii,4 iftin size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and County S Croix percent slope, scale or dimemsions, north arrow, and location and distance to nearest road. -- - -- Parcel I.D. APPLICANT INFORMATION - Please print all information. 830 2003 -16 (33.30.19.3 Personal information you provide may be used for secondary purposes (PrIvacy Law, s. 15.04 (1) (m)). w y Date s 7 P Owner Property location 7 Ostendorf, Richard Govt. Lot SE 1/4 NW 1/4 S 33 T 30 N R 19 W Propert Owner's Mailing Address Lot # Block # Subd. Name or CSM# 536 FITHW E City State Zi Code PhoneNurn E] city Village ®Town Nearest Road Hudson WI 5016 715 -549 1423 Joseph I CTHW E ❑ New Construction Use: ® Residential / Number of bedrooms 4 ❑Addition to existing building ® Replacement F Public or commercial describe Code Derived daily flow 600 gpd Recommended design loading rate -7 bed, gpd/ft- •8 trench, gpd/ft- Absorption area required 857 bed, ft' 750 trench, ftz Maximum design loading rate •7 bed, gpd/ft2 •8 tr ench, gpdfft Recommended infiltration surface elevation(s) 90.6 ft (as referred to site plan benchmar Additional design / site consideration in stall 2 - 3' x 72' Sidewinder, Hi capacity "turtle shell" trenches L =Unsuitable arent material sandy /loamy outwash Flood lain elevation, if applicable NA ft = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank for system M❑ U ®S ❑ U ®S F U ®S ❑ U ❑ S Z U ❑ S U 1 Depth Dominant Color Mottles Structure ure GPD/ft Borin 9# Horizon Text Consistence Boundary Roots Bed Trench in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. i 1 A 1 0 -8 I OYR 3/3 - A 2 f sbk ds cs 1 f/m .5 .6 2 8 -24 l OYR 3/4 - sl 2 m sbk ds gs IM .5 .6 Ground 3 24 -35 7.5YR 3/4 - lmcos 0 sg dl cs lm .7 .8 elev 93.1 ft 4 35 -88 7.5YR 4/4 - s/mcos 0 sg ml - - .7 .8 Depth to limiting - -- - - - - factor > 88' ;oil Remarks: Occasional gr below Z 1 0 -10 l OYR 3/3 - A 2 f sbk ds cs 1 f/m .5 .6 2 10 -19 1 1 OYR 4/4 - sl Imsbk mvfr gs if .4 .5 Ground 3 19 -30 7.5YR 4/4 - sl 2 m sbk mft cs lm .5 .6 elev 97,1 ft 4 30 -36 7.5YR 4/4 - s 0 sg ml cs lm .7 .8 Depth to 5 36-44 7.5YR 4/4 - cos 0 sg ml cs S7/ 9 8 frog 6 44 -120 IOYR 4/6,4/4 - s/mcos 0 sg ml > 120` -- Remarks: occasional gr below 44" CST Name (Please Print) Signature: I C TaleN X Henry F. Grote ` 71 Q Address erti ie of Testing a Refr P.O. Box 57, Knapp, WI.54749 /16/1998 222774 �/ . 3 S M 9 . to EA CA M M t A P .• J 3 � 3 ., cr. �- M - � 0 o W or 4- Cl cl � a a pA r. L+ of ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer /- Mailing Address Property Address 071 e (Verification required from Planning Department for new construction) City /State A ue/�r Parcel Identification Number 6 -3o� LEGAL DESCRIPTION Property Location _ 1 / _ 1 /4, Sec. 3 , T J6 N-R-Z LW Town of 1. Subdivision Lot # Certified Survey Map # Volume , Page # Warranty Deed # 306--o Volume Page # 173 Spec house ❑ yes ff no Lot lines identifiable Oyes ❑ 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 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. 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 da s of the three year ex ' on date. rly 7 Z/ 9$ GNATURE 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 roperty described ahnve, b v' a of a warranty deed recorded in Register of Deeds Office. GNATURE OF APPLICANT I 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 ST. CROIX COUNTY ZONING OFFICE �r,1. S% FOR UTILIZATION OF CERTIFICA AN EXISTING STATEM SEPTIC � N This is to certify - that I have inspected the septic tank presently serving the _4,1z"'d residence located at: S� ; , 17 J ; , Section 3.3 I f T R /y W, Town of e"eso1► Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced: // 3' Did flow back occur from absorption system? Yes X No (If no, skip next line) Approximate volume or length of time: gallons minutes Capacity: joo� Construction: Prefab Concrete X Steel Other Manufacturer: (If known): Age of Tank (If known) :15F (Sig ature) (Namal Please print (Title) (License Number) i,2- iv -9z9 Date Form to be completed by licensed plumber (s.145.06, Wisconsin Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative Code) — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank to the best of my knowledge will conform to the requirements of ILHR 83, Wis. Adm. Code (except for inspection opening over outlet baffle). Name /a, / / r Signature