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HomeMy WebLinkAbout030-2035-70-000 ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT Owner - Address 12 /B City /State Legal Description: , - Lot &_ Block &A Subdivision/CSM # AIA '/, Af1V 1 /, V&, Sec. ,,L, T_Jto N -RAW, Town of PIN # 0 -.20 - -2 SEPTIC TANK -- DOSE CHAMBER -- H" INFORMATION: Tank manufacturer aZa e A - S Size ST/PC Zn�dhloo Setback from: House LY Well -jz!!� P/L z Pump manufacturer Z oez4,4 -/R Model X3 7 Alarm location 1/ousA� (HO G TANKS ONLY) Sdtbac ks SZc road Vent to fresh air intake W z Metdr location ater Lin Alarm location SOIL ABSORPTION SYSTEM: Type of system: ra Width 3 Length 7 ,S Number of Trenches 02 Setback from: House 7 9' Well - Ll 3 P/L o/ O )'- Vent to fresh air intake _ 7 V ELEVATIONS Description of benchmark Elevation 1 Description of alternate benchmark Lo k ,, .2 Elevation /OB, 2 2 Building Sewer 82, ST/HT Inlet AL SS ST Outlet 86,30 PC Inlet PC Bottom Header/Manifold Top of ST/PC Manhole Cover F3,59 Distribution Lines (N) Bottom of System (t!) Final Grade 103 Date of installation / / Permit number State plan number Plumber's signature L id� - 1L.� i. icense number _,22/7 S// Date OG29/Y9 Inspector (:omplete plot plan ■+ Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM y: Safety and Buildings Division Count ST. CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary3grp�lbok Personal information you provice may be used for secondary purposes [Privacy L s.15.04 (1)(m)]. 33 v Permit Holder's Name: ❑ Cty ❑ II Town of: State Plan ID No.: LEVERTY, PATRICK ST. !P CST BM Elev.: Insp. BM Elev.: BM Description: Parcel T._2035 -70 -000 DD,.Ord /on •oo � 1a L� ✓ iZ -4 TANK INFORMATION ELEVATION DATA A9800092 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic ,r) , 1 _ t Benchmark /OS -7 5•'7 00, od Dosing JL Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P / L WELL BLDG. Ai Intake ROAD Dt Inlet /y �' ��,G C ' Septic NA Dt Bottom 23 - ay Dosing NA Header / Man. Aeration NA Dist. Pipe G 1� w Holding Bot. System g ' a PUMP/ SIPHON INFORMATION Final Grade �� 7 Manufacturer il Demand Model Number /3 GPM TDH Lift Friction I System TDH Ft oss H ead Forcemain Len gth Dia. Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS r - 5 DIMENSION SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type Of CHAMBER Mo Number: System J& lb ° l /�/ ff OR UNIT DISTRIBUTION SYS E Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing y56 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 24.30.20.470A,NW,SW 218 142ND AVENUE 61j', � Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD -6710 (R.3/97) Date —T Inspector's Signature Cert. No. • .:o Safety and Buildings Division SANITARY PERMIT APPLICATION Bureau of Building Water Systems 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707 -7969 0 Attach complete plans (to the county copy only) for the system, on paper not less County //'�� , than 8112 x 11 inches in size. �. t�Y J • See reverse side for instructions for completing this application State Sanitary Permit Number 3 C>770 The information you provide may be used by other government agency programs ❑ Check it revision to previous appli Lion ]Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION I - Property O er Name Property Location CULL WA c 5'C�f 114, S Tao , N, R ,2O E (oro Propert Owner's ailing Address D Lot Number Block Number (o A l / / - City State Zip Code Phone Number Subdivision Name or CSM Number II. TYPE OF BUILDING: (check one) E] State Owned El Cit Nearest Road E3 Village UL ❑Public 1 or 2 Famil Dwellin - No. of bedrooms —9 Town OF 55e 11 III BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 0 3 _' 03 = 0 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 12 I' 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) 98,x9 E�v tign S'd A 6 , Feet / 0 0 Feet Capacity VII. TANK in allo s Total # of Prefab. Site Fiber- Exper INFORMATION g Gallons Tanks Manufacturer's Name Concrete con- steel glass Plastic App New Existing strutted Tanks Tanks �p is Tank Q�0 r S LQ1 ❑ El ❑ ❑ El Lift umpTank Q� e ` S El El I I. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage s stem shown on the attached plans. Plumber's Name: (Print) Plu b is Signature: (No St UMPIMPRSW N Business Phone Number: DA,yA v �' — 7/,3— SY�-6G s / Plumber's Address (Street, City, State, Zip Code): _ S GLE /� IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitar Permit F e (Includes Groundwater RIssue Iss g Agent Signature (No Stamps) X Approved E] Owner Given Initial /A Surcharge Fee) ` t Adverse Determination [ 115 il 6 X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: SHD -6398 (H. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Ruildings Divi ion, Owner, Plumber Mog T - H P ©PEAT Lr N 3 1 5 3 is ` . ALT,gM I � I ALT' 1 SITE I 1 1 A � tT� � n 1 R. I � I Bs z n� W PRoPoseo o HOUSE rn 100 GAL S. � � rn 0 y Z ,3 ?C 7$ ztj LTgI4noe S /DE WrrvOCr? ��P.tNC�ES A 6 3 31.8 rTlsrC S'C'ALD 1 _ L ( ©' A am Q BfA =T ®P or 2-" PVC- PIPE EL /00.00 �ALT, =7oP or z" Pv( QiP gL, 108. 300 .PRAWI&)b pie 4w -PaTQl G K LE OEeTV rr� p�o�c .a /' 1 1 4a l v y o 4U6 -5 01+ LLF Y U d c w / ;a , f40 u LTO N w I SI-10 8 Z S© rn E e S F i W I: A �Z,/ 7 Z/ ,� rl v rw r f - j1vs veCT /o AJ ApoeoX. 6 INA5 y` PVC VENT t2NSP,_'cr/ofj 0 PPeoX, 28 C� �►� � � 100.00 �y �� S /OrW1N�OE J6" c,�amBcQ sl�c w1N o E EC o 98. Z9 cN�met� � �w��� L EV 5 _ 0 I9olAl1) fiVF X86 v ,4Lc6Y Vi cw Te 1400 i 0r W L S'om 6esCr W E SyDZS - A' 9 2/7Y/ Wisconsin Department of Industry SOIL AND SITE EVALUATION Labor and-Human Relations Page / of Divis!on 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 S7, 6 percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # (� 7 a -- APPLICANT INFORMATION - Please print all information Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). C^ 12 • 2O , Property Owner JJ Property Location tom+ ✓ / 7/ iC GC�r/ r 711 Govt. Lot N& j 114 1 /4,S ,? y T 30 ,N,R o2U 0') W Property Owners Mailing Address Lot / #!� Block# Subd. Name or CSM# p city Zip Code / Phone Number Nearest Road 0�(o 7 /.S ) � s�8o ❑City ❑Village �. 6S �, 7� le New Construction Use: ErResidential /Number of bedrooms K Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow gpd Recommended design loading rate . bed, gpd/ft trench, gpd/f1 Absorption area required QD bed, ft2 � / trench, ft Maximum design loading rate - bed, gpd/ft trench, gpd /ft Recommended infiltration surface elevation(s) W QA A 9? 0? � ,,j 7 . 4 ft (as referred to site plan benchmark) f 1 Additional design /site considerations Sfen I rent A Ps i"ec�•ti e rlei/ 6cc� use oj -/ Ae S9n oe- t Parent material / A 5Z ACia � G7ri t � Flood plain elevation, if applicable A ft Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank Unsuitable for system S U RI S ❑ U Er S ❑ U & S ❑ U Ff S ❑ U ❑ S ca 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 � F li d .-3 /Vo.t /r .� r r i.J • S` . �i Ground 8 A 7 , r' 13 111oN—Z elev. Depth to limiting factor Remarks: Boring # J 0-2 lee 1J I'll A — /1Ie)NC_ Ground l elev. Depth to limiting factor �- *&__in. Remarks: CST N ame (Please Print) Signature y I p \ u I Address Date CST Number Pa 3� V3 N, A / ,,aer�j A/ Lid' O p /c ol °Sfa \ P o? �� P!/C P p B6 60� ' g S LA rb 0 0 Lerrtif; ors OeI6INPL � 2E� h Teti-. h log LZ 1:4 06 Zoe T 9 SILPe . 'COf' k4t"ck Le,IPr4 lJ ra10 -A y gy= 777cmas J^ S e _ AM,1 ?6� s4e,t-7ar R cad CS % 07 O � udso , W r, s N SW v l/Ey v'e.> '7e-u, l Lof To of S � Se�o l, So,MP l.J %, .- V62a2S �� Ste+ � Se o25/ T 30 N 2 c7U c,/ l TE S) sy�- d6s/ 36 • PAGE OF PUMP CHAMBER CROSS SECTION ARID SPECIFICATIONS VENT CAP 4'C.Z. VENT PIPE WEATHER PROOF APPROVED LOCAMIG JUAICTION Box MAWHOLE COVER 2: 2S' FROM DOOR, 12•M11�. wINDOW OR FRESH I AIR INTAKE I GRADE I `f'MtW. I COWDUIT -- _— ____ —___ 10'I'11fJ, \� • PROVIDE -- INLET AIRTIGHT SEAL I I �I I I v APPROVED JOINT A I I I ( APPROVED JOINT W /C.I. PIPE I Ilk W /C.I. PIPE EXTENDwb 3' I II ALC E 3' ONTO 50L10 601E I I I ONTO 3OLID 601L o I 1 I I o w c I I I LLCV.___. FT. PUMP -- " - � OFF 0 CONCRETE DLOCK 3'• APPRC) RISCR EXIT PCRMITTrD GN LJ IF TAWK MANUFACTURER HAS SUCH APPROVAL �ppl SEPTIC 6 SPECIFICATIOKIS DOSE w�t�✓ �5 C P Nt1M9ER OF DOSES: PER DA4 TAWA MA►JUFACTURCR: TANK SIZE: 8190 GALLOWS DOSE VOLUME ALARM MAMUFACTURER: TAN 4 LEJ2T INCLUOINCs OACKFLOW: / 2 © ' 7 GALLONS MODEL IJUM6ER: � CAPACITIES: A =_L ! INCHES OR -� : 5 GALLON5 SWITCH TYPE: INCHES OR 13 GrLLOW5 PUMP MANUFACTURER: 7C9t` I_I,EIle C =_I N CHES OR /3_/• 1 GALLOWS MODEL NUMOER: 137 D - /Z- INCHES OR GALLOWS SWITCH TYPE: A EIZ u tt 7 ►DOTE: PUMP AND ALARM ARE TO OE MINIMUM DISCHARGE RATE i� 0 GPM INSTALLED OW SEPARATE CIRCUITS VERTICAL DIFFERENCE 15ETWICIJ PUMP OFF AAJO.015TRIBUTIOW PIPE S FEET + MINIMUM NETWORK SUPPLY PRESSURE , . , , . . . , , . . FEET + -S FEET OF FORCE MAIN X z 6 2 — F Y o r[FRICTIOM FACTOR.. 1 ° 3 , FEET .= TOTAL OtIUAMIC. HLAD = FEET IWTERWAL 0 MEWSIOW� OF TAWK: � � C /qo ;LIQUID DEPTH 3 7 SIGNED: LICE.WSE IJUM5ER : ; OAT E: -A o HEAD /CAPACITY CURVE EFFLUENT and DEWATERING WARNING: Model 185 should not be subjected to less than 30 feet TDH. TOTAL DYNAMIC HEAD /CAPACITY PER MINUTE EFFLUENT AND DEWATERING 63.55 aEAIEB___. __49 .� 4a._. _.07x6 _...9a_. .137- 13tL.__ _ 161___ __..tai.__ ._ 16.5__._._186__. —j n. -- m—, or: LA 1lr. i or ..Lk1 Hr .101::: 0 '01; .40 00.. 441 Lb► 40. ibl.. go, 'LlIt. Ilk AN, 4* Ak er . 6 11 47 18 ': 43 Itel: 71 175 's 101 394 ". 106 401,, 61 131... 61 131 511 0.: 155 :1127 11111 aBT: :> 20 P !'i8 .: 7 25 Y6 "> 38 1 'i' 82 310'i 59 $2$ "'i' 60 !$$7 S8 :y¢6 136 " 6 140 2s a 6oi >! 74 280.:; s7 318;: 59 n$.­ `! 58 !.920. its A k:i t33 1181:> 30 65 PIBIk SS 201 :: 58 :210,.' W !31 "' SB .x`10. tPt i116 1P7 4i'< 40 IB 1741'. 48 1721 SS X266 75 ;' 58 o 105 l: 114 tot tj 50 :,:.1524: i 21 80 33 1 1 6 : St ;191 SB "aiB 68 124 90 4111 100 819 'i LJ 60 .104: 15 57- 43 :.161**: ` 36 435' 58 210. 71 268 85 U.: .1' 70 30 :114 . 10 52 :101' 6 1 :16,4.70 366i' 11 80 :24.aa: 14 63 45 114 28 10.e 54 M 90 2XA3 32 .121 2 >G:i 37 .1AQ 34 too >aoi6. 11 110 32:04: 7 32 105 LockVWl: 21' 22' 19.25' 23' 26' 56 66' 87' 73' 115' 91' 112' 100 30 95 28 90 26 85 l 24 80 r" 75- 186 0 22 1� 70 x U 20 a 65 165 0 18 60 55 , 16-- 163 50 14 45 12 40 kk 185 35 10 30 j 189 i 8 25 6 20 161 15 188 4 i 10 2 98 5 42 Q8 53.55 13 ,139 57.59 0 U.S. GALLONS 10 281 30 41 50 60 1 70 80 1 90 100 1110 120 1130 140 150 160 LITERS 80 160 240 320 400 480 560 640 "I 0 FLOW PER MINUTE Note: For Head Capacity on Model 112, industrial column - explosion pr000f pump, see FMO219. s ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer PA TR /C K E( /C /? T k/ Maillsig Address 762 5'f 2Fte,, 2.gn/ R/3 . 11U,010M Property Address 2 �� L y � A10 A (Verification required from Planning Department for new construction) City/State 110uLTUAr Wt' Parcel Identification Number ?O — ,Z d 3,6 — 70 LEGAL DESCRIPTION Property Location AL42_ /4, `SLU 4, Sec. , T_30 N -RED W, Town of s%. c7gS6a�fi� Subdivision Lot # -AIA— Certified Survey Map # Volume . Page # Warranty Deed # Volume /� q _ , Page # 53 L-1 Spec house ❑ yes K no Lot lines identifiable 9 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 master plumber, journeyman plumber, restrictedplumber 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. SIGNATURE OF APPLIeANT 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 opeerty described above, by virtue of a warranty deed recorded in Register of Deeds Office. 6tl / / IGNATURE dF APPLIC 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