HomeMy WebLinkAbout030-2038-80-100 f
NOTICE: Please Provide the following:
A plan view sketch showing everything within 100 feet of the system.
• Two horizontal reference points to center of septic tank manhole cover.
Show alternate benchmark, if applicable.
PLAN VIEW
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INDICATE NORTH ARROW
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$, WI 54023 -C
CELL 651- 470 -17°
GOODI CO MPANY
IM401 s�rlers
(s) PU•JMBING • HVAC • PIPE • VALVES • FITTINGS • WATER WELL • INDUSTRIAL SUPPLIES
www.goodinco.com
Minneapolis St. Paul Duluth Detroit Lakes St. Cloud
(b 12) 588 -7811 (651) 489 -8831 (218) 727 -6670 (218) 847 -9211 (320) 259 -6086
Brainerd Medina Fargo Rochester Eau Claire
(218) 828 -4242 (763) 478 -8994 (701) 298 -3210 (507) 529 -'1284 (715) 830 -1800
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S'I'. CROIX COUN'T'Y ZONING DEPAR'I'MEN'I'
AS RUILT SANITARY RI;1'OR'I'
Owner
Address 3f�' r CRSO/�! 7;
City /Blatt �D 7" ,J,r'
Legal Description:
Lot -- I Block (& Subdivision/CSM It
y, '/, ", Sec. JS, T3,0 N- R_2QW, Town of
PIN it .3
0d-- .243$•-80 - jam
SEPTIC TANK — DOSE CHAMBER — If G TANK INI+'on
TION:
Tank manufacturer eMUrJ Size ST/PC /
Pump manufacturer =N,¢ Model � Setback from: Douse �O Well � P/L
'Alarm location V,4 MA
G TA NLY) Setbacks: Se Vent to fresh air intake Water Line
Meter location
Alarm location
SOIL ABSORPTION SYSTEM:
Type of system: use &
Setback from: Souse ec 14 Width __Z_ Length ,5 7 Number of Trenches �_
0/' Well /ya p/L e , 9 Vent to fresh air intake
ELEVATIONS:
Description of benchmark &7 I of Elevation hod. c
Description of alternate benchmark 4(AU i,y- Elevation _ 91,!F3
Building Sewer _ � ST/HT filet — 9Z,a ST Outlet 0 0,63 PC Inlet X,¢
PC Bottom ----N– Header/Manifold M, 3 Top of ST/PC Manhole Cover
Distribution Lines (I) gy, /_
Bottom of System (�) j? OD (Z) ;1 0 0 ( )
Final Grade ( ry' /, p y (� �� 0 0 ( )
Date of installation 7 &Pcrniit number - 7,2 State plan number j q
Plumber's si g nat ure tz License number /) • Date 4ilk
Inspector
Complete plot plan •r
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Wisconsin Department of Commerce
Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count
INSPECTION REPORT ST. CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary2 rmitN :
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: ❑ City ❑❑ Villa e Town of: State Plan ID No.:
P ETERS, E. JAMES ST. JOSEP
CST BM Elev. Insp. BM Elev.: BM Description: Parcel Ta No.:
030- 2038 -80 -100
TANK INFORMATION ELEVATION DATA A9800428
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic
�Z
n
("
c,. ., �;� "L Benchmark '
Dosi ng
Aeration Bldg. Sewer !) a
Holding St/ W- Inlet
TANK SETBACK INFORMATION St /++t- Outlet -7/
TANK TO P/ L WELL BLDG. Air I to ntake ROAD Dt Inlet
Air
Septic NA Dt Bottom
Dosing NA Header / Man.
'�
Aeration NA Dist. Pipe /3.5-1?i
3. tiq
Holding Bot. System �y' -7 y
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
r
Mod .I. Number,,-" N GPM
TDH I Lift,/ Friction"' S st,. TDH Ft
L oss Forcem, in Length Dia. Dist. To Well
SOIL BSORPTION SYSTEM
BED /TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia.. � Liquid Depth
DIMENSIONS 2) J DIMENSION
SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM
LEACHING Manufacturer:
INFORMATION Type of �� CH T CH Modef.Number:
System: U `� '/O/ /Xp '
DISTRIBUTION SYSTEM
Header /Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length Dia. 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 g p E] Yes ❑ No E] Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
CS /)v X11_71'7
LOCATION: ST. JOSEPH 25.30.20.482D,NW,NW 220 COUNTY ROAD E
(�� t S
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD -6710 (R.3/97) Date Inspector's Signature Cert. No
Safety and Buildings Division
Visconsin SANITARY PERMIT APPLICATION 20 E. Washin Ave.
Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 -7%9
• Attach complete plans (to the county copy only) for the system, on paper not less County �� C�OZ x
than 8 1/2 x 11 inches in size.
• See reverse side for instructions for completing this application State Sanitary Permit Number
3 2o Zz; 1
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
Lc C (U 1/4 IU 1/4, S T �0 , N, R �4 E (or�
Property Owner's Mailing Address Lot Number Block Number
8 Z o sT•
Cit State Zip Code Phone Number Subdivision Name or CSM Number
II. TYPE 0 F FILM N G: (check one) ❑ State Owned ❑ C it Neare oad R;to
❑ Village
Public fa 1 or 2 Family Dwelling - No_ of bedrooms Town OF S , r o
III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
1 E] Apartment / Condo V�I J - 7,0 - — 1(xD
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. X Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
System System Tank Only 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 [ Tank
12 ® Seepage Trench 22 ❑ In- Ground Pressure r 42 [] Pit Privy
13 E] Seepage Pit X 6 43 n Vault Privy "Ite 14 ❑ System - In - Fill Ca. i' iOJ� ,w , a
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
/ Q 1 15 18 Feet ' Feet
VII. TANK Capacit gal Total # of Prefab. Site Fiber- Exper.
INFORMATION g Gallons Tanks Manufacturers Name Concrete Con Steel glass Plastic App
New Existing structed
Tanks Tanks
Se tic Wo d U ❑ ❑ ❑ 1 ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ 1 ❑ 1 ❑ 1 ❑ 1 ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage s stem shown on the attached plans.
Plumber's Name: (Print) PI b is Signature: (No Stamp r MpiMPRSW No.;) Business Phone Number:
i - -665
um er's Address (Street, City, State, Zip Code):
L t1 �r1U
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved 5 tary Permit Fee (includes Groundwater D ate Issued Issuing Agent Signature (No Stamps)
Approved E] Owner Given Initial � co Surcharge Fee)
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Adverse Determination // �&-
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SOD63M (8.11/96) DISTRIBUTION: Original to Coonty. One copy To: Safety & Mr7dngs Diw6ion. Owner. Phwaber
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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
inglude, but not limited to: vertical and horizontal reference point (BM), direction and C "/
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I. D. #
APPLICANT INFORMATION - Please pr- / ( �a 7 Revi ed y ate
Personal information you provide may be used for seco axdur�6ses (Privacy Lady „s 1104 (1) (m)).
Property Owner \- r� ��� , s r \ operty Location
/y74n / Lot 1/4 1 /4,Sar T ,N,R ,,?U :QW) W
Property Owner's Mailing Address t Block# Subd. Name CS #
S 3 .S - 9 Ud£(- AS
w
City State Zip Code, "_ ". Phone grfv Nearest Road
Liz 53�0i ' 1 `" jlb� City El Village� Town
❑ New Construction Use: ® Residential / I4U_1mb ooms Addition to existing building
R ❑ Public or commercial - Describe:
Code derived daily T3
flow gpd Recommended design loading rate .7 bed, gpdfft gpd /ft
Absorption area required /D bed, ft �0.3 trench, ft Maximum design loading rate
g g bed, gpd/ft gpd /ft 2
Recommended infiltration surface elevation(s) c'1 ft (as referred to site plan benchmark)
Additional design /site considerations
Parent material O&V_AjaS 4 Flood plain elevation, if applicable IYX ft
S = Suitable for system Conventional Mound In- Ground Pressure SAT -Grade System in Fill Holding Tank
U = Unsuitable for system N' S❑ u N ❑ U ,S ❑ U ® ❑ U I ❑ s N u ❑ s R u
SOIL DESCRIPTION REPORT
Boring Horizon Depth Dominant Color Mottles Structure GPD /ft
g Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
I
10 e / - ---- --
s -� 10ve CAj oe _
Ground .� - A -- ---- -- hl m 'e- 7 .
elev.
9L�ft. 7/02 /0 V13
Depth to
limiting
factor
Remarks:
Boring #
/t1
7 -.? 1& 01
Ground �S D
elev.
8 �
Depth to
limiting
-� actor
/O in. Remarks:
CST Name (Please Print) Signature . / Telephone No.
7�
Address Date CST Number
Sa 4,///
1
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer J L-s t gS
Mailing Address 3 h �efi e� s v� �I oQ \k S y o g Z
Property Address a!D G % L/ /Ijo
,,JJ (Verification required from Planning Department for new construction)
City /State J1dai.- yiy j J Parcel Identification Number 030 -203g ::M
LEGAL DESCRIPTION
Property Location AW '/4, _ &W '/4, Sec. z s , T -R 1D W, Town of .5T, c7t sg:�2,M
Subdivision , Lot #
Certified Survey Map # y!? / 9 , Volume 6 , Page # 19 7
Warranty Deed # 583Ii , Volume 13 g o Page # J
Spec house ❑ yes L"no Lot lines identifiable LYyes ❑ 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 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
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.
q / tck /QSr
SIG TURF 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.
Q / /0
SIGN RE 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
401.96
CERTIFIED SURVEY MAP
LOCATED IN PART OF THE NW 1/4 OF THE NW 1/4 OF SECTION 25, T30N, R20W,
TOWN OF ST. JOSEPH, ST. CROIX COUNTY, WISCONSIN.
OWNER
AMANDA DAHLKE
ST. JOSEPH, WI. FILED
111985
-N
APR :;.,, �
..
JA 93 O' CONNELL ; y
R"Mw of Deods / `
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LEGEND
1" x 24" IRON PIPE WEIGHING
O BEARINGS REFERENCED TO THE SOUTH LINE OF
1.68 LBS /LIN. FT. SET. THE NW 1/4 ASSUMED TO BEAR N88 0 52 1 43 11 E.
COUNTY MONUMENT
APPROVED S CALE IN FEET
100 50 0 100
APR 0 4 1985
un platted _lands_owned_by_platter
ST. CROIX COUNT'
C"PR HENSWE PARKS PL,4N,*0
AND 20WNC C0.*tWrr"
S88 0 52 11 W 430.00'
I=
h
I d i0
CD LOT 1 ti
I w z r iCD
l a N r m o z i n.
o
I� 0 159,049 sq.ft.) INCLUDING R/W m
I E � w 3.651 acres ) 1°
= _ o cn z rn
m U ' ;
�� 138,200 sq.ft.) EXCLUDING R/W m r i;
I� 3.173 acres ) �n
IQ
I.-. w z K
Irt v
o ❑ garage CURVE DATA o r
o_
0 = 14 °41'16 1
house R = 987.98'
SO100714511E L 253.27'
C = 252.58'
N88 15 7.00' CB = S83
64.27' 114.24' _ �—
_ — — t •P N88C5o 1 I