HomeMy WebLinkAbout030-2057-90-000 '!k
ST. CROIX COUNTY ZONING DEPARTMT
AS BUILT SANITARY REPORT ^�A
Owner , =- 14,( E RL_/ r7 f �
Property Address ND T T -9,99
City /State eu�TlZ�� /1�. ` �d g2 S' Oi rr , �y
Legal Description: -
,r
Lot 4_ Block --7 Subdivision/CSM #
%a A Jc— %4, Sec. Z2, T.7
ON
-RIOW, Town of Si, PIN # 0340-.40S7 - S'lJ - -aclj
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION:
Tank manufacturer e /2a-: Size ST/PC /are/ Setback from: House Well _ ZkO PAL
Pump manufacturer dh Model
Alarm location &A
( RQLDING TA NKS ONLY)
Setbacks: Se v><ce ro — -- AtenLtQ—fr air intake Water Line
Meter location
SOIL = ABSORPTION SYSTEM
Type of system: TR�NC�I Width Length Number of Trenches
Setback from: House Well 100 PAL Vent to fresh air intake _IeV ?�-
ELEVATIONS
Description of benchmark - Elevation /DD O
Description of alternate benc ark TQQ lY//J Z a T :57 1tt Elevation
Building Sewer 5 ST/HT Inlet 13 ST Outlet M, PC Inlet
PC Bottom Header/Manifold 7 Top of ST/PC Manhole Cover y
Distribution Lines (1) 9 9, / 3 0) _ 1 2 L 13 ( )
Bottom of System (t) S 5 (2) �'_5 S 5 ( )
Final Grade (1) 9 p (2) 1 ( )
Date of installation / / / Permit number "3 102. �F State plan number /I/'.4
Plumber's signature Ad License number J:Z/ Y/ Date/ / / 9�
Inspector -&Cc
Complete plot plan ■*
' Wiscon §in Department of Commerce PRIVATE SEWAGE SYSTEM Count
Safety and Buildings Division bT . CROI X
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitarl�ecr J :
Personal information you provice may be used for secondary purposes [Privacy s.15.04 ( 1)(m)]. V GG
Permit Holder's Name: ty Town of: State Plan ID No.:
ERLITZ , KEVIN AND ANN �`�'�. i jai
CST BM Elev. Insp. BM El v.: BM D scription: Parcel &Jb : 2057 - 8 0, A2 00
TANK INFORMATION ELEVATION DATA A9800487
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic wa Ben o ,S.Z /D
Dosing 6� � , x.2- - 1
Aeration Bldg. Sewer r- f '9. 4 /�
Holding St/ Inlet (Z I F-7
TANK SETBACK INFORMATION St/ * Outlet (� ,j '71? 76
TANK TO P/ L WELL BLDG. AirrIntake ROAD Dt Inlet
Septic Z,� NA Dt Bottom
Dosing NA Header / Man. �•?✓7 Co °J Z
Aeration NA Dist. Pipe ` �1G � O f
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade 2,9 q8 7
Manufacturer errand $ 4, l
Model Number GPM T q(, :>
TDH Lift TDH Ft
Forcemain Lent .
SOIL ABSORPTION SYSTEM
BED / TR — Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIM NSIONS - 7S__ DIMENSION
SETBACK
SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION Type O -2-71 (�� OR UNIT CHAMBER Model Number:
Syst
DISTRIBUTION SYSTEM / �i�
Header/Manifold Distribution Pie , x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length / Dia. Sparing
ji
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 ❑ tJo
COMMENTS: (Include code discrepancies, persons present, etc.) N CJ -/-
LOCATION: ST. JOSEPH 27.30.20.557,NW,NE 1392 HAGGERTY STREET(�,A �)
At4 - & V1 -pop j
]Z;) ((01gg
Plan revision required? ❑ Yes RNo
Use other side for additional information.
SBD -6710 (R.3/97) Date I nspectori&g nature Ce rt No.
511 3
V isconsi n Safety and Buildings Division
SANITARY PERMIT APPLICATION 201 E. Washington Ave.
Code In accord with ILHR 83.05, Wis. Adm. Coe P.O. Box Wl
Department of Commerce Madison, WI 53707 -7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 1/2 x 11 inches in size. 51 • Cr - rK
• See reverse side for instructions for completing this application State Sanitary Number
The information you provide maybe used by other governm nt agency programs Check if reviefon'fo previous a lication
[Privacy Law, s. 15.04 (1) (m)]. ' a of ❑ Q State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT A INF RMATION
Property Owner Name Property Location
12 7 &) 1/4 S - 1/4, S A7 T ,70 , N, R 0 0 E (O W
Property Owner's Mailing Address Lot Number Block Number
r
C
it , State ip Code Phone Number Subdivision Name or CSM Number
L L 0- Q ( 7 1S —
1 . TYPE B 1L ING: (check one) ❑ State Owned ❑ it Nearest Road
❑ village
Public X 1 or 2 Family Dwelling - No. of bedrooms Or Town OF 57, I AA2� - Ar �4 - 17,
111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) a? 30. Q 5,58
1 ❑ Apartment/ Condo 0 , — RV — 00
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. KA New 2. l] 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 [$!Seepage Trench 22 ❑ In- Ground Pressure r i 42 E] Pit Privy
13 E] Seepage Pit 0' 3 7S 43 ❑ Vault Privy
14 ❑ System -In -Fill 9f Ok
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
Y15 0 5 - 25 - 0 16 1 Q Feet , D Feet
VII. TANK Capacity
INFORMATION in gallons Total # of Manufacturer's Name Prefab. Con- Fiber- plastic Exper.
New Exist in Gallons Tanks concrete structed steel glass App.
Tanks Tanks
e ti or Ing 7 an 60 1 EC / S' 19 ❑ ❑ ❑ 1 ❑ ❑
Lift Pump Tank /Siphon Chamber I ❑ ❑ ❑ ❑ ❑ ❑
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 Plum 's Signature: (No , , 't ps / W No.: Business Phone Number:
t -G6 -
Plumber's Address (Street, City, State, Zip Code);
6 t � oz
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater D ate I ssued Issuing ent Signature (No Stamps)
Approved ❑ Owner Given Initial C rj0 W l �harge Fee) / /4A
Adverse Determination O I /V (W b,. � L
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD•6398 (0.11/96) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Pkm&w
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k scons!W Department of Commerce SOIL AND SITE EVALUATION
Divisioh of Safety and Buildings Page of
Bureau of Integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code
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 � ,
C� 0 j
percent slope, scale or dimensions, north arrow, and location distance to nearest road.
Parcel I.D. #
APPLICANT INFORMATION - Please �a '
h1�1 /info ma /f;.,� Reviewed by Date
Personal information you provide maybe used for se c f purpo w, s. v9. ` 1) (m)). I lO J� p�
Property Owner V o erty Location
. Lot N14/ 1/4 /,/,1�114,S 7 T 30 , N,R a+DU alter) W
Property Owners Mailing Address z. T CROIX I, Block# Subd. Name or CSM#
137 G 1
�,4 a COUNTY i ;....,
Cit / y � State Zip Code ne um City El Village R Town Nearest Road
/% Orr /�Oy, L✓ ?. U .1 f- n et
19 New Construction Use: Residential /Number of bedrooms Addition to existing building
❑ Replacement ❑ Public or commercial - Describe: A- r , t /
Code derived daily flow gpd Recommended design loading rate - .5 bed, gpd /ft - 6 trench, gpd /ft
Absorption area required ?W Q bed, ft �Otrench, ft Maximum design loading rate S bed, gpd /ft " � trench, gpd /ft
Recommended infiltration surface elevation(s) ao ft (as referred to site plan benchmark)
Additional design /site considerations
Parent material . /CLCIG 7,& _ Flood plain elevation, if applicable ft
L : u [__ 1 Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
Unsuitable for system [R S U RS El U ® S 1:1 U (� S❑ U ❑ S I U ❑ S 9 U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure
in. Consistence Boundary Roots GPD /ft2
La -- / 7- 0- - 7 10ye 3
Munsell / Qu. Sz. Cont. Color l Gr. Sz. Sh. Bed Trench
f PV7,54 AC
Ground 3 3 -7 2 , - 5 - e y/y -- /
el ev.
V6 1 Depth to
limiting
,fac�tgr
�-r� in.
Remarks:
Boring #
z'7 51
v �s ,e VAI Pr
Ground
elev.
9?�fft.
Depth to
limiting
fac o
+YLin. Remarks:
CST Name (Please Print) Signature Telephone No.
;Zo k" a t ✓C X71771' 141
Address Date CST Number
PROPERTY OWNER =`r fal n/7 Lr Z OIL DESCRIPTION REPORT Page of
PARCEL I.D.# 0-�O -2162°' 9Q
Boris # Horizon Depth Dominant Color Mottles Structure 2
Boring Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
7 I -8 0 h L r A r,✓ /10
e S-
.7 -7r 70 2 5�_* SL e�stlic- P'16- 9 61 / . s- v
elev -- -- - - - -- - - - - -- - - - -- - f - - - S` fo
ft.
Depth to - -- - -- - - - - -- -
limiting
facto - - -- -
Remarks:
Boring #
o-lo /d
- - -- n- il le v1j
St—
Ground
elev. - - - - -- - -- - - - -- -- - - -- -- - -
Depth to - -- - - -- -
limiting 5 `
facto
°tYin.
Remarks:
Horizon Depth Dominant Color Mottles Structure GPD /ft
in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots
Bed ,Trench
Boring #
Ground
elev. - - -
ft.
Depth to
limiting
factor
in. Remarks:
Boring #
Ground
elev.
ft.
Depth to --
limiting
factor
In.
Remarks:
SBD -8330 (R. 07/96)
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer I'EI (Al it C RL / T Z
Mailing Address 13 � y Af,,4GG E/? i `j Or L Ta A r / : SV0
Property Address ejw7v �
(Verification required from Planning Department for ew �onsction) '
City/State ty —AnuLT'oIL'_ PVi • Parcel Identification Number 030 -
LEGAL DESCRIPTION
Property Location AIW %,, ' /4, Sec. 9 , T 30 N -R�p W, Town of 5 �, � b LdW AI .
Subdivision Lot #_.
Certified Survey Map # Volume , Page #
Warranty Deed # � r�S,� y`� Volume AO 9 , Page # / p�
Spec house ❑ yes W no Lot lines identifiable Dd 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, 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 y septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
days of ee xpiration date.
/D / /
IGNATURE OF DATE
OWNER CERTIFICATION
I (we) ertify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
the prope escri V ove, by virtue of a warranty deed recorded in Register of Deeds Office.
'ff GNATURE OF APIRE
ICA 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
V
S & N LAND SURVEYING -
HUDSON , WISCONSIN 54016
( 715) 386-2007
Nome :rn"s'. iruseman
Address !?, R. 1 Box 201 Stillwater Minn. 55032
Description j,r :l k, 7 ti:)u I ton
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