HomeMy WebLinkAbout030-2063-50-000 r
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count
Safety and Buildings Division bT. CROIX
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) ld Sanitar r�i.:
p�e
Personal information you provice may be used for secondary purposes [Privacy s.15.04 (1)(m)).
Permit Holder's - Name.- ty Town of: State Plan ID No.:
POND, STANLEY �'�i'�, I J
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel V3 �� -000
TANK INFORMATION ELEVATION DATA A9800570
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing
Aeration Bldg. Sewer
Holding St /Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
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
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
Forcemain Length Dia. Fi Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
D IM E NSIONS DIMENSION
SETBACK
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION Type Of CHAMBER Mo Number:
System: OR UNIT
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 ❑ Yes E] No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: ST. JOSEPH 34.30.20.599E 1282 HIGHWAY 35
Plan revision required C] Yes [] No
Use other side for addi tional information.
SBD -6710 (R.3/97) Date Inspector's Signature Cert. No.
Safety and Buildings Division
'- - SANITARY PERMIT APPLICATION 201 W. Washington Avenue
If6consin P O Box
In accord with ILHR 83.05, Wis. Adm. Code 302
h
Department of Commerce Madison, WI 53707 -7302
• 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. S ?'
• See reverse side for instructions for completing this application state sanitary Permit Number
P 2
Personal information you provide may be used for secondary purposes ❑Check if revision to previous application 3�2 ?SU
(Privacy Law s. 15.04 (1) (m)]. /a p ^ W t 35 State Plan I.D. Number
L APPLICATION INFORMATION - PLEASE PRINT ALL 1 FORMATION
Property Owner Name Property Location
D le 1/4 1 /4, S J? 41 T 2 4, N, R oZe E (or)60
Property Owner's Maili6g Address Lot Number 3 B oc �uiber,
City, State Zip Code Phone Number Subdivision Name or CSM Number d('
( ) G f»
II. TYPE Of BUILDING: (check one) ❑ State Owned Cit Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms it,,*/ ° To vv a g OF d $a✓
111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo 4 26• 599 ' 03
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. Ill New 2, ❑ Replacement 3 ❑ Replacement of 4 ❑ Reconnection of 5_ ❑ Repair of an
-- - - - - -_ System - Tank Only ------ -- --- - -- Existing System Existing System
-------------- - - - - -- -------- - - -
-- - -- 9 y - - --
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 R) 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) Elevation
some 9Slo Feet Feet
VII. TANK Capacity
INFORMATION in gallons Total # of Manufacturer's Name Prefab. Site Fiber- Ex p er.
New Existin Gallons Tanks Concrete Con- Steel glass Plastic A p p
Tanks s Tanks ADd
strutted
e tic Tan I 7et�.�J ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber 11 ❑ ❑ ❑ ❑ El
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sew ge system shown on the attached plans.
Plumber's Name: (Print) / Plumber's Signature: o 57/ Stamps) M PRSW No.: Business Phone Number:
r `. Q ra ✓�Gfi /h G!i o� —3 �6 J�l.�!
Plumber's Address (Street, C City, State, Ip Code :
,2 ,'
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater D atelss a Issuin Signature (No Stamps)
2kA roved ❑ Surcharge Fee)
pP Owner Given Initial dU /J
Adverse Determination `�
V.CONCIITIONS OF APPROVA / REASONS FOR DISAPPROV L:
4 e-2 a s-rkv
SBD- 6398 (R.11/97) DISTRIRUTI N: Original to County, One copy To: Safety ftluildings Division, Owner, Plumber �_�
,v � •' ,d dQ G �� �� la 7" 3 � s m Uo ll /3q 5 .� T34{O°? v74 cf�J T w,r/ c� �" S�`,,7os � • �(
ff 2 �-Aa e !( �ia�t► �.COFfiC� 8
�b a S
---- -' - rip U fi
�
'fo 5; to
b
1
f
i
,r '` �' "�-� �l%.d • . ®• f ^_ 46,8 p:J i0
Q Q
erI
19.31 59.66
1
I
U \
Cid
cr
i
10' ,.- 63.97'
i
N ( I eo •. D
FT I
v
� � N
m �
m tit
U) 0
EX
DR/ v/E WAY
Ul
O
Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page I of 3
Labor and Human Relations 9
Division of Safety &Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but Sr • z I�_Ql UC
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION— PLEASE PRINT ALL INFORMATION R W D B DATE
PROPERTY OWNER: PROPERTY LOCATION &AX 01
ptv GOVT. LOT 1/4 -- 1/4,S34 T 7% N,R Z Z E (O(
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # I SUBD. NAME OR CSM #
1319.9 L TN- STi' - No'Z_1'H 3 - eSM \)t t_ 1 ?9 ►3
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE MOWN I NEARESTROAD
S�1lUNt�`'`Lit, "IV . SS $Z ( (_3 lv q36 & ( 4q - 1 ST. $�j S 1A STvr)� VM D 3S
K New Construction Use pCJ Residential / Number of bedrooms y [ ] Addifign to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow 60,o gpd Recommended design loading rate bed, gpd$ • 8 trench, gpd/ft
Absorption area required SSf3 bed, ft — 1 S O trench, ft Maximum design loading rate • "7 bed, gpd /ft • $ trench, gpd/ft
Recommended infiltration surface elevation(s) q b • O ft (as referred to site plan benchmark)
Additional design / site considerations 1Z NEivtj 1 - L' 1< 7 Z ' L` 0 &L U 1'D 0 VV PC(- t� Ep
Parent material L0NMr1 0 \-) M Flood plain elevation, if applicable lei - A - It
S = Suitable for system CONVENTIONAL MOUND IN GROUND PRESSURE I AT GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable fors stem NI S ❑ U ®S ❑ U ®S ❑ U ®S El 0S ❑ U ❑ S W 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
p -1Z toy -!23/3 - S1 S
,Mm `7 fL 316 — si► _
Z wt`Rr c5 s •�
Ground 3 3 `1•SVIZ 3 /(/ Sg o S y►► — ,1 .�
elev.
1 01•b ft.
Depth to
limiting
factor
> 103 '
kti
Remarks:
Boring #
YY\ v �r a. S 1 v� • S
Z t.1 -3S �•SYR 3!y 1 S d G� sg wl CS •7 $
3 38 a 3 ► D 7 R V/ - S Gt- O S9
Ground
% e
Depth to
P
limiting - 1
factor t n
9 3' for I—
C X
Remarks: /CE ,
T Name.— Please Print Phone: ( Z
Arthur L. We erer 715- 425 -016
egerer Soil Testing & Design Service -P.O. Box 74 River Falls,WI 54022
Signature: l Date: CST Number:
Ct � z �� -z�t8 - ly_CT7 M00
PLOT PLAN Pa 3 of 3
SCALE 1 "= 3Q '
_'�tovSqE TO SE Wv lM� ZS' '1 _ - - --
_. B.z fn
aL 2lU r B fts 01 6 A
13.3 Ice -►2' � � I
L-L Qt 8
� ew+ - et. �oo.o' o►v s�tt�� z� '
�Z� y VNL� 3 S
To
wfc.E )� P,�.lwlu� y,Z" c�V �t oV� 1 btu 8�T•tow: �I Pis . - _ --
( 715 ) 425 -0165 14 00576
CST Signature Date Signed Telephone No. CST #
STC -105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER -Sc2 "tile
MAILING ADDRESS
PROPERTY ADDRESS �� T
(location of septic syste ) Please obtain from the Planning Dept.
CITY /STATE
PROPERTY LOCATION 1/4, 1/4, Section 3V , T SO N - 90 W
TOWN OF ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
CERTIFIED SURVEY MAP 7�.2:f-, VOLUME / , PAGE ,LOT NUMBER 3
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 licensed septic tank pumper. What you put into the system can affect the function of the septic tank
as a treatment stage in the waste disposal system.
St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost
of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that owners of all new systems agree to
keep their system properly maintained.
The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner
and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1)
the on -site wastewater disposal system is in proper operating condition and (2) after inspection and
pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum.
I/We, the undersigned have read the above requirements and agree to maintain the private sewage
disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR.
Certification stating that your septic has been maintained must be completed and returned to the St. Croix
County Zoning Officer within 30 days of the three year expiration date.
SIGNED:
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
i
1,
327625
LEGEND ASSUMED
BEARINGS
SECTION CORNER MOMIMENT NE CORNER
SECTION 34
T 30N, R20W —
0 1" X 24 IRON PIPE WEIGHING 1.68 # /lineal foot, �c'
EXCEPT THOSE PIPE SET ON THE MEANDER LINE OF \ �6
LAKE ST. CROIX ARE 1" X 48 IRON PIPE \` w
WEIGHING 1.68 # /lineal foot. — \may ' 'N
• 1" PIPE FOUND 4, `wqj.
SCALE 283 ° 00' 2 0\ \ M
100' 0 50' 100' SOUTHWESTERLY RIGHT -OF -WAY LINE � �' \N OD
r — =- 70 O' N
48.69' 2 � 4
1 N S38 2'W 3
si 2270 °00' �' 3 A"' 5.00' 'sv000a,,
e'� �Ji 2 '� 4 vi N POINT OF 229 °50'40'
327625 a '" ^� Z.A$ AC y ') BEGINNING
270 000' a,°�3 3 i, 3 ^�' \
Q+ DETAIL OF THE SOUTH- 0 °j h
` C WESTERLY RIGHT -OF- ti N N ^ h
ti y
WAY LINE. O �� ^ \ �� M
2 F-
�uH ZT 1915' o� 2.75 AGE 0 �1 o w
Am UQWW ��t GOVERNMENT L T ^ drj .~ w
crdx �' 0 0 h . 4.38 AC I
6 255023'5W
158" � 0 ^� h w
�•�i� AV •p z
OWNER $, SUBDIVIDER: sh o"� N too
GEORGE HOL MB �q F <iN s�92 .9s,
O o a
R.R. # 1, STILLWATER, MINN. 55082
o s�0 .22, N
SURV EYOR :
. 2i� ,* d
FRANCIS H. OGDEN
123 E. EIM ST. .q RIVER FALLS, WI. 54022
°pp ego 4 / >. 32• o_
DESCRIPTION \�ti c" O,6
d
A parcel of land located in Government Lot 1 of Section 34, T30N, R20W, fir.
Town of St. Joseph, St. Croix County, Wisconsin, described as follows: Commencing at the
NE corner of said Section 34; thence Sl ° 37 1 20 "E (assumed bearing) 768.03' along the East
line of Government Lot 1 to the point of beginning; thence N51 ° 28 1 W 308.16' along the
Southwesterly right -of -way line of present State Trunk Highway "35 "; thence S38 5.00'
along said Southwesterly right -of -way line; thence N51 ° 28 1 W 202.69' along said Southwesterly
right -of -way line; thence S2S ° 32 1 W 845 more or less, to the shore line of Lake St. Croix;
thence Southeasterly 890 more or Less, along said shore line to a point which is Sl ° 37 1 20 11 E
843.3 more or less, of the point of beginning; thence N1 ° 37 1 20 "W 843.3 more or less,
along said East line of Government Lot to the point of beginning._
NOTE: ALL BEARINGS ARE RE FFRFNC.F-.n Tn Tiff rT.1\W.DT TXTR n: CTATr T„rT,TV TTT/'W".TA %T 111—