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CROIX COUNTY ZONING DEPARTMENT �--- °� AS BUILT SANITARY REPORT ; Owner` Address City /State �--. – Legal Description: Lot 9 Block ubdivision/CSM # ` '/, A�L, Sec TAN -R21'W, Town of PIN # - SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer Size ST/PC Setback from: House _9 Well .//9 P/L 7 Pump manufacture_ r Model Alarm location (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM Type of system: �-, Width _. 5 -- Length ; 2L Number of Trenches Setback from: Souse Well, ones PAL Vent to fresh air intake ,� ELEVATIONS Description of benchmark - - Elevation Description of alternate benchmark Elevation ,lam Building Sewer 12-? �f ST/HT Inlet l,2 zy ST Outlet Z PC Inlet PC Bottom Header/Manifold Top of ST/PC Manhole Cover Distribution Lines Bottom of System Final Grade Date of installation 9 number _ z State plan number -§1'9z c ' Plumber's signatu License number �2j Date / / Inspector complete plot plan a Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County Safety and Buildings Division INSPECTION REPORT ST. CROIX GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-: Personal information you provice may be used for secondary purposes [Privacy L a, s.15.04 (1)(m)]. 315914 iteATf(j­loIdgrb#ame: j VgQ f Town of: State ID No.: CST BM Elev.: Insp. BM Elev.: BM Description: �., � � Par cel Tax N O.: 1 _S ash 032- 2013 -80 -000 TANK INFORMATION ELEVATION DATA A9800303 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark 5 2_ ay. a Dosing I L, /'95 Aeration Bldg. Sewer . 3Q /p 3 Holding St/ Ht Inlet �3 6L. 79 TANK SETBACK INFORMATION St/ Ht Outlet q4 D2, S-?— TANKTO P/L WELL BLDG. Air to i ntake ROAD Dt Inlet ir Septic ` >��p —� NA Dosing A Header / Man. /O, / 9 9 Z Aeration NA Dist. Pipe Holding Bot. System PUMP / SIPHON INFORMATION Final Grade (p,$s3 `1,63 Manu r mand p Y / Z— Model Number GPM TDH Lift Fric ' TDH Ft Forcem ' Length Did. Dist. To Well SOIL ABSORPTION SYSTEM TRENCH Width , Lengt No_ f T enches PIT No. Of Pis Inside Dia. Liquid Depth DIM [ DIMENSION SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING acturer: INFORMATION Type Of CHAMBER Model Nu System: ^ zaa OR UNIT DISTRIBUTIO SY STEM — P t -�„ Header/Manifold Distribut Pipe(s) at x Hole Size x Hole Spacing Vent To Air Intake Length -^ Dia. Length Dia. Spacing (6i] 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: SOMERSET 4.30.19.522A,NW,NE 598 180TH AVENUE 11 6 Plan revision required? ❑ Yes ❑ No Use other side for additional information. 03 a 2 s SBD -6710 (R.3/97) Date Inspector's Signature Cert. No NVi sconsin SANITARY PERMIT APPLICATION 201 Saf and s h n g t ngA ve sion In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Department of Commerce Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 81/2 x 11 inches in size. • See reverse side for instructions for completing this application State San-3 ita+r /y Permit Nu ber The information you provide may be used by other government agency programs El Check it revision 4opr6vious application [Privacy Law, s. 15.04 (1) (m)). State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION Prope yOwner me Property Location 1/4 1 , ,6 5 1/4, S T D , N, Ror) W Property Owner's Mailinq Ad ess Lot Number Block Num r City, State Zip Code Phone Number Subdivision Name or CSM Number II. TYPE OF BUILDING: (check one) ❑ State Owned it Nearest Road Public 1 or 2 Family Dwelling - No_ of bedrooms row OF 111. BUILDING USE ('f building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 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 ❑ S ice Station/ Car Wash 5 ❑Hotel /Motel 9 ❑ Off ice /Factory 13 they: specify )? IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. pg 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 $Seepage Trench 22 ❑ In- Ground Pressure ® / 42 [] Pit Privy 13 E] 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. /'" ch) Elevation j , , Feet 97 Feet VII. TANK Capacity in gallons Total # Of Prefab. Site Fiber- er- INFORMATION Gallons Tanks Manufacturers Name concrete con Steel Plastic Ex p New Existin structed glass App- Tanksl Tanks Septic Tan - ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber I I I I ❑ 1 ❑ 1 ❑ 1 ❑ 1 ❑ El VI11. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for in allation of the onsite sewage system shown on the attached plans. Plum er' Nam" (Pr ) Plumbe s n r (Nb a ps) MP /MPRSW No.: Business Phone Number: __10 Plum er's Add ress Street, ity, Stat p Code)y IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued nature (No Stamps) Approved []Owner Given Initial 7/4� rchargeFee) Adverse Determination X. C�ONDITI FAPPROVAL /REASONS FOR DISAPPROVAL: �i�pevr}t�1S COW) ►r1 1 \ r Auld SBD.BM (R 11/96) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber Safety and Buildings 15837 USH 63 HAYWARD WI 54843 -8107 NVisconsin Tommy G. Thompson, Governor Department of Commerce William J. McCoshen, Secretary May 27, 1998 CUST ID No.224263 KIM A O'CONNELL 504 3RD AVE OSCEOLA WI 54020 RE: CONDITIONAL APPROVAL Transaction ID No. 80145 APPROVAL EXPIRES: 05/27/2000 SITE: Site ID: 7809 ST CROIX County, Town of SOMERSET;, SOMERSET NW1/4, NE1 /4, S4, T30N, R19W JOE LANGE FOR: Description: NEW CONVENTIONAL SYSTEM Object Type: POWT'System Regulated Object ID No.: 19337 The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. This plan approval is for a 130gpd in- ground conventional. The following conditions shall be met during construction or installation and prior to occupancy or use: • This plan action is subject to designer comments on the plan Correspondence Note: • This approval does not include plans for the general plumbing systems or sewer piping leading to the septic tank that is required for project. See section Comm.82.20, Wis. Adm. Code. • The plumbing for this project discharges to a private sewage system. The approval covers only domestic /sanitary wastes directed into this system. The Department of Natural Resources (WDNR) must be contacted regarding the treatment and disposal of all industrial wastes, including those combined with domestic /sanitary wastes. A copy of the approved plans, specifications and this letter shall be on -site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of construction /installation/operation. 1 P.O. Cvndi APPF DEPARTM EN' DIVISION O SAP SEE CORR rr , i i O I i ® W.T.S. tronally IOVED / OF COMMERCE ETY BUILDINGS 3 � i XX _SPONDENGE Y i i i i ' PAC.0 OF �f C) Of p nn FleeA Ali Inlele And ODeo,aollon Pipe ! 1 (=- Appro..d Van, Cap Mlnlmrw II' Above Lj final Giad. I! 20. 12' Abo.e Pip' _ 1' Co.l Iron j To final G,aee Von, Pipe i ij Ma IA 11.E 0, S/nl Mik Co — Iny 2' Ayy,egois 0.., Pipe OUulo.uon ilpe —' o 0 0 -- Tee s �' Aee�eoa,e Bensal0 Pipe ° Puloio,.e Plye defer o ' Co -Pliny Tw.dnUlna A$ Bol,om 01 $/elem I� Pru(�o�ep SOIL FILL DISTRIBUTIOLI PIPE APPn(WEO a CO 2 "oFAGG9E6A1E --� - !'IATERIPl. oa 4" OF sTRI OR JAARSu HAIJ E�-EV. OF G1 ��YL 1 ` ,OF �2 - P AGGRCGATF- . , n •� � � ._y?,:- ; ^ ':� DI5rRIF)UTIOPW PIPE TO DE AT LEAST mr-1 -1[s BCLOW ORI;,IUAL GRADE AUU AT LCASTLO IMCHEL BUT AIO MORL THA►J 42 I►JC11ES 6LLOW FIAIAL GRADE �uM Dap of EXCAVAT1 FR O AL 6kAi)F- WILL BE IIJCHES I 1U imm ©EFTH OF EACA%/ATImN rAOM. eikI( (RAPF- WILL 6[ IrJCH[s i r LIC E U SE UUMBE R: DATE - - -- - - - - -•.. T l a Wisconsin Department ti Industry SOIL AND SITE EVALUATION REPORT P Labor and Human Relations g / Of Division of Safety &Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not ize. Plan must include, but not limited to vertical and horizontal refe int N.t�' ( ), direc % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and locatio axtistag pest ro APPLICANT INFORMATION –PL ,t PRI FORM N REVIEWED BY DATE r a, PROPER OWN ' "i PROPERTY LOCATION " vrv:, - �--< GOVT. LOT 1/4 1/4,S T ? N,R c (orb PROPERTY OWNER':ScMAILIN ADDRES �JktNt'C�ft LOJ�k BLOCK # S BD. NAME OR CSM # CITY TATE ZIP COD _`,' ; EN)1f�IBFPf; ❑ VILLAGE J�JOWN NEAREST ROAD > New Construction Use [ ] Residential / Number of bedrooms [ ] Addition to existing building (] Replacement Public or commercial describe Code derived daily flow gpd Recommended design loading rate _L_Z_ bed, gpd /ft gpd /ft Absorption area required /,r?f7 bed, ft { trench, ft Maximum design loading rate ._ bed, gpd /ft gpd/ft Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design / si considerations Parent material i ��� /�.�/"�� , P , /� � Flood plain elevation, if applicable . ft S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable fors stem [ S [:] U S ❑ U I QS ❑ U 13 ❑ U [Is O U [Is RU SOIL DESCRIPTION REPORT Texture Boring # Horizon Depth Dominant Color Mottles Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench " Ground _ _ _ 1 7 R elev. s W ft. Depth to limiting fact Remarks: Boring # d ;... 1 Ground e elev. ft. Depth to limiting factor Remarks: CST Name:— Please Print Phone: Address: r Signature: Date: CST Number: "Ol I v 1` ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer J uyer a -e Mailing Address Property Address (Verification required from Planning Department for new construction) City/State ,L Parcel Identification Number 15 Z­ 'f 4 LE GAL DESCRIPTION Property Location '/4, 44 -- '/4, Sec. , T _Z . L')_ N -R_/�__W, Town of Subdivision , Lot # Certified Survey Map # , Volume , Page # Warranty Deed # te r" 7 , Volume -_, 2 , Page # Z16 Spec house ❑ yes 14 no Lot lines identifiable ,0 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. 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 statin hat your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 day the thr a year ex t' n date. GNA OF P IC T DATE OWNER CERTIFICATION (we) certify that all st ements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the o r y describe above, virtue of a warranty deed recorded in Register of Deeds Office. 1 / / r " NATIJRE OF A IC N 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 N N n �, (n v .1 v N� m" N W O 7- m m. 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