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HomeMy WebLinkAbout032-2107-80-000 OCT -08 -98 12:48 AM BELISLE EXCAVATING 7152473038+ P.01� ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT Owner Address City /Stat Legal Description: Lot d— Block Subdivisicn/CSM # PIN # ' - -�� �% ' /. S AIL ' /.,�J, Sec, ,�,�, T„�N -Rf�W, Town of SEE11C TANK DOSE CHAMBER — IiOLA NG TAN I: IN '0 4A11ON Tank manufacturer L,�;��" Size ST/PC !!� / _ _ Setback from: House well L, P/L 11L Pump manufacturer _ Model Alarm location (BOLDING TANKS ONLY) Water Line Setbacks: Service road _ Vent to fresh air intake Meter location Alarm location SOIL ABSORPTION SYSTEM Tmx of system: — Width — /A— LAmgtb — Numbcr of Trenches Setback from: House /,91_ Well PAL _4e Vent to fresh air intake �L�vATior�S Elevation Description of bencbmark � � {� � /4 _��'' ` t mark Elevation D ascription of al eras to bench BWldins Sewer ./ -'7 t . RJ ST/HT Inlet _ »1 ST Outlet i PC Inlet PC Bottom -�,_ Header Manifold i f: _ Top of ST/PC Manhole Cover Distribution Lines Bottom of System( Final Grade () () ( ) Date of installation er it au er r67 7s. s _ State plan number / , , /22 Date � � Plumber's signature-:• License number - Inspector _ ` - `°"'°'`'` P 101 °11e or OCT -08 -98 12:48 AM BELISLE EXCAVATING 7152473038+ P.02 NOT 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. PL VIEW L,t' ,4cK /dWS�e MICATE NORTH ARROW Wisxon'sin D partment of Commerce PRIVATE SEWAGE SYSTEM Count Safety and Buildings Division INSPECTION REPORT Count ST. CROIX GENERAL INFORMATION (ATTACH TO PERMIT) Sanitarylb"? "-, Personal information you provice may be used for secondary purposes [Privacy LaV s.15.0 (1)(m)j. Permit Holder's Name: I ❑ ❑ Town of: State Plan ID No.: HEROLD, JIM & ALWELL, AUDREY S CST BM Elev.: Insp. BM Elev.: BM Description: Parcel T iUY2 - 2107 - 8 0 - 000 /00. TANK INFORMATION EL VATION DATA A9800142 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic 7 �.� ; M Benchmark Dosing -38 Aeration Bldg. Sewer `,gs -83� Holding St /Ht Inlet l-' TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Air l to ntake ROAD Dt Inlet ir Septic T 961 ai j �a 5 NA Dt Bottom Dosing NA Header / Man. S� Aeration NA Dist. Pipe —)-93 Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade I Manufacturer Demand a> ao.�� Model Number GPM TDH I Lift Lricti System F System Ft Forcemain gth Dia. Fi Dist. To well SOIL ABSORPTION SYSTEM BED /TRENCH Width Length No. Of Trenches PIT No Of Pits Inside Dia. Liquid Depth DIMENSIONS �5� I DIMENSION SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type C , CHAMBER Moe 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 ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: SOMERSET 12.30.19,SW,NW 807 165TH AVENUE i 1 r� :j Plan revision required? ❑ Yes No Use other side for additional information. SBD -6710 (R.3197) Date I spe or's Signature Cert. No. SANITARY PERMIT APPLICATION Safety W ashington ilAve Division 1 4sconsin In accord with ILHR 83.05, Wis. Adm. Coe P.O. Box 7969 Code 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. Z�, 4 • See reverse side for instructions for completing this application State sanitary Permit Number 3c>7�..s The information you provide may be used by other government agency programs E] Check it revision to previous application [Privacy Law, s. 15.04 (1) (m)]. 0 X Y State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE ' P ALL INF RMATION Prop rty Owner N me SEPropert ation 4 1/4, S T , N, R E (or)* � Prope ner's Mailin Add rsSSi Lot Number Block Num er Ci State; 1"Y Zip Code Phone Number Subdivisi n Name or CSM Nu ber ( ) Il l. E OF B ILDING: (check one) ❑ State Owned LJ t� Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms -� ° V own OF III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 A lob• c30. /9. /0 /a ®� ❑ partment /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 ❑ 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. 0 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 J21 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 E] 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 ElLsv. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min./ nch) Elevation -` 6 Feet Feet VII. TANK Capacity in gallons Total # of Prefab. Site Fiber- Ex p er. INFORMATION New Existing Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic A p p str Tanks Tanks Septic Tank or Holding Tank ❑ 11 El Lift Pump Tank /Siphon Chamber 1:1 El 1:1 ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for in allation of the onsite sewage system shown on the attached plans. Plum r' am : (P( )° Plumbe s na o a ps) MP /MPRSW No.: Business Phone Number: / 1 3 / Plumber's Ac dre treet ity, Stat 1p Code _ .c7 r IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issu Iss Agent Signature (No Stamps) Approved ❑ Owner Given Initial Cj0 (90 Surcharge Fee) Adverse Determination 0 // e"w S X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: s y S -edeV. = JD7- � / SBD -6398 (R.11/96) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, plumber / "y�E /� 1" 46 Sul �- �j/!�l %- size �- T.3Di✓ -� /��J h ) .A , ��' ' /t ig lfr3�n�seo ss' Q ` q ah 1 Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page 1 of 3 Labor and Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but 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. C 3 Z. - 2 - .0 Q - 0 APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION REVIEWED BY DATE 7 PROPERTY OWNER: PROPERTY LOCATION Gerald J. Smith GOVT. LOT SW 1/4 NW 1/4,S 12 T 30 N,R 19 kor) W PROPERTY OWNER':S MAILING ADDRESS LOT # I BLOCK # I SUBD. NAME OR CSM # 190th. Ave. N.W. 18 na N. Bass Lake Estates CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE J&OWN NEAREST ROAD Elk River, Mn. 55330 (612 441 -8888 1 Somerset 85th. St. [x4 New Construction Use (x] Residential /Number of bedrooms 3 ( ] Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow 450 gpd Recommended design loading rate .7 bed, gpd /ft trench, gpd /ft Absorption area required 643 bed, ft 563 trench, ft Maximum de loading loading rate .7 bed, gpd /ft gpd /ft Recommended infiltration surface elevation(s) 107.9 & 107.0 �U`7 ft (as referred to site plan benchmark) Additional design / site considerations alt. site system el. = 106.00' & 102.70 , Parent material outwash Flood plain elevation, if applicable na ft S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE I AT -GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem ® S ❑ U NI S ❑ U I RI S ❑ U ® S ❑ U 6d S ❑ U ❑ S [R U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD /ft in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trends .................. ................. .................. ................. .................. ................. .................. 1 1 0 -8 10 r3 3 none sl 2msbk mvfr cs 2f .5 .6 2 8 -18 7.5yr4/4 none is osg ml gw if .7 .8 Ground 3 18 -84 7.5 r4 6 none cos oSQ ml na na .7 .8 elev. 11 ft. Depth to limiting factor +84" Remarks: Boring # 1 0 -10 10 r3 2 none sl 2msbk mfr cs 2f .5 .6 2 2 10 -17 7.5yr4/4 none sil lcsbk mfr gw if .2 .3 Ground 3 17 -84 7.5 r4 6 none cos osq ml na .7 .8 elev. 1 11 ft. .` Depth to limiting rn fac �� Remarks: CST Name: -- Please Print Gary L. Steel Phone: 715 -246) -6)200 Address: 1554 200 ve. New h nj WI A4017 Signature: " Date: 4 -17 -97 CST Number: m02298 STEEL'S SOIL SERVICE Gary L. Steel Gerald Smith 4554 200th Ave. CSTM2298 WIWI S12- T30N -R19w New Richmond, WI 54017 MPRSW 3254 town of Somerset (715) 246 -6200 lot #18 -N. Bass Lake Estates N 1 " =40' BM.= top of mid lot survey stake C el. 100' Alt. BM.= top of 2 pvc pipe C el. 107.00 < 1� t V 43 C C�• 1 7` Gary L. Steel 4 -17 -96 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIF FORM Owner/Buyer � rt � t�WG ( �t'�►n �e ro �c� Mailing Address 6 40 � 4 - V S,'q�P Property Address (Verification required from Planning Department for new construction) _S�C__ City/State A e b EA= X Parcel Identification Number ©3 - C) LE GAL DESCRIPTION Property Location s '/4, '/4, Sec. ,/ , "1' N -R W, Town of Subdivision A)Ok-rg BA-$ L,l 5 STLT6S' , Lot # !8 Certified Survey Map # Volume , Page # Warranty Deed # S &6 960 Volume jc;L('& , Page # a- Spe• house ❑ yes - I.ot lines identifiable0yes ❑ no SYS " EM 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 of cct 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 11-ensed pumper verifying that (1) the on -site wastewater di ,posal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 fitll of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards y' 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 d� s of the three year expi tion date. zZ .3/7fi SIGN ATURE OF PPLICANT 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. 3 /-Pk" d _5i O A PLICANT 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 02/27/98 15:21 FAX 1 715 247 3822 R$H TE ,' RE Ax •, a _ • (V I r ;'i �J j •`9 � ° � 1 1 I. I ' +, t ' ' t1• �' .` C:� +i• r l�' I r , 'ri ,� b ! . . • . A ' 7 ~ ''I^`� ``.: ,• `� I I �'l I.) 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CROIX COUNTY GOVERNMENT CENTER now,• 1101 Carmichael Road Hudson, WI 54016 -7710 (715) 386 -4680 October 8, 1998 Hartman Homes Attn: Becky Somerset, WI 54025 RE: Septic Inspection for Jim Herold and Audrey Alwell located at 807 165th Avenue, Lot 18 of North Bass Lake Estates, Town of Somerset, St. Croix County, Wisconsin Dear Becky: A septic inspection of the above referenced property was conducted on August 21, 1998. This property is located in the SWY4 of the NWY4 of Section 12, T30N -R19W, Lot 18 of North Bass Lake Estates, Town of Somerset, St. Croix County, Wisconsin. At the time of the inspection, this septic system was found to be code compliant for a three (3) bedroom home. If you have any questions regarding this, please contact our office at (715) 386 -4680. Sincerely, A &T Mary J. Jenkins Assistant Zoning Administrator AM FAX ST. CROIX COUNTY ZONING OFFICE 1101 Carmichael Road Hudson, M 54016 (715) 386-4680 DATE: TO: Fax Number. 65�W7 - q 0 Name: FROM: Fax Number. 386 -4686 Name: �S Number of Pages Including Cover Sheet IF COMPLETE AND LEGIBLE INFORMATION IF NOT RECEIVED, PLEASE CONTACT: NAME: S&Ajvu� TELEPHONE NUMBER: