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HomeMy WebLinkAbout032-2108-10-000 ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT Owner Property . 4 Property City/Stat JS S;�Zl i 7 Legal Description: Lot Block — Subdivision/CSM it 1 t /4 &A) t /4, Sec. 1,2, T_f, N -RAW, Tow PIN # SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer 1J Size ST/PC / Setback from: House Well fne P/L Pump manufacturer 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: S% o Width 1 ,-- - 2 Length � Number of Trenches Setback from: House ,_-29 Well , /s PAL 5_ Vent to f air intake >- ELEVATIONS Description of benchmark Elevation Description of alternate benchmark B f�,�f s�' - Elevation �zz53, Building Sewer ST/HT Inlet R_ `-5l ST Outlet 9,2 s PC Inlet PC Bottom Header/Manifold 91,? Z Top of ST/PC Manhole Cover Distribution Lines Bottom of System () () ( ) Final Grade Date of installation 11,519 Pfijmit number -Y State plan number Plumber's signatur / License number G � /S Date Inspector 2 &0 Complete plot plaz Wisconsin Department Commerce PRIVATE SEWAGE SYSTEM Coun • .Safety and Buildings Di .4t. CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) SanitajnPV6rgt:lo.: Personal information you provice may be used for secondary purposes [Privacy w, s.15.04 (1)(m)). Permit Holder's Name: ge ❑ Town of: State Plan ID No.: CHMIT, WAYNEI CST BM Elev.: 71nsp.BM xZN Elev.: BM Description: ParcebT3o2108- -000 16z� bU ! " I v- 0 r? , y--, TANK INFORMATION ELEVATION DATA A9800554 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. o6D Bench a t{ 6 ID's y /60 r Dosing Aeration Bldg. Sewer ( 0 /5 . oc/ Holding t/ Inlet ll.s`� 92 . 6 y TANK SETBACK INFORMATIONG� 5 !# Outlet 1 2.13 g 3 S - TANKTO P/L WELL BLDG. - Air I to ntake ROAD Dt Inlet Air e -� 0 f NA Dt Bottom Dosing - _ A Header /Man. IZ_e1 F7 Aer ion A Dist. Pipe 12.1r 9 /, 7 7 Holding Bot. System t3.� 90.9 PUMP/ SIPHON INFORMATION Final Grade io 0 '4 S. g Manufacturer Dema Model Numb GP TDH Lift Friction =51__T D H Ft ess Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM ED N RENCH Width � Length 5r7 / No. Of Trenches PIT ZEACHING ia. Liquid Depth DIMEN I SETBACK N SYSTEM TO P/ L BLDG WELL LAKE / STREAM Manufacturer: INFORMATION ER Type Syste Qnt1 1 5 �� �� '�'�O m er: OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) r x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Sa Dia. L) Spacing (0 ASTrt^ Z Z ° j 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 815 165TH AVENUE �^ rowk n I l� Czu,o�Jt S rre+7 '-n 6 -^. 15 Plan e i 3 sion required? ❑ Yes Q'No Use other side for additional information. �) SBD -6710 (R.3/97) Date Inspector Signature Safety and Buildings Divisior Vivonsin S ANITARY PERMIT APPLICATION 201 W. Washington Avenue P O Box 7302 In accord with ILHR 83.05, Wis. Adm. Code Department of Commerce Madison, WI 53707 -7302 • 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 sanitary Permit Number Personal information you provide may be used for secondary purposes ❑ Check if r I hG"sion opf [Privacy Law, s. 15.04 (1) (m)]. application State Plan I.D. Number I. APP 1 ATI N INFORMATION - PLEASE PRINT ALL INF RMATION Propert y wrier Nam Property Location 1/4 1/4, 5 T 0, N, R (016V Property Owner's Mailing ddr s Lot Number Block Number Ci State E Y Zip Code Phone Number Subdiyis n ame or CSM Nu ber 1. T P BUILDING: (check one) ❑ State Owned ❑ It� Nearest Road Public 1 or 2 Family Dwelling T - No. of bedrooms -� E o age Town Of i II1. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo /a - � 0 - /'?- /0/5 V" — 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. jM New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5_ ❑ Repair of an - - - - -- System -- - - - - -- System Tank Onl y y Existing System Existing y S ster ---------------------- --------- - - - - -- - -- ----------------- ---- 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 RSeepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 [:]Holding Tank 12 E] 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 Gradi Required (sq_ ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. 'nch) Elevation f Feet Fee VII. TANK Capacity INFORMATION in gallons Total # of Manufacturer Prefab. Site Fiber- Ex p Gallons Tanks s Name Concrete Con - Steel glass Plastic A p r New Exi sting strutted Tanks Tanks eptic Tank ,C El ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber I ❑ ❑ ❑ El ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for ins allation of the onsite sewage system shown on the attached plans. Plum r' Nam : (Print) Plumb"sli t e Np S ps) MP /MPRSW No.: Business Phone Number: Plumber's Address (St t, Cit State, Zi Code): 4 IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitar Permi Fee (Includes Groundwater ate Issued Issu r ; mn�t Si gnature (No Stamps) Approved E] Owner Given Initial c�''000 Surcharge Fee) Adverse Determination • ` 9 1 1 �� X. CONDITIONS OF APPROVAL / REASONS F DISAPPROVAL: SBD- 6398 (R.1-1/97) DISTRIBUTION: Original to County. One copy To: Safety & Buildings. Division, Owner, Plumber A e10- 1�� l Bld/1 �N iy 30 s 3� Q a Wisconsin Dgpartment of Commerce SOIL AND SITE EVALUATION Division. 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 percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. If APPLICANT INFORMATION - Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location // ,,q , Govt. Lot 114 1/4,S T ,N,R �(or) W Prope Owner's Mailing Address Lot # Block# Subd. Name or CSM# City Stat 7 Zi Code Phone Number ❑ City ❑ Village ® Town Nearest Road New Construction Use: Residential / Number of bedrooms Addition to existing building Replacement ❑ Public or commercial - Describe: Code derived daily flow f5 gpd Recommended design loading rate 1 7 bed, gpd/ft trench, gpd /ft Absorption area required _ bed, ft .� trench, ft2 Maximum design loading rate . 7 bed, gpd /ft , trench, gpd/ft Recommended infiltration surface elevation(s) }5' ft (as referred to site plan benchmark) Additional design /site considerations Parent material Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system g] S❑ U M S ❑ U [Z S ❑ U M S ©U ❑ s ® U ❑ S M U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD /ft2 in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed , Trench b Ground ^ ele Depth to limiting factor gin. ; Remarks: Boring # 222 X'�Z } :::..... All 45L Zo S Ground p �^ elev. . 41 1 4 -- 7 Depth to limiting factor ?1�in. Remarks: CST Name (Ie a Print Signature J Telephone No. Address Date CST Number X, z, G�� �, ---71- 9? ' li r.3oll/ - x'i9w �® f �o f IMOR ior' Aela h.�i151%�LK 30 , i S �/ s TY Wiscgnsin Department of Industry SOIL AND SITE EVALUATION REPORT Page i of .. Labor and Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code 4 COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but St. Croix 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. 0 3 Z - 2 el 4 -- / 0 APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION Gerald J. Smith GOVT. LOT SW 1/4 NW 1/4,S 12 T 30 N,R 19 )� (or) W PROPERTY OWNERS MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # 11160 190th. AVe. N.W. na N. Bass Lake Estates CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE MTOWN IN EAREST ROAD Elk River, ( ) 441-8,9819 Somerset 1 85 . St. [ 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 ed, gpd /ft gpd /ft Absorption area required 643 bed, ft 563 trench, ft Maximum design loading rate .7 bed, gpd /ft gpd /ft Recommended infiltration surface elevation(s) 97.97 ft (as referred to site plan benchmark) Additional design / site considerations na Parent material outwasb Flood plain elevation, if applicable „ ft S = Suitable for system CONVENTIONAL I MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable for s stem ZI S ❑ U ZI S ❑ U )E7 S ❑ U E] S ❑ U C21 S ❑ U ❑ S K7 U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Roots GPD /ft' Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Tren 1 !< Mfr r'.CZ 9f 1 0- 2 10 -36 10yr4 /4 none sicl lcsbk mfr CrW I if .2 .3 Ground 3 36- 82 7.5yr4Z4 none r1r).q C)SCI ml na n;4 -7 elev. 101 ft. Depth to limiting factor +82" Remarks: Boring # 1 -12 10 r3 3 >< 2 € 2 12 -31 Ground 41 7_5yr4_14 none rncz os g M 1 Pa na e7 --a- elev. 10 ft. Depth to limiting factor +84 ° .. 1 �a01X t G Remarks: �. s CST Name: -- Please Print Gary L. Steel Phone: 715- 246 -6200 ON�N40 x\ Address: 1554 200t e. New Ric d WI 54017 Signature: Date: 4 -17_97 CS 1'i�uu�fier. + Iu0 8 w STEEL'S SOIL SERVICE Gary L. Steel 1554 200th Ave. CSTM2298 1 Gerald Smith New Richmond WI 54017 MPRSW 3254 Wawa S12- T30N -R19W town of Somerset (715) 246 -6200 lot #21 -N. Bass Lake Estates N 1 =40' BM.= top of NE lot stake @ el. 100' Alt. BM.= top of wooden post @ el. 102.70 G, o Lq' J 41 5 2� 131 U l t h it L"A Gary L. Steel 4 -17 -97 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND / OWNERSHIP CERTIFIICATION FORM Owner/Buyer /�f�U L V �t41/1Z 17 Awlal l' 40 j�� LIZ, �/!Z Mailing Address 6 o Sp Wl'/6 '5 / AQT Property Address ' ,- l (Verification required from Planning Department for new construction)'' City /State Parcel Identification Number 03z wOO — /© LE GAL DESCRIPTION Property Location -sVil ' /4, AJW 1 /,, Sec. Z , T 3 N -R f ! W, Town of D� Subdivision llk/I A19 4 ���ff O , Lot # Certified Survey Map # , Volume , Page # Warranty Deed # , Volume l�� , Page # / Spec house 1 1 yes ❑ no Lot lines identifiable X 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 your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the thre year year expiration date. y� c lr a �� /'/, _4xmtL _ AO l / 90 SIGN 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. SIGN TUBE 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 W O Q C ✓T O+ d ^ 0 W� p <OI-d U N QLpI O 0 c c Q Q UN�N � a� �- `_; a L v �a c c w( n<N zws c� 3 ? aco ,o c 0 E c 0 o X �. wO c. m Q L � 3 ; O o p wwC7°o m wz �, 3 L ° E a s v u > LL ��Q v.�0 0- ��3 52. c a s c`J' L c � aowo a aim o 0 0 �.� °c 0 r) T N O v)W0cr _ Z L O C N N O o o � a�i J v o �02m r�-� `� 3 v v 0� o z =�cn 0 - o v E00 a �C a C mZOZ- : 3 Co �O�� ��S ��!• V) L. x D0 00 0) 1- a; 0D o f Q `c n p= oai�°-u c0Z �!A >1 O o : •� o v '` iv a+. 0 0 C) � W w cn ; :. 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