HomeMy WebLinkAbout032-2047-60-100 ST. CROIX COUNTY I
ON[NC DEPARTMENT
MEN'I'
AS BUILT SANITARY REPORT
Owner
Address L ry
City /State
Legal Description:
Lot _ Block Subdivision/CSM # / Zy
_ {rte ' /,•, Sec., T,y Q_N - R/W, Town of
;— PIN # 0—c -2
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION:
Tank manufacturer G�i -s;t�s Size ST/PC Setback from: House Well P /Lf
Pump manufacturer Model
Alarm location
(BOLDING TANKS ONLY)
Setbacks: Service road Vent to fresh air intake Water Line
Meter location
Alarm location
SOIL ABSORPTION SYSTEM:
Type of system: ✓3�o Width _4a_ L le_�_ Number of Trenches
Setback from: House Well >_� p/I,, Vent to fresh air intake ELEVATIONS
Description of benchmark ',l
Elevation /° °.n
Description of alternate benchmark Elevation za? T9
Building Sewer -LZ 2 . ��, ST/HT Inlet /o�/_ /Iq ST Outlet / �, �� PC Inlet
PC Bottom Header/Manifold gA �7? Top of ST/PC Manhole Cover
Distribution Lines
Bottom of System ( ) ( ) ( )
Final Grade
Date of installation l/ / /B'/ P rmit number State plan number
Plumber's signature License number 3 Date
Inspector `ii�
complete plot plan +
Wisconsin Department Commerce PRIVATE SEWAGE SYSTEM Count
Safety and Buildings Division y:
INSPECTION REPORT ST. CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)J. 315961
Permit Holder's Name: ❑ City ❑ Village ffl Town of: State Plan ID No.:
RIVARD, HAROLD SOMERSET
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
o. U ti „ 032 - 2047 -60 -000
TANK INFORMATION ELEVATION DATA A9800350
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic °: ' /� U Benchmark, Y
Dosing Z „,
Aeration Bldg. Sewer
A 1
Holding St /Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outletr
TANK TO P/ L WELL BLDG. Air I to ntake ROAD Dt Inlet
ir
Septic aD / J4 NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe
Holding Bot. System r
PUMP/ SIPHON INFORMATION Final Grade',
Manufacturer Demand,,.t
Model Number GPM
TDH I Lift Fr' ion System TDH Ft
Fi
Forcemain L gth Dia. Dist. To well
SOIL ABSORPTION SYSTEM
BED/TRENCH Widt ` Length 9 p No. Of TrQnches PIT No. Of Pits Inside Dia. Liquid Depth
DIMEN I N ° ''' DIMEN I N
SETBACK
SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer:
INFORMATION Type O 777 CHAMBER
� ��� /� r' Model Number:
System:
'y ° 1 itJ A 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
xx Seeded/ Sodded xx Mulched
Depth Over Depth Over xx Depth Of
Bed /Trench Center . Bed /Trench Edges .. Topsoil El ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: SOMERSET 13.30.19.672C,SW,SW 812 150TH AVENUE
Y
/ t
Plan revision required? ❑ Yes M
Use other side for additional information. 1 /1 1 /e 1?
SBD -6710 (R.3/97) Date In ditor's Signature Cert. No.
SANITARY PERMIT APPLICATION S afety and Washington Division
201 W. Washin ton Avenue
Nv i scons i n I n accord with ILHR 83.05 Wis. Adm. Code P 0 Box 7302
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. :
• See reverse side for instructions for completing this application State Sanitary Permit Number
Personal information you provide may be used for secondary purposes ❑ check it I'20isio�n to previous Ipplication
[Privacy Law, s. 15,04 (1) (m)]. State Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION
Prop Ow r NaTV Property Location
a/a 1/4, S T , N, R j or
Property Owner's Mailing Ad res Lot Number Block Number
City, tate Zip Code Phone Number Subdivision Name or SM Num er
( )
11. TYP IF BUILDING: (check one) ❑ State Owned N earest Roa
E] VII age
Public JS 1 or 2 Family Dwelling - No. of bedrooms EX Town OF rJ
III BUILDING USE (If 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 ❑ 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 online B, if applicable)
A) 1. ® New 2. ❑ Replacement 3 ❑ Replacement of 4. ❑ Reconnection of 5, ❑ Repair of an
- ___ - ________ System____ _________TankOnly______________ Existing System _______ Existing -- -lstem
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 [9 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In- Ground Pressure r i 42 ❑ Pit Privy
13 ❑ Seepage Pit & V160 43 ❑ Vault Privy
14 ❑ System -ln -Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate S. Perc. Rate 6. System Elev. 7. Final Grade
Required (sq_ ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /'nch) Elevatio
- ,
97 Feet Feet
VII. TANK in Capacit llo Total # of r Prefab. Site Fiber- Exper.
INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existin strutted
T nks Tanks
eptic Tank o olding Tank 2 ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber I ❑ I ❑ 1 ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for I stallation of the onsite sewage system shown on the attached plans.
Plu b 's Na : (P tp Plumber's g a p MP /MPRSW No.: Business Phone Number:
umber's ddress (Street, y, tate ip Code):
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing A na ure (No Stamps)
. O
)4 Approved []Owner Given Initial /� 027 Surcharge Fee)
`� /
Adverse Determination C
X. CONDITI IS OF APPA0VAL / REASONS FOR DISAPPROVAL: J-,d- ksl? e %s Co�vP,✓�e �b �ti
�'o�2r r�lfl.�v rw+,�Sf o1��eLwr
04 jl7,a.�, �nl ndihu.rt.c -s.
rr Z
SBD- 6398 (R.11197) DI RIB ON: Original to Co nty, One copy To: Safety & Buildings Division, Owner, Plumber
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W sconsiri Department 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 81/2 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. #
APPLICANT INFORMATION - print// infel(7rption, by Date
Personal information you provide may be Privat' 4A s. 15.04 (1) (m)). 2 Z o f 8
[Properly rope A Property Location
Govt Lot 114 l 1/4,S T ,N,R F(oQ
Mailing Address ST CROIX Lot # 1 71 , 07 Subd. Name or C
,, WUNTY
azz City e El city El village 1 Town Nearest Road
FUI New Constriction Use: Residential / Number of bedrooms Addition to existing building
Replacement R Public or commercial - Describe:
Code derived daily flow - gpd Recommended design loading rate 5 bed, gpdfiF trench gpd*
Absorption area required ,2fJ bed, ft Z5�- reach, ft Maximum design loading rate _ ,_5 bed. gfd / �G�Jrench. gwe
Recommended infiltration surface elevation(s) zz 7 ft (as referred to site plan benchmark)
Additional design/site nsiderations
Parent material - Flood plain elevation, if applicable - ft
S = Suitable for system Conventional Mound In -Ground Pressure I AT -Grade System in FN Holding Tank
U = Unsuitable for system ® s❑ U LOS ❑ U [R] s❑ u 0 s❑ u ❑ s [Z u ❑ S E] U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Roots GPD/ft2
13 in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Y Bed , Trench
Ground
� ele e v..
%i ft,
Depth to
limiting
factor
Remarks:
Boring #
13 r
Ground
elev.
Depth to
limiting
factor
min. Remarks:
CST Name (PI a Pri ) � Signature r ,r� Telephone No.
Address Date CST Number
b' /Sf�"��.e �S�J� -sW'�/ s.�e /3-T_3a,✓- :s /9�
.� ,B /UIC�/��e'K' � - 1��0 0 �T/z�iL Tds� • /� /�G5
34
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FROMI A &E LAND SURVEYING LS FAX! 715 -246 -4319 Jan -29 -98 Thu 15 :38 PAGE! 04
N 671 B
(
671 A
ivy A 0o,�t
i
6722: A 672 B
1
SW 114— SW //4 j <zo�'I
i �
07;'01�'88 12:12 FAX 1 715 217 3622 REMAXTEAMIREALTY Rol
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer f7 A r10 ��! Ar u -I
Mailing Address 1.Ve v
Property Address _ _ _ / s `� ` ,d/ a
(Verification required from Planning Department for new comtntetion)__ ^�
Cityfstate r.. 4 Parcel Identification Number � 4 �.7 � D /;A• 4 0 - e au
LEGAL DESCRIPT M
Property Location %, SW 1 4, Sec.. 13, T 2 - Qjo� R W, Town of SP - Iffke !
Subdivision Lot
Certified Surve=y Map # _ � 7S _/�` �' . Volume Page #
Warranty Deed # 3 2L I 1p . Volume ,r/ _ _. Page # 072
�-
Spec house ❑ yes ano Lot lines identifiable LD' ❑ no
SY STEM MAE"TNANCE
Improper use and main tcr mce of your septic system could result in its premature failure to handle wastes. Proper umintenance
consists of pumping out the septic tank every three years or sooner, if needed by a Licensed pumper. What you pat into &C 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 licensedpuntper verifying that (1) the on -site wastewatwilicposal system
is it 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 rctumed to the St. Croix County Zoning Office within 30
days of the three year expiration date.
y
SIGNATURE OF APPLICANT DATE
OWNER CERTMCAT ON
I (we) certify that all statements on this form are true to the best of my (our) knowledge. 1 (we) am (are) the owner(s) of
the property dawn-bed above, by virtue of a warranty deed recorded in Register of Deeds Office.
J --e,� 2
IONATURE OF APPLICANT DATE
* * * * ** Any information that is mis- represented may resuh in the sanitary permit being revoked by the Zoning Departmett, * * * * **
'* 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 C
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575751 CY S1998
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C E R T I F I E D SURVEY MAP
Located in part of the Southwesj Quarter of the Southwest Quarter of Section 13 Township 30 North,
Range 19 West, Town of Somers$1, St. Croix County, Wisconsin.
Prepared for and at the request of:
BENCH MARKS:
OWNER: 0 C v
U V)
Harold and Theresa Rivard ELEVATIONS ARE ASSUMED. U
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804 150th Avenue BM #1 J\ k
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New Richmond, W! 54017 TOP IRON PIPE = 95.98 _zt
Q-: o" o .t! •2
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BM /2 I U I Q ° o
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TOP IRON PIPE = 100.26 �J j Z 0 0
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UNPLATTED LANDS
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CERTIFIED S RVEY MAP I s
Located in part of the Southwesj Quarter of the Southwest Quarter of Section 13 Township 30 North,
Range 19 West, Town of Somer t, St. Croix County, Wisconsin.
Prepared for and at the request of: v m
BENCH MARKS:
cd(A
OWNER: ELEVATIONS ARE ASSUMED.
Harold and Theresa Rivard
804 150th Avenue BM #1 c
New Richmond, WI 54017 TOP IRON PIPE = 95.98 I I o N ..
a 0 ' a BM2 ( V I X .. •� 0
TOP IRON PIPE = 100.26 QI 33 �� Z »= —° o
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UNPLATTED LANDS IS 1 j .,'I� 0
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