The URL can be used to link to this page

Home My WebLink About032-1006-95-100 WiscoAsin Department of Commerce Safety and Buildings Division PRIVATE SEWAGE SYSTEM County: INSPECTION REPORT ST. CROIX GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Personal information you provice maybe used for secondary purposes [Privacy Law s.15.04 (1)(m)]. 320218 Permit Holder's Name: BACKUS, JOHN ❑ City pp RSE�P Villa e Town of: State Plan ID No.: CST BM Elev SOME Insp. BM Elev.: BM Description: Parcel Tax No.: /40, 032- 1006 -95 -100 TANK INFORMATION ELEVATION DATA A9800406 TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV. Se p ti c C Benchmark -- Dosing Aeration Bldg. Sewer �,� � ' olding St/ I�f-'f Inlet TANK SETBACK INFORMATION St/ FjeOutlet TANK TO P/ L WELL BLDG. A I to ntake ROAD Dt Inlet - Septic °' p ^�° � � h NA Dt Bottom Q �� NA Header / Man. Aeration,.,. -- ' M '` NA Dist. Pipe ' Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer •�� Demand � /'9"'1,,;;x.,... � !1�• t0 Mo el Numbe .r' GPM TDH Lift System TDH Ft •" pad I Ff Forcemain Length Did. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT `" 1 ---__ No. Of Pits Insi=Daucluicl Depth DIMENSIONS S , c� DIMEN I N SYSTEM TO P/L BLDG WELL LAKE /STREAM LEAC ManuafbctttiYer: SETBACK , Mode yp COO . CHAMBER INFORMATION T e O ne,�...+ �gr: System: r^e d 5 s"7 OR UNIT DISTRIBUTION SYSTEM Header ham Distribution Pipe(s) o, M , x Hole Size x Hole Spacing Vent To Air Intake Length Dia- Length Dia. e 7 l 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.) LOT 3 � STREET — L OCATION: SOMERSET 3..31 516 22ND STREE 3 �''[i^Y (, - .' • . I'Yyl�,,. r dR.: �..r. :P G.+%% c:.^.�... c�,l't- .�e.prrrt e� .,'" I CR..,C.t°- •✓,..�'�. &7 d Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. Safety and Buildings Division I SCO/1S %/1 SANITARY PERMIT APPLICATION 2 1 Box Washington Avenue Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code 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 320 , Personal information you provide may be used for secondary purposes ❑ Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Property Owner Name Property Location f , R E (Or) W 1 /4 1 /4, 5_5 T N 3 �l Property Owner's Mailing Address Lot Number Block Number .S !- City, State Zip Code Phone Number Subdivision Name or CSM Number e a- : O J, ( > 7.S II. Y F BUILDING: (check one) ❑ State Owned ❑ Cit Nearest Road ❑ Village Public 1 or 2 Family Dwelling - No. of bedrooms Town OF S;T~tes a. III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment / Condo 6,g l QO G - 95 -/,a 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. K 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 XLSeepage 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) �( ,Y /J Ele ali�n 60 0 fddd-� Q , of O Feet S Feet VII. TANK in Capacity g Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturer's Name Concrete con Steel glass Plastic App New Existin structed Tanks Tanks Septic Tank or Holding Tank OL o� , p( `. p ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ I ❑ 1 ❑ 1 ❑ 1 ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite se age system shown on the attached plans. Plumber's Name: (Print) Plumber's Signat e: No Stam s) PRSW No.: Business Phone Number: s & a� �a 715' -. 3Pe -31RI Plumber's Address (Street, City, State, Zip Code): 0 o e �d 3yo /G IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitar Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps) Approved []Owner Given Initial V surchar Fee) Adverse Determination U > �� X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.11/97) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber s:iE:e 1' " mm*/ .5 y r-' 9�l�j e v %18,. m �,L T 5 T� :F/'re x ;2 SO iU6�7 o r� Ne liJ 7� sT" f'� e r "bu s� �� s % %D /�/ 97 - e o,8 6 131 . Pa68 s�r�" c mks 3 a 1�.�Of_�� Wisconsin 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 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and S percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I. D. # APPLICANT INFORMATION Please print all information Reviewed by Date Personal information you provide may be used forsecondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location U h M 0. U Govt. Lot S 1 /4�(,/ W4,S T (, -.,N,R r E (or ' Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# -? 6 d 7 S & d iz a5" City State . Zip Code Phone Number ❑ City ❑ Village ® Town Nearest Road a iy ( ) Some- e_ o9L3Z nef 5] New Construction Use: ® Residential / Number of bedrooms 3 - y Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow - j660 gpd Recommended design loading rate &_ bed, gpd/ft gpd /ft Absorption area required /2.00 bed, ft 0 p trench, ft �M��`�m design loading rate a bed, gpd/ft • &� trench, gpd/ft Recommended infiltration surface elevation(s) 4t e Ae-K •{ Y� � 4 96, - /0 to ft (as referred to site plan benchmark) Additional design /site considerations Parent material b- 40,c,& -( -f-i I ' Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In- Ground Pressure I AT -Grade System in Fill Holding Tank U = Unsuitable for system 1�4 S❑ U 1A S ❑ U [g S❑ U X S ❑ U EIS M U EIS X U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD /ft Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench /f /o S �+'hQb 0 /r fa ry I►'►S s rr1 �' • 7 Ground ins cs . 7 elev. 90.lo ft. , Depth to limiting factor 1 in. Remarks: Boring # S lmaik Wti.Cr Z. / / "So ... ; . I ts 3 Sb f p E yri 1 C-S Ground g elev. Depth to limiting factor 436_in. Remarks: CST Name (Please Print) Signature Telephone No. C 71A V7 —&6V c t Address Date CST Number N-Ctz r— soh �. k�s 30 S S'n ( elrv. /0o -0 Z' `pcuc, P,; L Z e &P-0 . (oo. o �iA. a "Pvc. r of o d YSf�O-N a-Co. n o W --- N -- E L: n � 133 3v / v a ti P �vs e � WiscQn §in Department of Commerce Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count y INSPECTION REPORT ST. CROIX GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Per nal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 315947 Permi older's Name: ❑ City []Village Town of: State Plan ID No.: BACKVS, JOHN SOMERSET f, CST BM E v.; Insp. BM Elev.: BM Description: Parcel Tax No.: 032- TANK IN RMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFO*ATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic NA Dt Botto Dosing NA Head / Man. Aeration NA Dis . Pipe Holding ot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GP TDH Lift Friction System TDH Ft oss Forcemain Length Dia. FFii Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length N . Of Trenches IT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS IMEN I N SETBACK SYSTEM TO P/L BLDG I WELL LA E /STREAM LEACHING Manufacturer: INFORMATION Type Of CHAMBER Model Number: System: OR UNIT DISTRIBUTION SYSTEM Header / Manifold Distribution P e(s) Hole Size x Hole Spacing Vent To Air Intake Length Dia Lengt Dia, Spacing i SOIL COVER x essure Systems Only xx Mound Or At- rade Systems Only Depth Over pth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center led/ Trench Edges Topsoil Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include co a discrepancies, persons present, etc.) LOCATION: SOMERSET .31.19,NW,SW 516 232ND Altv , IA2i Plan revision requi ed? ❑ Yes ❑ No Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Signature Cert. No SANITARY PERMIT APPLICATION 20 Safety and 1 W.W Avenu isconsin Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code P O Box 7302 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. %e • See reverse side for instructions for completing this application State sanitary Permit Number Personal information you provide may be used for secondary purposes - / Z , (Privacy Law, s. 15.04 (1) (m)]. E] Check if revision to previous application 1. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATI N State Plan I.D. Number Property Owner Name Property Location Qa 1/4 S /4, S .3 T 3! , N R /4" E (or)Q Property Owner's Mailing Address Lot Number Block Number 3 City, State t Zip Code Phone Number Subdivision Name or CSM Number II. TY PE OF B ILDING: (check one) ❑ State Owned ❑ it earest Road Public 1 or 2 Family Dwelling - No. of bedrooms _ ❑ vo n OF 111 BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo Q 3 a — /64 G — 9S /d d 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 [RN 2. E] Replacement 3, E] Replacementof 4 E] Reconnection of 5 E] Repair of an ------ S ystem -------- - - - - -- Existing System Existing System ---------- System Tank Only E i --------------------- - - - - -- ----- -y - - -- B) ❑ A Sanitary Permit was previously issued. Permit Number T 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 Id 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 G� Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) r S -� Elevation 00 d fdd d �t/c� p , G Feet 0 0. VII. TANK Capacity ° Feet 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 Tanke. Tanks structed Septic Tank or Holding Tank 4 A I Q� 1 �Yl, v� R ❑ ❑ El O ❑ Lift Pump Tank /Siphon Chamber 1 11 TM ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite se age system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature o Stam s) MP PRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved San Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps) Approved [ Given Initial G/t/ Surcharge Fee) Adverse Determination �`�— 1,/,t (_�_ . CONDITIONS OF APPROVAL/ REASON FOR DISAPPROVAL: SBD- 6398 (R.11/97) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, owner, Plumber 0 D • �M 0� v L e nd Department i ons Industry SOIL AND SITE EVALUATION 3 Labor nd Human Relat Page ( of Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. 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 '�• C O (• percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # APPLICANT INFORMATION Please rin �.� � 03 Z — � • / S • � P 4J '� Reviews b Date Personal information you provide may be used for seconda es (Privacy&w, s. 15.04 (t) CA Property Owner D!(fJC�� t Property A10kM 1 P06- /E'0&2 Go • L"ot Nw 114 S T 3 / ,N,R /9 E (or) W Property Owner's Mailing Address BET Lo Block# Subd. Name or CSM# (04 260 UA, 5'r • sT CR aF v(r- CSi'-1 6 city State Zip Code h4n NuAftINGOFFI :u Nearest Road v e !GEd ��• S�D z ( 34 Village NO To z 3 z New Construction Use: esidentlal / Number of bedrooms 3 Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: IVIN - NO T e Eeip y liezv& Code derived daily flow gpd Recommended design loading rate .*bed, gpd /ft2 • // O trench, gpd /ft Absorption area required bed, tt � trench, It Maximum design loading rate NI� Ca 9 9 bed, gpd/fIF trench, gpd /11 Recommended Infiltration surface elevations) ,si 1, 2 3. i / it (as referred to site plan benchmatk) Additional design /site considerations VSE7 A r IWE `p r a v �J'l25 471 PA P O JL� , Parent material n5AVP Y Flood plain elevation, If applicable It S = Suitable for system Conventional , Mown in-Ground Pressure A -Grad System in Fill Holding Tank U = Unsuitable for system ❑ U L7 S ❑ LI 1 �I 5 ❑ U [[� S Flu D-g U ❑ S SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure PD /112 In. Munsell Ou. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots I Bed ,Trench �Y�33 Z � Jam, s if 7 g Ground 7.S /C f!D J elev. —'^ y �. � tt. Depth to limiting factor Remarks: Boring # Z- L S �14*1 cs 8 7 1W ��X oE-� S D S a — - 2 : 8 Ground elev. / w 1 of Ott. Depth to limiting Le ctor > in. Remarks: CST Name (Please Print) Signature Telephone No. Ro6tFRT �� - 7rs•V6 , •P /S--9 Address Date CST Number Assuclattlo Cs7',4 lip b' — si . a z O W o PI p Zia tA 7 w Q � Q G� w rn 0 73 � r ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address S ((o Property Address �"`, /I l 1 ' C,_ i (Verification required from Planning Department for new construction) % City /State (k) A Parcel Identification Number 2 •- 1&3 4 — LEGAL DESCRIPTION Property Location k� Uj '/4, *) ( 1 , % ' /4, Sec. , T _ ,3 i N -R I W, Town of So t7r S(I •- Subdivision Lot # Certified Survey Map # S� d /9 GO , Volume C , Page # Warranty Deed # S ; Y , Volume /.3 ' , Page # O Spec house ❑ yes fkno Lot lines identifiable 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 sta prig that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 da of the 7ee year xpirat' n date. c IFE S A OF APPLICANT DATE OWNER CERTIFICATION the t 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 p , de rxbed ove, by, / Virtue of a warranty deed recorded in Register of Deeds Office. v key SI(,"i TURF 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 81900 JUN � 12 S � 6 1998 6, � I ro ofD ,- 1 urCo. Ws CERTIFIE EY MAP Located in part of the Northwest Quarter of the Sou Quarter of Section 3, Township 31 North, Range 19 West, Town of Somerset, St. Croix County, Wisconsin; being Lot 1 of a Certified Survey Mop as described and recorded in Volume 12 page 3390 at the St. Croix County Register of Deeds Office. Prepared for and at the request of: OWNER: TOTAL AREA LOT 3: Roger Kukowski 174,274 SO. FT. / 4.00 ACRES Kowski Farms, Inc. AREA EXCLUDING R.O.W.: 6 2 th Oscc eolaa, , WI 54020 O. / 171,715 S FT. 3.94 ACRES Drafted by. Kristi A. Eylandt TOTAL AREA LOT 4• WEST 1/4 CORNER 174,274 SQ. FT. / 4.00 ACRES SEC. 3 -31 -19 i AREA EXCLUDING R.O.W.: co (FND 1 ° IRON PIPE) 170,695 SO. FT. / 3.92 ACRES m TOTAL AREA LOT 5: 261,464 SO. FT. / 6.00 ACRES � NORTH LINE OF LOT 1 OF it 3 C.S.M. VOL. 12 PG. 3390 AREA EXCLUDING R.O.W.: I iv 226,782 SQ. FT. / 5.21 ACRES rn UNPLATTED LANDS Flo I - - -- - - - -- -- S88'S8'S3 "E -------- 889.55'-- - - - - -- - -- s - --- 397.87'- - \ 358.01' - - -- 265.77' 265.77' — — — — — - r 1 39.86' 33 I ~ I 10G' O,i I I T 4 oil Wi � . N :LO 5 LOT 4 LOT 3 v ZI cN JI � 3 c � N MI cp t O to O I �, = cp �p LO co I I I Q io co o to p QI 3 w ^ v LOT 2 w� Q - 2i sr I°'� 3 3L, �� C.S_M. ill f7 M a0I Q: IN i J M M W VOL_ 12 to ° n z c Z� : o ° P I. j PG. 3390 I m N O O Q V l I N W� I I I - --- -- .O Co I I R.O. W. ,� .............. ..,n.............. N I L ^ - N88'09'14 "W _ 884.32 -- 353.00' l 265.66_ 265.66' - — 399.60' - - — 265.77 - 265.77' F — — — — — — :N88' *58'53 "W 931.14 _ _ __ _ N UTH LINE OF THE NW 114 OF THE SW 114 232ND AVENUE i C'0& W � cli UNPLATTED LANDS 9 � 1 � LID 1 � I o M SOUTHWEST CORNER F ' �� SEC. 3 -31 -19 JOHNSON (ALUM. CO. MON.) S ' R' AMErtY, NOTE: The parcel(s) shown on this map is /are subject to State, County and W15. Township laws, rules and regtfttions ( i.e. wetlands, minimum I&ftize, access R O<L�` to etc ar, . or developing an parcel, contact the St. .1 - P - � . Before urchasin - - -p 9 P 9 Y P ._