HomeMy WebLinkAbout032-2114-10-000 ST. CROIX COUNTY ZONING DEPARTM
AS BUILT SANITARY REPORT
Ownet
Property Address
City /State
Legal Description:
Lot _� Block
. A Subdivision/CSM #
t /,,a� t /4, Sec. -,f , T, N -R,aW, Town of - PIN # A3- - 9D -oars
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION
Tank manufacturer Size ST/PC / Setback from: House Well _(� 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: , & Width /,,q Length Number of Trenches
Setback from: House Well _qs' , P/L : j14 Vent to fresh air intake Si*�
ELEVATIONS
Description of benchmark % - , Elevation / &,,i
Description of alternate be nchmark 0 ,,� //1 Elevation
Building Sewer ST/HT Inlet ST Outlet 9376 PC Inlet
PC Bottom Header/Manifold 9/, 97 Top of ST/PC Manhole Cover
Distribution Lines () 2Z,75' ( ) ( )
Bottom of System ( ) 2,r �s? O ( )
Final Grade
Date of installation ermit number z yS State plan number
Plumber's signature License number Dat
Inspector
Complete plot plan
NOTICE: 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.
PLAN VIEW
A eA s
INDICATE NORTH ARROW
Wisc6nsin Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and Buildings Division CountbT . CROIX
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary�e,Cr�itJ
Personal information you provice may be used for secondary purposes [Privacy s.15.04 ( & G INC. 1)(m)]. 3 UULL
Permit Holder's Name: a Town of: State Plan ID No.:
��ES�
CST BM Elev.: � Insp. BM Elev.: BM Description Parcel
&J o.:
— 2114 -10 -000
TANK INFORMATION ELEVATION DATA A9800484
TYP MANUFACTURER CAPACITY STATION BS HI FS ELEV.
eptic Ben and r - 2 7 TZ7
Dosing ,4J 3.3
Aeration Bldg. Sewer [1 ,G • �S`
Holding (9 / fit Inlet
rg q3.
TANK SETBACK INFORMATION "t Outlet ;� R
to
TANK TO P/ L WELL BLDG. Air Intake ROAD Dt Inlet
eptic ' Db� r NA Dt Bottom
Dosing NA Header / Man. $
Aeration NA Dist. Pipe
1
Holding v g •Z
g Bot. System Q�
PUMP/ SIPHON INFORMATION Final Grade 0 /`/ G3
Manufacturer mand m,
Model Number GPM
TDH Lift L Syste TDH Ft
Forcemain Length Ia. Dist. To well
SOIL ABSORPTION SYSTEM
BED / RENCH Width Length / No. Of Trenches PIT No. Of Pits Inside Dia. Liquid � De t
- DWE NSIONS DIMENSION
SETBACK
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION Type t /] CH Mo e N er:
syst OR U T
DISTRIBUTION SYSTEM
Header/Manifold r Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length � Dia. Length ( Dia. Spacing A 5 r
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 El ❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: SOMERSET 3.31.19,NE,SW 2322 53RD VREET — MEADOWOODS LOT 1
n4 ola Si /l c. ova r��7`
/T � • Alf
Plan revision req fired? ❑ Yes No 4
Use other side for additional inforn'iation. jL
SBD -6710 (R.3/97) Date Inspector's Si atu e . No
Vi Safety and Buildings Division
SANITARY PERMIT APPLICATION 201 W. Washington Avenue
In accord with ILHR 83.05, Wis. Adm. Code P O 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 8 112 x 11 inches in size. S
2
• 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 revision t p Zouk a lication
[Privacy Law, s. 15.04 (1) (m)].
j a_ s �/ State Plan I.D. Number
1. APPLICATION INFORMATION- PLEASE PRINT ALL INF RMATION �—
Propert wner Name Property Location
1/4 5 1/4,5 T . , N, R E (or
Property Owner's Mailing res Lot Number Block Number
City tate Zip Code Phone Number S bdivis ame or CSM Number
II. T YPE OF B IL IN (check one) ❑ State Owned ❑ It� Nearest Road
Public 1 or 2 Famil Dwellin - No. of bedrooms _ [I Town OF ' dam
III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 4Z
1 171 Apartment/ Condo 3 ' !
9 Q 3� - �Il 4 r
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. ;4 New 2 ❑ Replacement 3. ' ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an
- - - - -- System - - - - - -- - -------- y 9 Y - y
System Tank Only Exi sting 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 JA 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 ❑ 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/da /sq. ft.) (Min Inch) Elevat'on
- �� Feet Feet
VII. TANK Capacity
INFORMATION in gallons Total # of Prefab. Site Fiber- Ex er.
Gallons Tanks Manufacturers Name Con- Steel Plastic p
New Existing Concrete strutted glass App.
Tanks Tanks
eptic Tank — ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ 1 ❑ I ❑ I ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, theAindersigned, assume responsibility for ins Ilat' of a onsite sewage system shown on the attached plans.
Plum r' Name (Pr ) Plumber' S at o s MP /MPRSW No.: Business Phone Number:
Plumber's Address (Street, Ci , State, Zi ode):
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued ssuin gen Signature (No Stamps)
A roved Adverse Determination Surcharge Fee) /
® pp El Given Initial / �O 60 / �
l
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD- 6398 (R.11197) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
-gol"Xesal s ' s
A
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,eiew l oex
Jo� g ss
Wisconsin Department of Commerce SOIL AND SITE, EVALUATION Page 1 of 3
Division of Safety and Buildings
Bureau of Integrated Services in accordanc,� wtthj s: IL( - I�i 83Q, Wis. Adm. Code
Attach complete site plan on paper not less than 8 1/2 x 11 ing6es`in siz zR�t� County
include, but not limited to: vertical and horizontal reference in# j$M), d�6l ficW a
percent slope, scale or dimensions, north arrow, and locatio 4nd' distance to nearest road parcel I.D. #
APPLICANT INFORMATION - Please print all ObimatiorfT '' " ' ` Reviewed by Date
Personal information you provide may be used for secondary purposes epvaCy Lavv
Property Owner Prop@rty:lbcalion
Richard Stouter GoYt•1Lo NE 1/4 Sw 1/4,S T N,R 1 E (orV
Property Owner's Mailing Address of # Block# Subd. Name or CSM#
1353 Awatukee Trail 1 Meadowoods
City State Zip Code Phone Number ❑ City ❑ Village ® Town Nearest Road
Hudson ri 54916 (715 X496731 Somerset 232nd Ave
[;New Construction Use: f] Residential / Number of bedrooms 4 Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow 600 gpd Recommended design loading rate . 7 bed, gpd /ft gpd/ft
Absorption area required 8 5 8 bed, ft 750 rench, ft Maximum design loading rate - 7_ bed, gpd /ft gpd/ft
Recommended infiltration surface elevation(s) See plet plan ft (as referred to site plan benchmark)
Additional design /site considerations
Parent material CoC2 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 S❑ U I k JS ❑ U jP S❑ U I P S❑ U ❑ S u ❑ S P u
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
1 1 _ _ tviSb k
2 -36 10 r4/6 Isicl 2XS47 mf --
Ground 3 36-89 10yr4/4 Ms 0 sq ml cs --
elev.
9 4 -6 - Oft .
Depth to
limiting
factor
8 9 in. at
Remarks:
Boring #
P. i I yrt
2 2 16-81 10 r4/4 -- s osq ml cs --
Ground
- elev.
92. ft.
Depth to
limiting
factor
-8-1— Remarks:
CST Name (Please Print) ZS'inature Telephone No.
y ) SC _ / Z
Address Date CST Number
G -?b c .,. ,d r/\, W �
1
SyST:e
Y
•QM�.
D
i
Z- e- S o J e( }y h' n e-
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERS141P CERTIFICATION FORM
Owner/Buyer tm d
Mailing Address e 0, f (o 2 w i G-1 b D. 5
Property Address a
(Verification required from Planning Department for new construction)
City /State wpm Parcel Identification Number Q3 Q - 1n0 Lp -!2O- 00
LEGAL DESCRIPTION
Property Location ,a- ' / <, J ' /4, Sec. TN -R W, Town of
Subdivision l0cr, L'�l D c� - . 2) , Lot # —I
Certified Survey Map # , Volume , Page #
Warranty Deed # ; f���GS�` — ,Volume /, ,Page # _ 3�
Spec house yes ❑ no Lot lines identifiable,F�yes ❑ no
SYSTEM MAINTENANCE
Improper use and maintenanceof 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 wastewaterdisposal 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
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 three yea expiration date.
r
SIG ATURE 0 1 APPLICANT DATE
OWNF,R CERTIFICATION
I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) ant (are) the owner(s) of
the property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
SIG ATURE 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
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ST. CROIX COUNTY
WISCONSIN
�.� ZONING OFFICE
r r r r r r r r r ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
Hudson, WI 54016 -7710
(715) 386 -4680
February 15, 1999
REMAX Team 1 Realty
Attn: Stacy
103 Main Street
Somerset, WI 54025
RE: Septic Inspection for M & G Inc. located at 2322 53rd Street,
Lot 1 of Meadowoods, Town of Somerset, St. Croix County, Wisconsin
Dear Stacy:
A septic inspection of the above referenced property was conducted on January 29, 1999.
This property is located in the NEA of the SW% of Section 3, T31 N -R1 9W, Lot 1 of
Meadowoods, 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.
Si rely,
od Eslinger
Assistant Zoning Administrator
/sm