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HomeMy WebLinkAbout032-1009-90-100 (2) % V. S /. /'?. L-9,e q9 - W isconsin' Department of Commerce Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count § . CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary f2fE9144 Personal information you provice may be used for secondary purposes [Privacy w, s.15.04 (1)(m)]. Permit Holder's Name: I�Iitu.,Ll9*tge El Town of: State Plan ID No.: NDT , BRENT SUMJ;K 1" CST BM Elev.: Insp. BM Elev.: BM Description: Parce -90 -000 TANK INFORMATION ELEVATION DATA A9800505 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic A Benchmark /ad -lo Dosing Aeration Bldg. Sewer 7 11 3' Holding St /Ht Inlet q TANK SETBACK INFORMATION St / Ht Outlet �� y TANK TO P/ L WELL BLDG. Air I to ntake ROAD Dt Inlet Air Septic S / NA Dt Bottom Dosing NA Header / Man. q ' �a, qo, Aeration NA Dist. Pipe �r��,{ Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer .r , f_�_. -�, Demand .K�..x��, 2.3 Model Number GPM TDH I Lift Sri n $yst m TDH Ft ss Forcemain` Length Dia. Dist. To well S IL ABSORPTION SYSTEM BED/TRENCH width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSION SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: CHAMBER INFORMATION Type Of / At_u_1 Model Number: System: 1641 7 U � ' ' 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 4.31.19.59B,SW,NW 2323 40TH STREET Plan revision required? ❑ Yes ❑ No 1, Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. Vi sconsin Safety and Buildings Division S ANITARY PERMIT APPLICATION 201 Box Washington Avenue Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 4302 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Num r 3zq�/I 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 1. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION Property Owner Name Property Location 61 41 1/4 6W 1/4, S y T N, R I E (or) Property Owner's Mailing Address Lot Number Block Number 0 7 7 City, State Zip Code Phone Number Subdivision Name or CSM Number d fig G W • c ( ) �S /yl �,Q O / .? II. TYPE F BUILDING: (check one) ❑ State Owned " !t Nearest Road p Village Public 1 or 2 Family Dwelling - No. of bedrooms Town OF 5 e tr 9 e Yl �fi III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo ©3� ' lQ8 9 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. g New 2. ❑ Replacement 3_ I] Replacement of 4. ❑ Reconnection of 5, ❑ Repair of an ,______System ________System __________ _ __ Tank Only______________ Existing System _________ExfstlngSystem 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 Ej Seepage Trench 22 ❑ In- Ground Pressure / 42 Pit Privy 13 E] Seepage Pit c2 5 X 57 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 6 :� 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade 4�5'11y Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation If — 4 _I" 7 4 I VA— Feet Feet acit VII. TANK in Ca ga llon s Total # of r Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existin strutted Tanks Tanks Septic Tan an (j (� 7" ,� ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber, EIL 1 ❑ 1 ❑ ❑ I ❑ 1 ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: oStamps) PRSVWNo.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): l k Q� IX. COUNTY / DEPARTMENT USE LY ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuin Agent Signature (No Stamps) ] Approved [_ Given Initial / oa surcharge Fee) Adverse Determination t f /GYM X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.11/97) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber I h 0 �d�p �� • v� w ��' � fir G � h 0 � 0 gnn2 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 percent slope, scale or dimensions, north arrow, and location and dtanoe tonefir Parcel I. D. # 0 C79 APPLICANT INFORMATION - Please print all inform #tlom L- Revigwed by Date Personal information you provide maybe used for secondary'purposes (PnyaQY s. 15.04,(1) (m)). Property Owner emo6ilocation ; (e �rhG/ f/4 A1 �/ 1/4,S L T 3 N,R ` E (or Property Owner's Mailing i of #._..., Blogk# Subd. Name or CSM# <- City State Zip Code Phone Number ❑ City ❑ Village [ 3 Town Nearest Road I 4-1v �] New Construction Use: Residential / Number of bedrooms — / Addition to existing building ❑ Replacement I Public or commercial - Describe: Code derived daily flow gpd Recommended design loading rate ' ` bed, gpd/ft gpd/ft Absorption area required ft 7 tre cG� ft Maximum design loading rate bed, gpd/ft gpd/ft U P Recommended infiltration surface elevation(s) t' SF -rerv- In 97,.7— q 1 Z U ft (as referred to site plan benchmark) Additional design /site considerations 1 Parent material & lac i ,r L 4 i ' I 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 5a S ❑ U M S ❑ U � S ❑ U El S 0 U El S [,X 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 ! C v r 1 S L I ym bk, n S L rn b vh r • 5' Ground `1 -ll$ © ►' y FJ S C s elev. Depth to limiting factor in. Remarks: Boring # gmahk pi4l Ground elev. "ft. Depth to SS limiting factor I in. Remarks: CST Name (Please Print) Signature / Telephone No. c Address Date CST Number 30c Sw 5 L-u I �r per Wer At''' . DI � 3 o-+ 3S i S� bz� • ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Own , y�/� A 3uye r r.2 ie� / � t , ✓I Mail ; Address a - 3L 07 YD 57 T , (V)' 5-V d Z 5 Prop y Address -;� 3 a 3 -0 44-N S, f, (Verification required from Planning Department for new construction) City, ate Parcel Identification Number � 3z-- Iov9'9 U " LEC 1_ DESCRIP'T'ION Prop Location S 1) '/,, U) 1 /4, Sec. L , T_ / N -R / q 'W, Town of Sy�'I PrS2� Subc ision Lot # Ceri ed Survey Map # 528 12 Y , Volume 1 3 . Page # - 3 S2 War aty Deed # // F- /-/ 7 , Volume , 4�1 -�S , Page # 3� Spec Ouse ❑ yes .N no Lot lines identifiable Z yes ❑ no SYS K NI MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes_ Proper maintenance eonsi of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can a ct 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 mash umber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in per operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set R „ herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification statir hat your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 da ys �'he three year expiration date. ay 44 9e SIGP LURE OF APPLICANT DATE OW Ef ,R 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 F wrty described above, by virtue of a warranty decd recorded in Register of Deeds Office. SIGt ;i JRE OF APPLICANT DATE Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department, ** Ii cede 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 . CV FILED 588124 JLP 3 0 1998 ► KATHLEEN H. WALSH StgCroix Co Deeds Wi CERTIFIED SURVEY MAP; Located in part of the Southwest Quarter of the Southwest Quarter of Section 4, Township 131wNorth, e 9 West, Town of Somerset, tSt Croix County, Wisconsin. Prepared for and at the request of: APPWV OWNER: v v rn Brent v L) N t A Bren 40th Street � -4EST 1/4 CORNER o ° Somerset, WI 54025 // i SEC. 4 -31 -19 (F RR SPIKE) o N u Drafted by. Kristi A. Eylandt U o v N 8T, pXb& 4f - 2 a M CaMp o E U O z NO TH o 3 c o 0 s u H! w '� a a] UNPLATTED LANDS y y; �(� 3 >, c ----- - - - - -- - -c 1 I IMI p y c v 0 r I IpI �n NORTH LINE OF THE SW LL, � Z Z v 1/4 OF THE SW 1/4 ^ ° a v I 1 ,I �a �3 ° - S89'58 05 E 657.43 I • Lj ' ai o - - - -, 'v a y 628.01' \ 31�Z� �`'� o I ! ,: ,,. 7.5 to M m c o a� ti� �I j,� i 3� %`` 29.42' I \ 111 N 0� i° o 2 � c 1 O O V Z c — ° v of ��,' , 100' •W LOT N o,�v —'I i III ,� - ►: j TOTAL AREA v i I L` 11 R m o v° •a �i i I Io �M i 346,490 SO. FT. i tyi c o C v o 0 I I I co I C 7.95 ACRES `� o U LL 0 o v 9 4 ' c Q _ _ 1 w -w =' M.- wi LOT I i�� �� I AREA EXCLUDING R.O.W.: dH `,�N Uj —_� _ _ —'o , I I ' i := 330,537 SQ. FT. � Q v` a 3 a 7.59 ACRES ? 0 cn r a 4) 'o N .Q1 i t w Z�- L ot DI ~� N I I I ' p I I Q Q \ U F c a.x 1 -I LL, �1 WI '1 .N. I I S N m� O °° O 01 O, (;5 1 W 0 I/ I I Z 2 -0 —'I �i o �i o I / N89'55'24 "E 657.83' 5.0' 1 i1 a, I C) N I 1 626.76' / I " � d - — — —(.q- _ !! 1 31.07' ,I N I J W •W I 1 c0 pl O � G I �3 �I N� Cal O ~ I 1 rq 'I if 0 i�i W 1, CCN I I � � i 1 i :: LOT 2 + o� �S'�`4 IN Iad i } �` TOTAL AREA• �° I i j �0 %8 01 1 U rn 1, LD F. I 520,092 SO. FT. I C� m I JOHNSON a �, � 11.94 ACRES � ' , Q � W , 1 s— 1 W c� RY >i CC o I I I f i AREA EXCLUDING R.O.W.: i i I A 473,936 SO. FT. I I 10.88 ACRES I p� .,'�• � il � N° s U R VE� .a ~v. p ���a>r J i` I j BUILD /NC SETBACK LINE I 1 ( O l� \ j I .. .. 1 SOUTH 114 CORNER I / ... .. M. ..I. "- Q R.O.W. . •f 1 1 I , SEC. 4 -31 -19