HomeMy WebLinkAbout032-1031-50-600 i
ST. CROIX COUNTY ZONING DEPARTMENT
AS BUILT SANITARY REPORT
Owner _ o B�1r,t-
Property Address i
City /State
A i d'.CSA ,.,•
' Src 6 �n
Legal Description: ^',� ca R
Lot Block — Subdivision/CSM # S"
1411,V t /4, Sec. , TAN -R 9 W, Town of PIN #
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION
Tank manufacturer - Size ST/PC Q / Setback from: Housed Well ZL 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 3 Length Number of Trenches
Setback from: House � Well of P/L 1,!� Vent to fresh air intake /0a
ELEVATIONS
Description of benchmark �N Elevation leAl
Description of alternate benchmark ,,�S. %/ ,�.� iJ�HI��� Elevation
Building Sewer ST/HT Inlet : ST Outlet i'-1, 1 /7 PC Inlet
PC Bottom Header/Manifold — 2?, SB Top of ST/PC Manhole Cover
Distribution Lines ( ) () ( )
Bottom of System () 907,
Final Grade
Date of installation ?6?3/ P it number State plan number
Plumber's signature �; ' 1 �� License number d ��� 7 Date /
Inspector _
Complete plot plan
V
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Coun19T. CROIX
Safety and Buildings Division INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanita3yf@ r_" gto.:
Personal information you provice may be used for secondary purposes [Privacy ow, s.15.04 (1)(m)].
Permit Holder's Name: F-1-1 EA�ilJjjge ❑ Town of: State Plan ID No.:
TONER, RHONDA
CST BM Elev.: Insp. BM Elev.: BM Description: ParcelQe10 — —
/00 TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI 7 FS ELEV.
Septic Vl.� Q� 6bC� Be c rk G /� /f�G -/ 16
Dosing _ 14 -f- 4 7 61 q(,
Aeration Bldg. Sewer /A6• /3 /D $g S a
_r-
St Inlet
Holding /qG, 11
TANK SETBACK INFORMATION I St/ IErt Outlet qQ, /� �� q L/ `/
T TO P/ L WELL BLDG. Air in ROAD Dt Inlet
Set -4 5Z �7 r �Qj' NA Dt Bottom
A
Dosing Header /Man.
Aeration NA Dist. Pipe
Holding Bot. System /DG• /� /.(o q �'o�.
PUMP / SIPHON INFORMATION Final Grade (oG W °!/ / 2 4
Manufacturer and 54, W,, / ( fi , //I(>,•t /
Model Number GPM
TDH I Lift Friction_,_ •. stem TDH Ft
Loss _M
i
Length Dia. Dist. To well
SOIL ABSORPTION SYSTEM
BED RENCH Width r Lengt No. Of enches PIT No. Of Pits Inside Dia. Liquid Depth
DIM -7&.z 'd DIMEN 1 N
LEACHING Manu acturer*
SETBACK SYSTEM TO P/ L BLDG WELL LAKE /STREAM /„ 1"; /./
CHAMBER Mo a Num er: .
INFORMATION Type r
Syste {j { fjU '�'`^ OR UNIT
DISTRIBUTION SYSTEM
Header / r?ifold Distribution Pipe(s) I ' x Hole Size x Hole Spacing Vent To Air Intake
Length � Dia. L Length (L ��Bfa. `E 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 E] No E] Yes E01 No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: SOMERSET 11.31.19,SW,NW 618 LAKESIDE "LANE — LOT 6
1 If; - �� Q �dt -Sid\ v�.b
; z,-1m % o �a V\ - �¢.�{�►� the �# ' �
Plan revision required? Yes ❑ No H
Use other side for additional information.
SBD -6710 (R.3/97) Date Inspector's SWnature ert. No.
A lsConsin Safety and Buildings Division
SANITARY PERMIT APPLICATION 2 1 B W shingtonAvenue
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 Count
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 if revisi on [o pre (p
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N
Prop Owner Name Property Location
va va, S T , N, R �or
Property Owner's Mailing Addres Lot Number Block Number
et 2
r
City, State Zip Code Phone Number Subdivision Name or CSM N um er
S - ( )
II. TYPE OF BU LING: (check one) ❑ State Owned its Near st Road
Fl Public 1 or 2 Family Dwelling - No. of bedrooms r Town of -�
III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo /,o '52/7 v leo
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. M 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 &PLO;Gf ( 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 gSeepage 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. ate 6. System Elev. 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/d /sq. ft.) (Min./i ch) Elevation
Feet Feet
VII. TANK Capacity
in gallons Total # of Prefab. Site Fiber- Ex p er.
INFORMATION New Existin Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic A p p
Tanks T
strutted
Septic Tank or Holding Tank ❑ ❑ 1 ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber El El El El 11 El Vlll. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for iriatallatiog oft the onsite sewage system shown on the attached plans.
Plumb s N me' �rI Plum is gna S s) MP /MPRSW No.: Business Phone Number:
Plumber's Address (Strut, City tate, Zip e):
. C ; 7 9 , – A0X Z
IX. COUNTY / .• D �� DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater 4 te ssue Issuing Agent Signature (No Stamps)
A roved Surcharge Fee) l
pp [ Given Initial o0
Adverse Determination 5� t •0.
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD- 6398 (R.1 DISTRIBUTION: Original to County, one copy To: Safety & Buildings Division, Owner, Plumber
Safety and Buildings Division
V hc�6onsin SANITARY PERMIT APPLICATION 2 01 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 8 112 x 11 inches in size.
• See reverse side for instructions for completing this application State Sanitary Permit Number 9
Personal information you provide may be used for seconds purposes 3 a 0
[Privacy Law, s. 15.04 (1) (m)],
El Check if revision to previous application
State Plan I.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION
Pro pe caner Name Property Location
1/4 q j j 1/4, S IZ T , N, R r o
Propert Owner's Ma' ing Address Lot Number Block Number
r
City ate Zip Code Phone Number Subdivision Name or r
S ( ) S"
IL IL IN (check one) ❑ State Owned it� ear st Road
Public 1 or 2 Family Dwelling - No. of bedrooms M Town of
III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) ^
1 ❑ Apartment/ Condo 8 . 3
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, DK New 2. ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of - 5. ❑ Repair of an
- - - - -- System -- - - - - -- System ---- --- - - - - -- Tank Only -- Existing System System
stem
---------- - - - - -- -----------------------
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
11fi� 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 1 3. Absorp. Area 4. Loading Rate S. Perc. ate 6. System Elev. 7. Final Grade
Requ re� q, ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /i ch) Elevation
Feet Feet
VII. TANK Capacity
INFORMATION in gallons Total # of Prefab. Site Fiber-
Gallons Tanks Manufacturers Name Con- er.
glass Plastic App
New Existi an
n Concrete structed Steel
Tanks Tanks
Septic Tank or Holding Tank — _ ® ❑ ❑ ❑ 1 ❑ ❑
Lift Pump Tank /Siphon Chamber, ❑ ❑ ❑ I ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the ndersigned, assume responsibility for in llation of the onsite sewage system shown on the attached plans.
Plum e ' Name: rin Plumbe s nat o a MP /MPRSW No.: Business Phone Number
r
3 / =
Plu ber's Address (SY et, C y, State, Zi ode):
IX. COUNTY / DEPARTMENT USE ONLY
` A
E] Disapproved Sanitary Permit Fee (Includes Groundwater [ ssue Issuing Agent Signature (No Stamps) ) Pp ❑Owner Given Initial [ roved �1 Surcharge Fee)
/ _ J
�� Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
.SBD- 6398 (8.11197) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber '
s
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I
5
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7
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Wail '
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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 �Z Y'
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D.
O
APPLICANT INFORMATION - Please print all information. Rev ed Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). 2
Prope ner Property Location
Govt. Lot 114 1/4,S T N,R E (or
Pr erty Owner's Mailing Address Lot # Bloc # Subd. Name or C M#
s�
Ci State Zip Code Phone Number El city ❑ Village IR Town Neare oad
i f s ( -
New Construction Use: JZ Residential / Number of bedrooms Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow gpd Recommended design loading rate 7 bed, gpd/ft trench, gpd /f1
Absorption area required /_ y5 bed, ft
trench,
,ft/2p Maximum design loading rate f bed, gpd /ft trench, gpd/ft
Recommended infiltration surface elevation(s) t2' 7 / ft (as referred to site plan benchmark)
Additional design /site considerations
Parent material 4 "& . :x/ Flood plain elevation, if applicable 4� ft
S
U = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
= Unsuitable for system �Z S ❑ U 0 S ❑ U JZ S ❑ U I �Z S ❑ U I ❑ S 2 U ❑ S 0 U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth I Dominant Color Mottles Structure GPD /ft2
in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots
Bed , Trench
Z I,. -
Ground
I
pp
Depth to , >' RECEIN • ,
limiting
factor 1 MA A W
Remarks:
Boring # I
Ground
� S
elev.
9�ft.
3
Depth to ^
limiting 1
factor
��in. Remarks:
CST Name (Pie a Pri ) Signature Telephone No.
Address 1 D CST Number
eV
z
o �t
I z �
1
Wisconsin•Department of Industry SOIL AND SITE EVALUATION
Labor and Human Relations Page of
Division of Safety and Buildings 1� i�1 r < e with s. ILHR 83.09, Wis. Adm. Code
Attach complete site plan on paper no an 1/ hes ' sR Plan must County
include, but not limited to: vertical a zontalqNt ;int (BM ; d* ction and
percent slope, scale or dimensions, rth arrow, and location and distant to nearest road.
Parcel I. D. #
I APR 2 . 1997
APPLICANT INFORMATION- Please prygn"form i Reviewed by Date
y
Personal information you provide may be u d for seconds
a Lraa s. 15.04 (1) (m)).
Prope Owner
Property Location
Govt. Lot 1/4 1/4,S T N,R (or�
Property Mailing Address Lot / # . Block# Subd. Name or CSM#
C G Stat
Zip Code Phone Number
( El City El Village Town Nearest Road
S S
�] New Construction Use: Residential / Number of bedrooms Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow gpd Recommended design loading rate bed, gpd/ft trench, gpd/ft
Absorption area required bed, ft trench, ft?
Maximum design loading rate �Z bed, gpd/ft trench, gpd /ft
Recommended infiltration surface elevation(s) 215 ft (as referred to site plan benchmark)
Additional design /site considerations
Parent material Flood plain elevation, if applicable ft
S = Suitable for system Conventional M� In- Ground Pressure AT -Grade System in Fill Holding Tank
U = Unsuitable for system S❑ U X S E-1 U X S El -o S❑ U ❑ S W U El S U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Structure
in. Munsell Qu. Sz. Cont. Color Texture Consistence Boundary Roots GPD /ft2
Gr. Sz. Sh. Bed Trench
i
Ground
g elev.
Depth to
limiting
factor
Remarks:
Boring # Aj
Ground _
elev.
Depth to
limiting
factor
,9_�in. Rema ks:
CST Name (Pleas rint) Signature Telephone No.
Address Date
CST Number
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer 'r" cs�ere
Mailing Address r l X 9 1 4L,!� r Jaj r�el_3 r'hmo LL,' i s `Ad I 1
Property Address �Z _ �J p ,� ,� P p - y e- 1_�� Oa
(Verification required from Planning Department for new construction)
City /State Parcel Identification Number v a I b -3 - SO - 6 00
LEGAL DESCRIPTION
Property Location 6 '/4, #0 '/4, Sec. _41_, T_,&_N -R_L5� W, Town of
Subdivision , Lot #
5 73 - 7 1 1
Certified Survey Map # _ , Volume 1 , Page #
Warranty Deed # 5 (o , Volume � o , Page #
Spec house ❑ yes ❑ no Lot lines identifiable K 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 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 year expiration date. 9 Q
IGNATURE 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.
SIGNATURE 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
b
_ m 3' D
r n 3 0'
J [� FILED
7< :7 y y O N C
G u x ® APR 2 4 1997 ►
5 58,374 �' $ m Z w 9
o St CrObt (�O, MA
UNPLi I CD LiaNDS �, r
00
C.T. H. II I FI
WEST LE OF THE NW 1/4 ft
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E 746.27' — �0 ° 35'00 "E s`L
361.00 385 —�-
5 771 1324.98'
328.00' 385.43' w m
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PARCEL IN V. SJC' PG. 531 0 0