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HomeMy WebLinkAbout032-1036-50-100 t P_ ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT Owner �a a / �C Address oo / City /State Legal Description: Lot �_ Block -- Subdivision/CSM # ' / +' /. 'Sec.4?, T N -R/W, Town of rne,- PIN # SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer cl f / � � -, 1.� ,� Size ST/PC / Setback from: House 3,f Well? 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: s rem Width _ Length Number of Trenche �2 Setback from: House Well P/L a L 722 Vent to fresh air intake ELEVATIONS Description of benchmark Elevation Description of alternate benchmark Elevation Building Sewer ST/HT InJ6? ST Outlet PC Inlet PC Bottom Header/Manifold !i? Top of ST/PC Manhole Cover z Distribution Lines ( ) Bottom of System Final Grade Date of installation // ermit number %✓ State plan number Plumber's signature License number _�o�� Date Inspector h- complete plot plan �* a ' Wisconsin Department o f i Commerce PRIVATE SEWAGE SYSTEM Count Safety and Buildings Di tT . CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar8P24Pv1jI4.: Personal information you provice may be used for secondary purposes (Privacy La s.15.04 (1)(m)]. �Qr1Ui2HnldesNam S � �Ei,Ca 1cie ❑Town of: State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description: CJ L�+C Parcel bSt 0 3 6-50-100 TANK INFORMATION U EL NATION DATA A9800625 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic , Benchmark / prs' �' qq, Dosing Aeration Bldg. Sewer a . /U Holding St /Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic '760/ NA Dt Bottom Dosing NA Header/ Man. �'7 / 9 7` 71 , Aeration NA Dist. Pipe Holding Bot. System r 2 PUMP/ SIPHON INFORMATION Final Grade — S.7, Manufacturer ca _), l �' Demand Model Number GPM TDH Lift Friction System TDH Ft H ead Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Widthy, i Length No. Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSION DIMENSION SETBACK SYSTEM TO P/L I BLDG WELL LAKE /STREAM LEACHING Manu INFORMATION Type Of �}t -per , CHAMBER Model Number. System: 4 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 E] No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: SOMERSET 13.31.19,NE,NW 749 220TH AVENUE - LOT 1 g4 ' 0 "6 Plan revision required? ❑ Yes [f No Use other side for additional information. SBD -6710 (R.3/97) Date Aspecto ignature Cert. No. 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. G,� • See reverse side for instructions for completing this application State Sanitary Pe it lu r r Personal information you provide may be used for secondary purp ses E] Check if to previous a plication [Privacy Law, s. 15.04 (1) (m)]. 7 - 1 r� , 0 1 jyt� . S State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT A INFO RMATION Property Owner Na Propert L c tion /4i/4, S / T , N, R� E (o Property Owner's Mailing A�,ess /„ 'at City— Lo Number B ock Number City, State - Zip Code I Phone Nu gr Subdivision Name o 2 (� 13, PA II. PE OF B IL ING: (check one) ❑ State Owned It rest Road L Public 1 or 2 Family Dwelling - No. of bedrooms j Tow O � ��rs c O u� 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 on line B, if applicable) A) 1.New 2 E] Replacement 3 E] Replacementof 4_ [D Reconnection of 5_ ❑ Repair of an ystem -- - - - - -- System ------- - - - - -- Tank Only------ - - - - -- 9 y Existing System Exist(n 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 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12eepage 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) f' Elevation Feet Feet VII. TANK Capacity in gallons Total # of Prefab. Site Fiber- plastic Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete con steel New Existing strutted Blass App. T nks Tanks Septic Tank or Holding Tank Er ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ 1 ❑ 1 ❑ I ❑ I ❑ 1 ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber' me: (Print) Plumbe 's SignatureX(Ntpmps �^ MP /MPRSW No.: Business Phone Number: Plu r' ddress (St et, City ate, ip Code): r IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signat re (No Stamps) Approved El Given Initial surcharge Fee) ✓ Adverse Determination 19k* X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.11/97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber rLU FLAN PROJEC _ ADDRESS l�_ 1 /4 G� 114 rr ////�� MPRS B Bird J 3318 DA E/ y =TOWN �o� `e_ COUNTY ' S BEDROOM - , CLASS PERC CONVENTIONAL LIFT_ MOUND CONVENTI L_ IN- GROUND PRESSURE SEPTIC TANK SIZE — HOLDING TANK «B� LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE ABSORPTION AREA o A D SIZE __ 3 � __BE �► Benchmark V.R.P. As Elevation R 1 00 E Location of Benchmark��� 0 Borehole Q Well Scale = Feet O Perc Hole - --- -_____ ystem Elevation y� , r A)& i d 3� /3�a r n ,o . Dis Department commerce SOIL AND SITE EVALUATION Division ion of f Safety and B ldings Bureau of Integrated Services in acco*nc ' with s. ILHR 83.09, Wis. Adm. Code Page °f Attach complete site plan on paper not less than 8 1 x`4 include, but not limited to: vertical and horizontal r e e p oh in qe. Plan must y ]] r percent slope, scale or dimensions, north arrow, V61 ation I M , and '7 -. 1 f b nearest road. Parcel I.D. # IN APPLICANT FORMATION - Please r t a// infq��i trot : ' R (2 32 -1©.; 6 O E'411 Personal information you provide may be used for sew (P �r�rrh P Property Owner % pu °ses If. s. 15.04 (tf (roi �' Z /� E Location t-tJl T NJ 1/4 4,S 3 31,N,R / E (or F r' Property Owners Mailing Address Lot # Block# Subd. Na or CSM# City State Zip Code Phone Number o r ❑ CitY ❑ village Town O r/ New Construction Use: residential El Public / Number of bedrooms Replacement -- Addition to existing building Code derived daily flow b 20 0 gpd Recommended design loading rate L bed, Q Absorption area required a 59 bed, ft2 2 g --s�tr . gpd* trench, ft Maximum design loading rate _ bed, gpd* , trench, gpd* Recommended infiltration surface elevation(s /7 9j�.� � cc�� r� � Additional desig (as referred to site plan benchmark) design/site considerations Parent material ?� Flood plain elevation, if applicable /L/Z ft S = Suitable for system Conventional Mound In - Ground Pressure AT - Grade S U = Unsuitable for system ystem in Fill Holding Tank ,�(s ❑ u s❑ u ,I� s❑ u .k� s❑ u ❑ S ' Rru ❑ s or u SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles in. Munsell Qu. Sz. Cont. Color Texture Structure Consistence Boundary Roots GPD/fl2 C3 Gr. Sz. Sh. Bed Trerxh Ground 3 Depth to limiting j �in. C2' 7 Remarks: Boring # al .-4-- ^ d V Ground elev. Depth to limiting LEE=- factor LEI �n. Remarks: CST Name (Please Print) ignature ^ f Telephone No. Address 6 v Date CST Nu �. Project Name David Sindt Soil Test Plot Plan Shaun Bi Address 683 200th Ave #16 Somerset Wi 54025 CSTM #3922 Lot --- -- Subdivision Date 3/30/98 NE 1 /4 NW 1/4S T 31 N /R W Township Somerset Boring Q Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft. Top of White Stake with Orange Ribbon System Elevation 97.6/95.2 *HRpSame as Benchmark Alt. BM Top of White Stake with Orange Ribbon @ 99.3 220th Ave 385' Pro 310 veway B B -4 30, B -2 w 10' 0 0 10% 40' Pri A ` Slope -3 ° o ep A lt. 35' r B.M 50' cu 10' B -5 0 B -1 Pro 3 or 4 Bedroom House 660' Property Line • y 5800 t7 CERTIFIED SURVEY MAP Located in port of the Northeast Quarter of the Northwest Quarter of Section 13, Township 31 North, Range 19 West, Town of Somerset, St. Croix County, Wisconsin. Prepared for and at the request of: OWNER: UNPL4TTED LANDS John Hanner ------- - -- - -- 1172 McKusic Road 2 2 0 T H AVENUE Stillwater, MN 55082 - -- - -- Drafted by. Krielt A. Eyiandt NORTH LINE OF THE NE 114 OF TH£ NW 11 4 CENTERLINE - - -- ------ NB8'35'41 - E 26 - - - - - 2201h A►re. N88 J lf 660.22' — N8 8 5'41 - E 2021.13' _ — `� _ _ _ _ _ _ _ _ _ _ N88'3541'E 660.22' NORTHN�ESr CORNER O 7 SEC. 13 -31 -19 w o R.O. W. w ( a .... .............. .. ... .......... ALUM. CO. MON.) -� o BUILDING SETBACK Ct j '� n �O Z LOT 1 I I TOTAL AREA h 871,200 SQ. FT. to U 0 20.00 ACRES o c Y ' I AREA EXCLUDING R.O.W. p � 1Z A -0 r� 849,413 SO. FT. w {` ' ^ 1 00 19.50 ACRES rn m o , j IZ o I ae ,r Iv) ID .oy 10 W 1� W N � IZ I *1 NO !a m 0 1 N OJ 0 N 2 I "' Q o� RONALD F. �, t 1 JOHNSON I AMi' 18433 Wt 1 A ( AREA POSSESSED BY OTHERS I ��� SUR so I N S88'30'44 - W 660.22' SOUTH LINE OF THE NE UNPLATTED LANDS 114 OF THE NW 114 s I NOTE: The parcel shown on this mop Is subject to State, County and Township laws, rules and regulations (i.e. wetlands. minimum lot size, access to parcel, etc.). Before purchosina or develooinn I