HomeMy WebLinkAbout032-1047-30-120 ST. CROIX COUNTY ZONING DEPARTMENT `
AS BUILT SANITARY REPORT f % { Y(;F_j,,(r
Owner
Address s; crux ,..
City /State �,�r.rF "� / ),r,�"��� c ouNTY
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Legal D cription:/ (� 1
Lot Block Subdivision/CSM #
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'/+ 5 ' /., Sec. ,6, T, -RAW, Town of e PIN #
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION
Tank manufacturer Size ST/PC Setback from: House Well ._;z/ 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: 2_g o Width �_ Length Number of Trenches
Setback from: "House Io- Well P/L _Pe Vent to fresh air intake t-/oo
ELEVATIONS
Description of benchmark Elevation
Description of alternate benchmark ,. AFs;p Elevation / /z. -y9
Building Sewer / //; �.3 ST/HT Inlet /1,o ST Outlet- / /0, s PC Inlet
PC Bottom Header/Manifold /D6, _2W Top of ST/PC Manhole Cover
Distribution Lines
Bottom of System
Final Grade
Date of installation q & P mit number _ ?o7791 State plan number -
f
Plumber's signature License number ,f Date 8/ /
Inspector "en, ,
complete plot plan
= Wisconsin Department of Commerce
Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count9 CROIX
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar�yPefp�ixAlo.:
Personal information you provice may be used for secondary purposes [Privacy w, s.15.04 (1)(m)].
Permit Holder's Name: nn Ci ❑❑yy�( e
AINES , DONALD Town of: State Plan ID No.:
501�IE1�SE
CST BM Elev.: Inq BM Elev.: BM Description: Parcel
! 0 0 IOL2 go(\ -0 1 — 5 ,, 1,4 CS7FS d 1047 -30 -110
TANK INFORMATION ELEVATION DATA A9800181
TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV.
eptic
Benchm q8 1 3- T3 -z.
1 DC7
Dosing L l g� pc `
Aeration Bldg. Sewer 7 >—
Holding St Ht Inlet �, 55 // 0 . -7
TANK SETBACK INFORMATION St Ht Outlet
TANK TO P/ L WELL BLDG. AirI to ntake ROAD Dt Inlet
Air I
eptic GO' / 2�/ a-7 NA Dt Bottom
Dosing NA Header / Man. '
`7• o? l06 - g
Aeration NA Dist. Pipe � I ce, -0
Holding Bot. System 9, 7L l S O
PUMP/ SIPHON INFORMATION Final Grade 3 ��--
Manufacturer De nd C e' . V
Model Num /
TDH ift Friction System TDH Ft
Forcemai n F f Dist. To well
BSORPTION SYSTEM
BE - RENCH width Length 7 + No. Of Trenches PIT No. Of Pits Inside Dia. Liquid D th
1 N DIMENSION
SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEA G
INFORMATION T
? j� + ba C � J OR U BER M e N er.
DISTRIBUTION SYSTEM
Header / Manifold � N Distribution Pipe (s)� x Hole Size x Hole Spacing Vent To Air Int' ke
Length Dia. "Y Len th /
g Dia. of Spacing S11 A 1 0
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 16.31.19.239A10,SE,SE 2120 CTY RD I
(4 ' - q 4 1`71- q
�j � t �
' Plan 1eviPoi( re2i ed? ❑ Yes I No
Use other side for additional inform(�tion. C ' f g C,,t SBD -671 0 (R.3197) Date Inspe is Signature .
SANITARY PERMIT APPLICATION 201 E.W Washington Ave.
ion
Visconsin 2 01 E. Washington Ave.
In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
Department of Commerce Madison, WI 53707 -7%9
• Attach complete plans (to the county copy only) for the system, on paper not less Count!::z
than 8112 x 11 inches in size.
• See reverse side for instructions for completing this application State Sanitary Permit Number
The information you provide may be used by other government agency programs ❑ Check it revision to�vi us application
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
opti I. APPLICATION INFORMATION - PRINT ALL INF RMATION
Propert wner Name Property Location
S 1/4 1/4, S T , N, R or 1 9,
Property Owner's Mailing Address Lot Number Block Numb r
1
Cit State Zip Code Phone Number Subdivision Name or C5b&Number
( ) -
11. TYPE OF BUILDING: (check one) E] State Owned E] ity NearestRoad
Lj Public 1 or 2 Family Dwelling - No. of bedrooms ❑ Town of
III BUILDING USE (if building type is public, check all that apply) Parcel Tax Number(s)
1 [] //"" `�
Apartment/ Condo �' /- /'? �
• Q3'?4 ,2 �, 10'1 —�
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 lane A. Check box on line B, if applicable)
A) 1. ® New 2. ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of -5_ ❑ Repair of an
- - - - -- System n
-------- System ------------------- Tank Only ------------- - - Existing g 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 M 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/day /sq. ft.) (Min�/hch) Elevation
S Feet Feet
VII. TANK Capacity
INFORMATION in gallons Total # of Prefab. Site Fiber- Ex er.
Gallons Tanks Manufacturers Name Con- Steel Plastic p
New Existin Concrete strutted glass App.
Tanks Tanks
Septic Tank or Holding Tank A& ® El El El ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ I ❑ ❑ I ❑ I ❑
VIII. RESPONSIBILITY STATEMENT
I, the yndersigned, as me responsibility for inst a ' n pf lbonjte sewage system shown on the attached plans.
Plum er' ame: r Plumb 's atur . m MP /MPRSW No.: Business Phone Number:
, — L
Plum er's A( ree , City, Stmt , Zip Cod
r� 1
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary P ermit Fee (Includes Ground water ] Date Issue ]I Lent Signature (No Stamp
/ qA roved surcharge Fee) -
/ � _
pp ❑Owner Given Initial
Adverse Determination C
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
$BD -6399 (8.11/96) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber -
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vuj sconsir� Department of Industry SOIL AND SITE EVALUATION
Labor and Human Relations —_._ Page of
Division of Safety and Buildings jn - *499ofdraSge I S. ILHR 83.09, Wis. Adm. Code
`'' ;\
Attach complete site plan on paper not less thttn $,9/2 x nMsized € la must County
include, but not limited to: vertical and hon lrtalireferen )di vft nd /'
percent slope, scale or dimensions, north rgvr'and location and distance to-`,naa road. St v r D • t
W/ Parcel I. D. #
r
APPLICANT INFORMATION - P/ sef rint a�ri at�on. 3 — ib - L b p
r r , Reviewed by Date
Personal information you provide may be used fors onsgry P P9 N (t) (m))
Property Owner ` Property Location
Govt. Lot 5E 1/4 SE 1 /4,S 6 T 3) N,R 1 E (orQW
Pro erty Owner's Mailing Address '- Lot # I Block# Subd. Name or CSM#
P. �L oc 4 la
City S to Zip Code Phone Number El city ❑ Village ®Town Nearest Road
ovncr t,+ �. S N 615 (_715 ) ( i I r C, t - F + R,
[& New Construction Use: [?Residential / Number of bedrooms Addition to existing building
❑ Replacement ❑ Public or commercial - Describe: +
Code derived daily flow q S O gpd Recommended design loading rate 77 _ bed, gpd /ft ► a trench, gpd/ft
Absorption area required 64 3 bed, ft 5 trench, ft
Maximum design loading rate " I bed, gpd /ft trench, gpd /ft
Recommended infiltration surface elevation(s) 2 1 3 ( 105. 20 3 5 ( 10 Y. pq� ft (as referred to site plan benchmark)
Additional design /site considerations D C>t �I $o r V �,� mg p�
Parent material i ` "t W 0. r C Flood plain elevation, if applicable / ft
S =Suitable for system Conventional Mound In- Ground Pressure �A -Grade System in Fill Holding Tank
U
— =unsuitable for system I�S ❑ U �S El [A S ❑ U [�� S ❑ U ❑ S U CIS 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
1
I F56YL hv 5 r . g
Ground 3 ai33 7,S R. S/ S
elev. Q- M L G W _' 7 .2
qj
Depth to
limiting
factor
0 in.
Remarks:
Boring #
o -°I oY P 31,E ca
s - r^ L GW I
r ^L
Ground 7 - 0 4 )
elev. -5 %n L • 7 $
103 ►eft.
Depth to
limiting
factor
90 in. Remarks:
CST Name (Please Print) Signature Telephone No.
'S S+arY.. 1 5 -a4$ -3-S 9
Address Date CST Number
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II I
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer -
Mailing Address
Property Address -- �--
(Verification required from Planning Department for new construction)
City /Stat,, >� VL�L Parcel Identification Number , /f��`� -SD J
LEGAL DESCRIPTION
Property Location � '/4, -fzE '/4, Sec. �1� T L N -R Town of sr��lscf
Subdivision , Lot # �.
Certified Survey Map # S'�: / /�'? , Volume J , Page #
Warranty Deed # Volume Page #
Spec house ❑ yes J" no Lot lines identifiable A 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 I Department a certification form, signed by the owner and by a
master, plurrtber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewat. rdisposal 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.
I /we, the widersigned 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 C ommerce and the Department of Natural Resources, State of Wisconsin. Certification
stati at your septZexp has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
ys of a three y par o�n �date.
SIGNATU i {E O APPLICANT DATE
OWNEI ` CERTIFICATION
I ; ve) certify that aI tatements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
e pro en descri abo , by virtu of a warranty deed recorded in Register of Deeds Office.
S ATURE 6F XPAICANT DATE
* * * * ** Any information that is mie r�prr m ay result in the sanitary permit beinp, revoked by the Zoning Department. * * * * *•
** Inrluth' ��illl Ihl� ttlnlnlit ttllnu .1 ,l ill-rd fiomt the of(ict.
it copy of the certified survey map if reference is made in the warranty deed
/�
i
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yy FILED
SEP 0 9 1997 ► i
E; ` KATHLEEN H. WALSH f;
Register of Deeds
SL Croix Co., WI �
LOT 2 CSM VOL. 8, PG. 2116_
(N00 0 16 1 30 11 W 660.06 O IV
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