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HomeMy WebLinkAbout032-2100-60-000 ST. CROIX COUNTY ZONING DEPARTMENT J � AS BUILT SANITARY REPORT `. Owner r Address �✓� r �, �� City /State cou,Rvc »x l s ZONINGO FICE v Legal Description: / f Lot �_ Block Subdivision/CSM # %+ ,&L '' /, . �A) Sec. .. T N -R � 1-7 .W, Town of _� „�C� PIN # _. 2.� --�i� • -�r'� SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer Size ST/PC / Setback from: House ,Z,�I_ Well , P/L q,� 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: ,4c� Wid —.Z� Length 1 ' Number of Trenches Setback from: House 0_ Well P/L / Vent to fresh air intake ELEVATIONS Description of benchmark - Elevation o Description of alternate benchmark _ Elevation oe, Z% Building Sewer STM Inlet ST Outlet U7 2 7 PC Inlet — PC Bottom Header/Manifold Top of ST/PC Manhole Cove Distribution Lines Bottom of System Final Grade () () ( ) Date of installation // / Pe mit num e 20 77 s State plan number Plumber's signature i -� / License number 1 C3 Date / F Inspector ,,�,� Complete plot plan or x Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Y' Count Safety and Buildings Division INSPECTION REPORT ST. CROIX GENERAL INFORMATION (ATTACH TO PERMIT) sanitarI;esmjtNA.: Personal in fo rmation you provice may be used for secondary purposes [Privacy L , s.15.04 (1)(m)]. HARTMAN M E [j8k&g"e []Town of: State Plan ID No.: CST BM Elev : Insp. BM Elev.: BM Description: 0 Parcel 131 �p :2100 -60-000 TANK INFORMATION ELEVATION DATA A9800118 6 117 /y TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic (�� sC r, Benchmark Dosing /G0, y Aeration -- -_ Bldg. Sewer Holdin St /,Of Inlet TANK SETBACK INFORMATION St I5t Outlet 3,7 q 7 37' Ventto TANKTO P/L WELL BLDG. Airintake ROAD Dt Inlet Septic - 2D " NA Dt Bottom Dosing NA Header, �, s� 9s!sS Aeration NA Dist. Pipe .70 W 9 0 � Holding - Bot. System ' PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand MoPM TDH Lift L fiction ystem TDH Ft Head Forcemain Length Dia. Dist.Tovvell SOIL ABSORPTION SYSTEM BED/TRENCH Width - i Length No. Of Trenches IT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS g DIMENSION SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREA AC INFORMATION Type O f)�; ,-> A er. System: �c !J OR UNIT DISTRIBUTION SYSTEM Header Distribution Pipe(s) le Size x Hole Spacing Vent To Air Intake Length ? Dia. Lengt Dia. Spacing - SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Sys 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.) -) 45 LOCATION: SOMERSET 26.31.19,NW,SW 1948 62ND STREgT — PINECLIF-.,F LOT 16 f= 1 ;o E;e cep d ��? <— ,� > o ✓1, o ��L c ,J Plan revision required? ❑ Yes R Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. Vi scons in Safety and Buildings Division SANITARY PERMIT APPLICATION 2 01 E. Washington Ave. P.O. Box 7969 Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code P Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less county than 8 1/2 x 11 inches in size. �✓ • See reverse side for instructions for completing this application State Sanitary Permit Numb The information you provide may be used by other government agency programs E] Check if revisioT�to'�revio s application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATI N Prop) e caner Na Property Location ti4 1i4, S, T , N, R E (or Property O ner's Mailing A dress , Lot Number Block Nu r m e City, State t j Zip Code Phone Number Subdivision N e or Z mber ( ) . TYPE OF BUILDING: (check one) ❑ State Owned ❑ Cit Nearest Road ❑ Village Public 1 or 2 Family Dwelling - No. of bedrooms_ prTown OF 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 Q 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. 2 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 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 ❑ Seepage Trench 22 ❑ In- Ground Pressure / X 7� 42 ❑ Pit Privy 13 ❑ Seepage Pit - 7 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. Perct/ch) Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min Elevation f $� Feet Feet Capacit VII. TANK in allons Total # of Prefab. Site Fiber Exper. INFORMATION New Exist in Gallons Tanks Manufacturer's Name Concrete st Coted Steel glass Plastic App Tanks Tanks eptic Tank ® ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber I 1 ❑ 1 ❑ 1 ❑ 1 ❑ 1 ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, thej undersigned, assume responsibility for insta a ion of the onsite sewage system shown on the attached plans. Plum ere Name (Pri \ Plumb e s Si u St ) MP /MPRSW No.: Business Phone Number: Jr J 1 = S Plumber's Ac dress (Street, Cit , State, Zi ode): IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued Issuin gent Signature (No Stamps) Approved []Owner Surcharge Fee) Owner Given Initial 1D pd >!� L3 )� i ed nation l / / �� XeM OF APPROVA REASONS FOR DISAPPROVAL: J� k �� - e-pm fa Wo t e cv t Y`e- 1etr -6 Sv c t ms s+ S� h w:� #o'_ (0 �C'.wt f/`Corane -� O n +".0 2 -C60 SBD -6398 (R 11/96) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber y A)4 �s 3- aw —� �Z ��kwrp� ,p 1 1 ® l+�o�oos.c't> 211e�� _ Wiscpnsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page of Bureau of Integrated Services in accordance with - 83:0,9, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches ih size. Plar.Arust County include, but not limited to: vertical and horizontal reference point (BM) dire4opq percent slope, scale or dimensions, north arrow, and location Od distance 6h6ii/esCKNEW. 'i el I.D. # APPLICANT INFORMATION - Please print all information. ,. �, ,;, b D ate Personal information you provide may be used for secondary purposes (PrivaCy;law, s. 15X (.tl Property Owner roperty l b it 1 1/4 1 /4,S T ,N,R E (o Property Owner's Mailing A dress ` tit',' Subd. Name or M# //. r"V7 I City Stat Zip Code Phone Number ❑ City ❑ Village Town Nearest Road ® New Construction Use: ❑ Residential / Number of bedrooms Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow Cry / ©O gpd Recommended design loading rate __7 bed, gpd1ft gpd/ft Absorption area required bed, 11: , . 5'_ trench, ft2 Maximum design loading rate _ bed, gpd/ft Z— Vench, gpd* Recommended infiltration surface elevation(s) 7 ft (as referred to site plan benchmark) Additional design /site considerations Parent material s 4�� - Two , /f Flood plain elevation, if applicable d!"� ft S = Suitable for system Conventional Mound In -Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system IZI S ❑ U ❑ S ❑ U ® S ❑ U 1 10 ❑ U ❑ S ®U ❑ S O 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 l '/ e s' Ground FR elev Depth to All N/ limiting factor , in. Remarks: Boring # iu ee 27 Z22 e . d _1Z1 Ll , a, 2, — 3 17-19 S Ground < s - elev. Depth to ' limiting factor � Rem rks: CST Name (PI Pri ) Signa re Telephone No. Address bata CST Number �l 0 71 /r�,j��s 3 e 077 � I , -_L 1 l �� Wisconsin Department of Industry SOIL AND SITE EVALUATION Labor and Human Relations Page of Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. 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 distance to nearest road. Parcel I.D. # APPLICANT INFORMATION - Please print all information. Reviewed .., ` 1 } ' +e� ? D e<r Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).r Props Owner !� Property Location r Govt. Lot A A J 1/4 t S r:, X ,N,R (or)® Property Owner's Mailing Address Lot # Block# Subd. Na VIN100 � JL Ci State Zip Code Phone Number ` 14"fie ❑ 11' ® Town © New Construction use: Residential / Number of bedrooms e l l Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow ZDD gpd Recommended design loading rate ! bed, gpd/ft trench, gpd /ft Absorption area required ed, ft 2 rW trench, ft Maximum design loading rate 4 1 bed, gpd/ft gpd/ft Recommended infiltration surface elevation(s) , /F.� , '7 ft (as referred to site plan benchmark) Additional design /site co siderations Parent material '3;' cv _ 6�-Je Flood plain elevation, if applicable ft r S = Suitable for system Conventional' Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U unsuitable for system [D S 2 u N S ❑ u ❑ S I I ❑ S ®U ❑ s ®u [Is O 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 'Va c Ground elev. �Zft s �/ s - - — — Depth to limiting factor (L in. Remarks: Boring # l JL - Ground , — elev. ft . Depth to limiting factor Remarks: CST Name (Pie se P nt) Signature Telephone No. Address Date CST Number 3 �O S �l+a/'LSif 4Fjjo 4aal IS, fed .E199 r • ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OW I:� NERSHIP C RTIFICATION FORM OwnOwner/Buyer k a_ , y - uyer /rl� �e A^� Mailing Address 0• 'Foy 3 ar Property Address /r�'J S]z 1 (Verification required from Planning Department for new construction) City/State Parcel Identification Number O LE GAL DESCRIPTION Property Location —AL '/ Sec. , "T �N -R �W, Town of Subdivision pr;- e, G i t' Lot # Certified Survey Map # Volume , Page # Warranty Deed # _ S� 9 ' 73 0 1 --,Volume Page # 3 Spe house 1 � 1 7es ❑ no 1.ot lines identifiable byes ❑ no SYS " EM 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 aff.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 master p lumber, journeyman plumber, restricted plumber or a 1 i - pumper verifying that (1) the on -site wastewater di ,posal 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 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 0�y of the three year xpiration date. SI A E OF APPLICANT DATE OWNER CERTIFICATION 1 (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 1 S0. FT. 131,409 SO. FT. O • \ ck 34 ° 4 • 6'0 "E vWi 2.06 AC. EXC. ESMT • 00 r' 351.60' 89,97 SO. FT. �S+ CD to m A 10 2.55 AC. EXC. ESMT. C� o � 111,151 SO. FT. R V BR \ 5 N BO • $ BN 80 3.09 ACRES / 3.0 ACRES BP 1 34,629 SO. FT. C A. 130 / , \ , 857 V 2.21 AC. EXC. ESMT. \ .� 96, 344 $Q P BU M / p 0 8 � N85 SL h •' \ yy g 493.58' _�BG 343.01' BT BJ BS BF 12 373.58' 150.57' 12 0.00' 9 3.13 ACRES / CO 136,282 SO. FT. 3S 1.30 AC. EXC. ESMT. 0 S 769 SO. FT. .2 p 24, 17 8 gOb p• IY a 0 3.00 ACRES /2 S 6'p. 130,918 S0. FT. 4 2• 2.54 AC. EXC. ESMT Tr 110, 896 SO. FT 3100 ACRES 130 ,856 SQ FT a Y� w 61 O 0 0 Olt ot _SMT. 15 W N 02 W 4b, G O, 3.05 ACRES 273 35. 132,846 SO. FT. �3v s