HomeMy WebLinkAbout032-1076-40-100 ST. CROIX COUNTY ZONING DEPARTM � T
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AS BUILT SANITARY REPORT /A � tcl'�(�
Owner
Address ,. 1 a
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City /Stat
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Legal Description:
Lot Z_ Block Subdivision z
'/. '/, , %z, Sect, TAN -R -4W, Town of J� g 7 1 PIN #
SEPTIC TANK — DOSE CHAMBER — HOLDING TANK INFORMATION
Tank manufacturer Size ST/PC /c� / setback from: House ,� Well 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: 9 Width --Z2 Length /E� Number of Trenches
Setback from: House Well _ P/L Vent to fresh air intake
ELEVATIONS
Description of benchmark a Elevation _
Description of alternate benchmark / Elevation 1
Building Sewer ST/HT Inlet ST Outlet- /„2E, PC Inlet
PC Bottom Header/Manifold Top of ST/PC Manhole Cover /.�Z R
Distribution Lines
Bottom of System
Final Grade
Date of installation / / P 7mit number 3/S'� /�� State plan number
Plumber's signatur License number Date
�-2- k2l,?
Inspector
complete plot plan or
Wisbonsin Department of Commerce PRIVATE SEWAGE SYSTEM County:
Safe.ty and Buildings Division
. INSPECTION REPORT 5 {-C
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-:
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)j. Z I S I Z
Permit Holder's Name: ❑ City ❑ Village ,® Town of: State Plan ID No.:
Lc- V Uk 5 oevxw - 5 L+
CST BM Elev.: Insp. BM N BM Description: Parcel Tax No.:
0?i2- 10 (P
TANK INFORMATION ELEVATION DATA Acq
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
/ .lee- lll, Ben c r Sv l 15 > ) 8D
Dosing , Vvl
Aeration Bldg. Sewer 3,� 13Z L f
Holding Inlet , (0 13(orl
TANK SETBACK INFORMATION ^Outlet , I
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air intake
NA Dt Bottom ?
Dosing f NA Header/ Man. Z�,Cb Is% lO.fpp 10
Aeration ,� r- ,� NA Dist. Pipe 10.6 -. - /6S. Z(
Holding y_ -r- A- Bot. System .L
PUMP/ SIPHON INFORMATION Final Grade II [Is, 1,W 10$.Z
Manufacturer Demand ,VAuritIC 13U,[ 33 1 2-9-b - 5
Model Number ,C GPM
TDH Lift x Friction System y TDH ,.,Ft
oss Head
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
RENCH Width 12 Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSIONS , F _ '- 1 1*1
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING manuf acturer:
SETBACK CHAMBER mo Number:
INFORMATION Type +
�L. '� I ��- OR UNIT .z
Sys m `(
DISTRIBUTION SYSTEM
Header /Manifold , I � Distribution Pipe(s) r / x Hole Size x Hole Spacing Vent To Air Intake
Length A Dia. 4 Spacin
Length Dia. `► g b LEST 21Z-°j
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed/ Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS (Include code discrepancies, persons present, etc.) 1°12� (� / sj , 5\rj, Sec, Z7 - f31
A u+� � 14A
�
Plan revision requir ? [ No
Use other side for additional information. f
SBD -6710 (R.3/97) Date Inspector's Signature ert.
F Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM y:
Safety and Buildings Division Count
INSPECTION REPORT ST. CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Personal information you provice may be used for secondary purposes (Privacy L , s.15.04 (1)(m)]. 315912
LeARbI& sEM E�Ciiy_11�(j c1� Town of: State Plan ID No.:
CST BM Elev.: Insp. BM Elev : BM Description: (�MLKJ 1' Parcel T No..
1076 -40 -100
16b ffl
(rG , I � L
TANK INFORMATION ELEVATION DATA A9800301
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic �u , Benchm 115 _ lob
Dosing ,� „� /' ���
Aeration Bldg. Sewer 3 '7 32 C1
Holding ` (3>4t Inlet "' - 136, I / ' Z 7
TANK SETBACK INFORMATION St /Ht Outl ( Z �, -120
TANK TO P/ L WELL BLDG. Air I to ntake ROAD Dt Inlet j(
Air
Septic tX� NA Dt Bottom
Dosing - _.._. NA Header/ Man
Aeration NA Dist. Pipe Z��� illt(ot /C
Holding Bot. System 11.y3 /oy• q
PUMP/ SIPHON INFORMATION Final Grade 7 Gz� I o$. 20
Manufacturer Demand(
Model Number GPM
TDH Lift Friction x System TDH Ft
Forcemain Length �r Dia. Fi L Dist.ToWell
SOIL ABSORPTION SYSTEM
E RENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia . Liquid.De,pth
N I N � DIMENSIONS r_ x
SETBACK
SYSTEM TO P/ L BLDG I WELL LAKE/STREAM LEACHING Manufacturer: x
'
INFORMATION Type / CHAMBER Mod Number:
of
Syste" ' pnwm t, " OR UNIT
DISTRIBUTION SYSTEM
Header / Manifold ei Distribution Pipe(s) ` x Hole Size x Hole Spacing Vent To Air Intake
Length Dia.' Length S—Z Dia. Spacing ASTvv 2"I
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 2 1926 CTY RD I
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD -6710 (R.3/97) Date Inspector's Signature Cert. No
SANITARY PERMIT APPLICATION 201 E W ashington iAv D ivision
Visconsin
In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
Department of Commerce Madison, WI 53707 -7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 81/2 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 if revision to previous application
[Privacy Law, s. 15.04 (1) (m)]. 3 /y tM O State Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE C P I R II N � T ALL INF RMATION
Prope y Owner Name Property Location
1 E /a, S T , N, R E (or)O
Property Owner's ailing Addre s Lot Number Block Number
Cit ate Zip Code Phone Number Subdivision Name o CSnn Uum e
f ( > 7
.TYPE OF BUILDING' (check one) ❑ State Owned 0 Cit Barest Road
Public 1 or 2 Famil Dwelling - No_ of bedrooms ,� 0 ia Io w a n OF
III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo a 7. 3 / • 1q, 3 ; 9 C 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. [0 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 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.) Proposed1sq. ft.) (Gals/day /sq. ft.) (Min./j Elevation
/ Feet Feet
VII. IrANK C apacity
INFORMATION in gallons Total # of Manufacturer's Name Prefab. ion Fiber- Plastic Exper.
New Existin Gallons Tanks concrete structed steel glass App.
Tanks Tanks
e tic Tan ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, thp undersigned, assume responsibility for i tallation of the onsite sewage system shown on the attached plans_
Plu s Nam (P Plumb "s nat o MP /MPRSW No.: Business Phone Number:
r
z — 3
Plumber's Address eet ity, Stat ip Code):
IX. COUNTY / EPARTMENT USE ONLY
❑Disapproved Sanitar Permit Fee (includes Groundwater at Issued Issuing Signatu (No Stamps)
Approved ❑ Owner Given Initial rcharge Fee)
Adverse ion
X. CONDITIONS IPF APPROVAL / EASONS FQR I APPROVAL:
�P
S (A t 1196) DISTRIBUTION: Original to County. One copy To: safety 8 Buildings Division, Owner, Phunber
1
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wi s6ongin 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 /4
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
APPLICANT INFORMATION - Please print all information Re ' by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner Property Location U 6
GovL Lot 11 114,S T5, ,N,R 19 E (or)�W
Property Owner's Mailing Address Lot # Block Subd. Name o CSM#
I Cs , z a-
City Stat 1 e Zip Code Phone Number ❑ City ❑ Village ( Town Nearest Road
New Construction Use: 0 Residential / Number of bedrooms Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow gpd Recommended design loading rate _ gpd/fl gpd*
Absorption area required l bed, ft �_ trench,, ft2 Maximum design loading rate 1 7_ bed, gpdjft , ,Q trench, gWt
Recommended infiltration surface elevation(s) It (as referred to site plan benchmark)
Additional design/site considerations Z9<164 ,
Parent material 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 0 S❑ u P9 S❑ U ® s❑ u [Is O U ❑ s 21 u
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
13 in. Munsell Qu. Sz. nt. Color Gr. Sz. Sh. Bed , Trench
7 —
r •
Ground /l
elev. AJ 7 `
Depth to
limiting
factor
in. ,
Remarks:
Boring #
i3i P--'2,' Z�2 2��
i
Ground 8
elev. p �,
Depth to ?
limiting 1
factor l F1
�in. Remarks:
CST Name (PI Print) Signature
Address Date CST Number
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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,; urstr � Parcel Identification Number f3Z, 72,0Yl - LYO' A&
LEGAL DESCRIPTION
5 Su. , 31 N -R�W, Town of
Property Location ' /,, l ' /�, Sec. T
Subdivision Lot
Certified Survey Map # - -- ° , Volume , /,.,? , Page # 1
Warranty Deed # S Z�///3 ,Volume Page
Spec house (] yes ;k no Lot lines identifiable Ayes 0 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, i I 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.
ITe 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 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 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 the three e r expi ion date.
SIGNATURE OF APPLICANT 0 DATE
OWNEI CERTIFICATION
1 (ve) 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 opei , describ bove y virtue of a warranty deed recorded in Register of Deeds Office.
c,O-cm) A44 _ 5 /x°
SIGNATURE OF APPLICANT U DATE
* * * * ** Any infnrmntinn that ie miv reprr m ay result in the unitary permit being revoked by the Zoning Department. * * * * *•
" lnt'Itt+lt• t0lh IhlN itl►plit idiot► a %I;unl'. J k dretl Flom the Prl-i•,tri of Drcik office
it copy of the eeitified survey Inap if t Is made in the warranty deed
r I
5 7 .0'70
CERTIFIED SURVEY MAP
Located in part of The Southeast Quarter of the Southwest Quarter, Section 27, Township 31 North,
Range 19 West, Town of Somerset, St. Croix County, Wisconsin. o
F' repared tor and at e request o:
OWNER:
Robert C. and Patricia Landry Y
1930 C.T.H. "I" '
Somerset, WI 54025
Drafted by Ty R. Dodge
UNPLATTED LANDS
Li
LOT 1 0 3
CERTIFIED SURVEY MAP '' w 0)
VOL. - 2 PG_ 461 $ (D J w
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HIGHWAY DEED r ~_N ` ` c = O
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Total Area: < 1 w
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SEC. 27 -31 -19 ;n
w I i (ALUM. CAP MON.) Z 0
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UNPLATTED LANDS 014 a Z ° N o
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_SOUTH 1 4 CORNER
- SEC. 27 -31 -19 0 d �
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ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
N p/ p p p N Nl ST. CROIX COUNTY GOVERNMENT CENTER
NNN,N 1101 Carmichael Road
Hudson, WI 54016 -7710
(715) 386 -4680
March 10, 1999
�I
Laurie Landry
1926 County Road I
Somerset, WI 54025
RE: Septic Inspection for Laurie Landry located at 1926 County Road I,
Town of Somerset, St. Croix County, Wisconsin
Dear Ms. Landry:
A septic inspection of the above referenced property was conducted on January 5, 1999.
This property is located in the SE of the SWA of Section 27, T31 N -R19W, Town of
Somerset, St. Croix County, Wisconsin. At the time of the inspection, this septic system was
found to be code compliant for a three (3) bedroom home.
If you have any questions regarding this, please contact our office at (715) 3864680.
7d ly,
inger
Assistant Zoning Administrator
AM