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HomeMy WebLinkAbout032-2105-10-000 ST. CROIX COUNTY ZONING DEPAR T AS BUILT SANITARY REPO O. - Owner �1 Address D City /State six " J / Legal Description: `.` a>v;,vcaoFFic Lot _�_ Block Subdivision/CSM # '/4 '/4, Sec., 'ILN -RAW, Town of SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION Tank manufacturer it Size ST/PC / Setback from: House - 4z - Well P/L 7z 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" Wi Length y Number of Trenches Setback from: House -k / Well P2 Vent to fresh air intake f� ELEVATIONS Description of benchmark Elevation Description of alternate benchmark - Elevation ,9,,�;g Building Sewer 112 y ST/HT Inlet z4ZZ, ,? ST Outlet PC Inlet PC Bottom Header/Manifold Top of ST/PC Manhole Cover / ©7, 7l Distribution Lines ( ) ,���,� 7 ( ) ( ) Bottom of System ? " ( ) ( ) Final Grade O /AZ^, 72 O ( ) Date of installation 1jZ� rmit number � / State plan number - Plumber's signnatur License number Date Inspector Complete plot plan Wisconsin Department o f Commerce Safet PRIVATE SEWAGE SYSTEM Count ' Safety 'and Buildings Division Y: �' �� INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Personal information you provice��,,m//aay'y be used for secondary purposes [Privacy Law, s.15.04 (1)(m)). 00 7rp2 Permit Holder ❑ e: fM��C�.- City ❑Village ®Town of: State Plan ID No.: r CST BM Elev.: Insp. BM Elev.: l BM Description: Parcel Tax No.: I DO 00 7'ov or e r7svr ar ♦ G o _4 015 - 4OU TANK INFORMATION ILEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. e tic 1 000 Benchmark ,q {Z.�(o / /2•S�(o �jd0 Dosing Ad. BNI+ 2.7 .09 Ae on Bldg. Sewer l70 / 0 7-7 d Holding t Inlet 1 ,064 g TANK SETBACK INFORMATION St 0 Outlet � •�7 �D.S TANK TO P/ L WELL BLDG. AirI to ntake ROAD Dt Inlet irl Gi f NA Dt Bottom Dosing NA Header/ Man. ?V7 I /O3•3 AeC4tion NA Dist. Pipe 9-/9 Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade S 14(a -7 Manufacturer emancl g y , 7 /0776 Model ber GPM TDH ift Friction em TD Ft - 1 F Forcemain Length Did. Dist. To Well SOIL ABSORPTION SYSTEM IME NSIO H Width / 2. Length , No. Of Trenches PIT No. Inside Dia. Liqui epth DIMENSI SETBACK SYSTEM TO P / L BLDG WELL LAKE / STRE LEACHING facturer: INFORMATION Type O COHAMBER M o e N Syste . �Z DISTRIBUTION SYSTEM Header/manifold Distribution Pipe(s) / x Hole Size x Hole Spacing Vent T Air Int ke Len Dia. t1 � Len th -55 Dia. S p acin g (O ASTM S M 7 75 - SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over over xx Depth Of xx Seede xx Mulched Bed/ Trench Center ❑ Yes ❑ Yes ❑ No COMMENTS (Include code discrepancies, persons present, etc.) l��l �l / 90`Ak 4 ve. � A��•�3� - %,p W d mil 7a_ 1 1 1 -oK A0el bbve 8u� �(I {N" not cl� ✓i /l�e die, -4 o-,' -4 Plan revision required? ❑ Yes ® No Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's nature ert. No 'A Safety and Buildings Division sconsin SANITARY PERMIT APPLICATION 201 E. Washington Ave. 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 8 112 x 11 inches in size. • See reverse side for instructions for completing this application state sanitary � N , um m � ber The information you provide may be used by other government agency programs ❑Check if revision- r (Pousrapplication (Privacy Law, s. 15.04 (1) (m)]. Sa�f'rt.ei State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N Propert Owner N m Property Location 1/4 t /4, S T , N, R (o Property Owne 's Mailing Ad r ss Lot Number Block Num G 1 City, S e Zip Code Phone Number Subdivision N e or CSM Nu r i ( ) ,' z5t II. TYPE BUILDING: (check one) E] State Owned ❑ C it y Nearest Road Vil lage 6fQ El tYa� Public. 1 or 2 Family Dwelling - No. of bedrooms -� ❑ Th To wn wn Of F III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/Condo d6 q c 1 go o 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 f] 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. jg New 2. ❑ Replacement 3. I] 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 JZ 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. ate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed q. ft.) (Gals/day /sq. ft.) (Min. /' ch) Elevation Feet Feet VII. ANK Capacity in gallons Total # of Prefab. Site Fiber- Ex p er. INFORMATION New Existin Gallons Tanks Manufacturers Name Concrete Con- steel glass Plastic APP structed Tanks Tanks Septic Tank ❑ ❑ ❑ ❑ ❑ lift Pump Tank /Siphon Chamber ❑ I ❑ I ❑ 1:11 ❑ 1 ❑ VIII. RESPONSIBILITY STATEMENT I, the ndersigned, assume responsibility for inst iat, n of nsite sewage system shown on the attached plans. Plum er' Nam (Pr )° Plumb is Si atu N amp MP /MPRSW No.: Business Phone Number. P umber's Ac dress (Street, Pty, State, . Code): I e � D Wd, t _/�10 Y�' �/ j _�, _)� I z _: Z - t7 IX. COUNTY /- DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued. Issuing Agent Signature (No Stamps) A roved Surcharge Fee) pp ❑ Owner Given Initial �oa " t� / .Zl.70 AdWW Adverse Determination / / X. CONDITIONS (I �'j/ J O APPROVAL � / FO DISAPPROVAL: -SBD -6398 (R.11/96) DISTRIBUTION: original to County. One copy To: Safety & Buildings Division, Owner, Plumber XM i f r i rases / / , 3 �.52 lRa iJ ell OL Dl Wisconfin Department of Commerce IL AND SITE EVALUATION , Division bf Safety and Buildings Page of Bureau of Integrated Services o`�h�, 'h s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not I �t 8 1 in siae., must County include, but not limited to: vertical and tal ref (BM), direcpn and J per slope, scale or dimensions, no w, and location and distance to earest road. Parcel I.D. # D `° .� u B- i 37 1 8� - / -moo APPLICANT INFORMATION - / e prim*W rmauon.. ; Review by Date Personal information you provide may be used T r� &M� y LsW,�s. 5.04 (1) (m)). , ' Z C Property Qywn er S Property Location v £ 2 ' Govt. Lot 1/ Gv 1/4 0 T ,N,R E (ord Property Owner's Mailing Address Lot # I BI SubZe or CSM# r Ci Stat Zip Code Phone Number ❑ C ❑ Village ,❑ Town Nearest Road New Construction Use: Residential / Number of bedrooms Addition to existing building Replacement ❑ Public or commercial - Describe: 77 Code derived daily flow _ gpd Recommended design loading rate _ bed, gpdM gpd* Absorption area required _ bed, _ trench, ft Maximum design loading rate �� bed. gpdHl trench, gpdAt Recommended infiltration surface elevation(s) //" s ft (as referred to site plan benchmark) Additional design/site nsiderations Parent material - Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In -Ground Pressure AT -Grade System in Fill Holdng Tank U= Unsuitable for system El S❑ U EIS [3 U 0S ❑ u El s❑ U [Is ®u Ms 21 U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 13 in. Munsell Ou. Sz. Copt. Color Gr. Sz. Sh. Bed , Trench Ground _ S elev. 1 Depth to limiting factor Remarks: Boring # / z Ground — — elev Depth to limiting facto �in. R marks: CST Nam (r ase rint Si _ Telephone No. CA S� Address 9 Date CST Number 97: LA-;; I } I I i I I I 1 ,. 0 0 � � �k r O `M 1.1t V► e � — r � `� m `� M �n �.tv � N ,�,^�'• � to �+ ��;J� M s ('� M \ �� L STC -105 SZPTIC TANK NL414 ZNANCIC AGRZZMNT St. Croix County O WNERIBUYKR MAII.iNG ADDRESS 6¢- S ©�� • PROPERTY ADDRESS (location of septic system) Dime obtain from the Planning Dept. CITY /STATE PROPERTY LOCATION 1/4, 5 L 3 1/4, Section a T__?>_LN -R__aW TOWN OF v1 6C j ST. CROIX COUNTY, WI SUBDIVISION 1__d L 65- w - e;;z LOT NUMBER I_ CERTIFIEDSURVEY MAP VOLUME --_ , PAGE . LOT NUMBER 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 licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed um the on -site wastewater disposal system is in proper operating condition and (2) after pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expirati n te. SIGNED: a DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 aTC -100 This application form is to be completed in full'and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner /contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted -to this office with the. appropriate deed recording. ------------------------------------------------------------------- Owner of property - Location of property Li 1/4 1/4, Section vZe ,; 'j j N -R W Township _ ®� ���j Mailing address (,c> aS" ter. �s S­4-oes� Address of site Subdivision name 64/4 Ck,- e9ijA Lot no. .�- Other homes on property? Yes No Previous owner of property Total size of property Total size of parcel Date parcel was created Are all corners and lot lines identifiable? _Yes No Is this property being developed for (spec house)? Yes No Volume and Page Number as recorded with the Register of Deeds. ------------------------------------------------------------------- INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the office of the County Register of Deeds as Document No. , and that I (we) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the office of the County Register of Deeds as Document No. Signature of Applicant Co- Applicant # Date of Signature - Date of Signature ST. CROIX COUNTY �� WISCONSIN ZONING OFFICE p 9 8 N lr �� ■ n ■ ST. CROIX COUNTY GOVERNMENT CENTER _ r " "� 1101 Carmichael Road Hudson, WI 54016 -7710 - (715) 386 - 4680 July 21, 1998 Hartman Homes Attn: Becky Somerset, WI 54025 RE: Septic Inspection for Chad Maack located at 444 190th Avenue, Lot 1 of Gracie Estates, Town of Somerset, St. Croix County, Wisconsin Dear Becky: A septic inspection of the above referenced property was conducted on January 26, 1998. This property is located in the SE of the SWA of Section 28, T31 N -R1 9W, Lot 1 of Gracie Estates, 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) 386 -4680. ; rely, e Esinger Assistant Zoning Administrator /sm