HomeMy WebLinkAbout032-2105-30-000 ST. CROIX COUNTY ZONING DEPARTMEN
AS BUILT SANITARY REPORT
Owner _ 4
Addresses
8 CRD4x
City /State
Zt
Legal Description:
Lot __?_ Block _ Subdivision/CSM #
'/• %, Ste, Sec., TAN -R /�W, Town of S � PIN #
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION:
Tank manufacturer Size ST/PC 1 / Setback from: Housed 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: Width _ Z Length Z, :2 - - - Number of Trenches
Setback from: House /lam Well -.1:2 P/L ,e �-_ Vent to fresh air intake
ELEVATIONS
Description of benchmark �.� 5,� Elevation
Description of alternate benchmark, �J Elevation /ice
Building Sewer / //, g — ST/HT Inlet iii ; -�� ST Outlet i i, 9 PC Inlet
PC Bottom Header/Manifold , / /,�, s� Top of ST/PC Manhole Cover , /I/.,,4
Distribution Lines
Bottom of System O 14 9 , 71 O ( )
Final Grade () f
Date of installation /,LLB p mit nu er D7r9/ State plan number
Plumber's signatur - License number D &/q/
Inspector
Complete plot plan or
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County ST. CROIX
Safety and Buildings Division INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitarf�P,eGLrlitlUo.:
Personal information you provice may be used for secondary purposes [Privacy L , s.15.04 (1)(m)]. tJJ Ob y 1 1
p Lpit F�pI�Q[s Narne� L �b>k e ❑ Town of: State Plan ID No.:
S t1A(:t1�iL J Parcel Tax No.:
CST BM Elev.: P. BM Elev.: BM Description: v Z ' u O 2 6
TANK INFORMATION
ELEVATION DATA A9800080
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic- Bench r� 9� 0 2,3 •6�7 1,03.6-7 07Z-')
Dosing
Aer ion . Sewer
Holding Inlet
TANK SETBACK INFORMATION -ftvv�- t/ Outlet
kze ROAD Dt inlet
TANK�OP/ WEL L BLDG. I Air Intake
epti �� (p(p' Z 1 �3' NA Dt Bottom
Dosing A Header / Man. 1 2•gR / /0.
NA Dist. Pipe 13
ation
Holding Bot. System )3 .YL loq • 7 /
!A •s /c{Oa
PUMP/ SIPHON INFORMATION Final Grade 9ti z
Manufacturer Demand G•7 //G Ff
Model Number -- -- GPM
TDH Lift -' Friction S st DH Ft
oss
Forcema" Dia. Dist. To well
S ABSORPTION SYSTEM
BE TREN Width Length ,/ No. Of Trenches PIT No. Of Pits
Inside Dia. Liquid Depth
EN I r DIMEN I W$
Mau acturer:
SYSTEM TO P / L BLDG WELL LAKE / STREAM LEACHING
SETBACK CHAMBER Mo a Num
INFORMATION Type y I O' 1 s OR UNIT
Syst
DISTRIBUTION SYSTEM
Header / Ma� ifold // Distribution Pipe(e) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length Dia. Spacing
�cl� 2 7 ZGr
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over =/Trevnch xx Depth Of xx Seeded /Sodded �E] Mulched
I Bed /Trench Center ges Topsoil ❑
Yes ❑ No Ye s ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: SOMERSET 28.31.19,SE,SW 436 190TH AVENUE - GRACIE EST LOT 3
J
v1 I+ Sp.A - �r �� t ( ccf y ul�u,�kor�
Plan revision required? ❑ ZI- -No
No
Use other side for additional information. Cep_
Date [ ��lnspect 's Signature
SBD -6710 (R.3/97)
Vi PERMIT APPLICATION 2 01 e E.W and shn sion
n P.O. Box 7969
Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 -7969
•
XA,�ach complete plans (to the county copy only) for the system, on paper not less County
a 8 112 x 11 inches in size. Lza I I/
• See reverse side for instructions for completing this application State Sanitary Permit Number
y ou p rovide may be used b other g overnment agency programs �� I
Y P Y Y 9 9 Y P 9 ❑Check if revision to previous appg
The information cation
(Privacy Law, s. 15.04 (1) (m)]. 1
State Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION
Prope y Owner Name Property Location /
1/4
1/4,5 T , N, R (or
Propert ner's Mailing Ad res Lot Number Block Numbe
Cit ,State '�� j ZipCode Phone Number Name or CSM Num er
II. TYPE OF BUILDING: (check one) ❑ State Owned 0 !t Nearest R oad
p ,
p Village f
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 � �g� D3�- ZIO _>d —DOD
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, jA 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 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 .h ch) Elevation
Feet Feet
Capacit
VII. TANK in Ca g allons Total # of site
INFORMATION Gallons Tanks Manufacturer's Name Concrete Con Steel fiber plastic Expel.
New Exist in strutted glass. App.
Tanks Tanks
eptic Tan , ❑ ❑ ❑ 1 ❑ ❑
Lift Pump Tank /Siphon Chamberl ❑ 1 ❑ ❑ 1 ❑ 1 ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for insta ation of a onsite sewage system shown on the attached plans.
Plumber' a : (P t)' Plumb is Sig a s) MP /MPRSW No.: Business Phone Number:
ele
3 _
Plume Ac d ess (Steet, City, Stat Zip Code
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit F (includes Groundwater D ate issued Issuin ge t Signa re (No Stamps)
EgApproved []Owner Given Initial Surcharge Fee) i
Adverse Determination to&
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD -6398 (R.11/96) - DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber -
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Wisconsin Department of Commerce L AND SITE EVALUATION
Division of Safety and Buildings i Page of
Bureau of Integrated Services Id ! h S. ILHR 83.09, Wis. Adm. Code
�\ 41, �✓
Attach complete site plan on paper not 1 81 in si must County
include, but not limited to: vertical and ref BM), and
percent slope, scale or dimensions, I tion and rest road. Pari�el #
' j d ra "' 1997 / %%��
�F�� leg 20_3 (rO
APPLICANT INFORMATION - prin�i»ati e w by Dat
Personal information you provide may be used 5.04 (1) (m)). r 4 g
Property er S Property Location
/ Z Govt. Lot 114- 114,S T ,N,R E (or
Piope Owners ling Address Lot # BI Subd. Name or CSM#
State 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 gpd Recommended design loading rate —,,_7— gpd,* , trench, gpd/fl
Absorption area required _ bed, ft rich, ft 2 Maximum design loading rate bed,
g g �� gpd/ft � trench, gpd/fl
Recommended infiltration surface elevation(s) /dfl 8 ft (as referred to site plan benchmark)
Additional design/site considerations
Parent material Flood plain elevation, if applicable ft
Fu
= Suitable for system Conventional Mound In -Ground Pressure AT -Grade System in Fill Holding Tank
= Unsuitable for system 1 0 s u 0S El u ® S U Jz s❑ u ❑ S (ZU ❑ s Z u
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
13 ' 1"�2h I JA �es__lv A) - 5 1 ; 1 lei
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
S
Ground ..s f
elev.
.k24% rte, t
Depth to ,
limiting
factor
Remarks:
Boring # 1
13 _9
D _ J
Ground
elev. l
1 4;� ft. — —
Depth to
limiting
factor
>94
L in. Remar s:
CST Name (PI a rint) Signature Telephone No.
Address Date CST Nu be
�- tl� ✓� /�'�� ,ht of .5,+2'�.f'5,7r�'.c' �
3a,
j
ez
Jo
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP C RTIFICATION FORM
OwnerBuyer L
_j T
Mailing Address F -0. E�
Property Address
(Verification required from Planning Department for new construction)
City/State - Parcel Identification Number
LE GAL DESCRIPTION
Property Location ' /,, S� '/4, Sec. ,28 , T N -R Town of _50irrE�02
Subdivision 65mml__ �( u , Lot # 3
Certified Survey Map # f/ Volume , Page #
S6 &
Warranty Deed # 6 j& -7 _, Volume 1 2,7 Page # 3
Spe house ❑ yes % - no Lot lines identifiable Xf yes ❑ 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 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 Department a certification form, signed by the owner and by a
master plumber, journeyman plumber, restricted plumber or a 1 i--ensed 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.
Uwe, 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
07 vs of the three y r e .raj on date.
✓. 1W 3 /-30/ y
E OF APPLICANT DATE
OWNER CERTIFICATION
I (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 pr p rty described above y irtue of a warranty deed recorded in Register of Deeds Office.
- �_ 3 /3u19' 8
S OF X.PPLICANT 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
w GRACIE ESTATES
23
LOCATED IN PART OF THE SE114 OF THE SWI 14 OF SECTION 28 AND IN PART
OF THE NE114 OF THE NW114 OF SECTION 33, ALL IN T31N, R19W, TOWN OF
SOMERSET, ST. CROIX COUNTY, WISCONSIN; BEING LOT 5 AND PART OF LOT 2
OF CERTIFIED SURVEY MAP RECORDED IN VOL. 11, PAGE 3101 AT THE
ST. CROIX COUNTY REGISTER OF DEEDS OFFICE.
Pole or buried cables are to be placed such that the installation would
leturb any survey stake, or obstruct vision along any lot line or street
lne.
t.e disturbance of a survey stake by anyone is a violation of Section
36.32 of Wisconsin Statutes. Utility Basements as herein set forth are for LOCATION SKETCH
20 use of public bodies and private public utilities having the right to
srve the area. SECTIONS 26 8 33
T31N R19W
I i
I
1 U"JPLATTEI^ LADS
1 I cy - - -- —
r192ND I AV �`J Uf —NORT LINE of TH E s[w of THE awes, s[cr1oH zs �
•
9' r Fi
OEDICA�TED 70 TN[ N
a�
LOT 6
I� >e 3.00 ACRES
�� $ 130,[64 90.
LOT 4 1 O 3
I�� 114 1 -1
z .�.
g $99 3x9.301 89'43' 'E 656.64
o� 377.09' 40.5v 214.02' 392.99'
u
OT 5
LOT 5 LOT 5
I.II A01111 1,11 ACI111 INC 11W
1111714 11, FT. OT I 4 1111/1f 10. FT.
11.0c ACRES ext [fRr►. LOT `T 3 -1 Ank[ F%C. [a►R.
A 130,7J0 so. FT. 3.11 ACRES 136,471 b. Ft
W 136,143 fO,FT. k
�i NNE ' / �
W ` M
I _ 0 T L
g
JOINT sew[w1►r LOT 2 $ $ p .�
4p
3.18 ACRES INC. AMT. �� U
139,6011 110. FT. \
3.09 ACRES [XC. [$MT.
e +'' 134.416 $0. rt rYl
� R r
t 140 a9� w \ �►. 1 I Y'
w � \ �i. 399 277.00'
TIMPPll ; am '•.� ' \ 161.60 �I 10"AO
LOT 1 I6 ^
3.02
ACM! 11 INC. E11MT. I I