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HomeMy WebLinkAbout032-2105-70-000 ST. CROIX COUNTY ZONING DEPARTMEIy, , : AS BUILT SANITARY REPORT Owner C�I Address �� - City /State sr C�clx"998 z OFFICE Legal Description: ,, ; �,., Lot _� Block Subdivision/CSM # ' /., Sec., T_LN -RAW, Town of �,� �k PIN # SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer L- Size ST/PC /,�, / Setback from: House __2?t= Well 22 P/L eL Pump manufacture_ r. 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: .,�a Width _1!2 Length &Z Number of Trenches Setback from: House fZ Well // /9' P/L Vent to fresh air intake ELEVATIONS Description of benchmark 7_ /� �x Elevation /? Description of alternate benchmark , , �,,, A,�X �� /5��r Elevation Building Sewer - �� ?, /,s ST/HT Inlet /0,�7_45 ST Outlet j,� Z PC Inlet PC Bottom Header/Manifold ,1,1 Top of ST/PC Manhole Cover Distribution Lines Bottom of System( 97 9� () ( ) Final Grade Date of installation/ -/ a rmit number _�i��'i/ State plan number Plumber's signature License number Date / 4!7/� /1 Inspector complete plot plan + Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM cou nt Safety and Buildings Division � 1' . CRO I X INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) San itylt Personal information you provice maybe used for secondary purposes [Privacy • w, s.15.04 (1)(m)]. Permit Holder's Name: ge ❑ Town of: State Plan ID No.: ETERSON, MICHAEL SD F���& CST BM Elev.: Insp. BM Elev.: FBM Description: Parcel tp2�105- 70-000 4' Ye._ TANK INFORMATION ELEVATION DATA A9800199 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. e Ben hma k 7. /o7 3 (0 0 Dosing 14 M - , OG SS Aeration Bldg. Sewer 3,-76 03 Holding St Inlet loa. TANK SETBACK INFORMATION f'w St/ tp Outlet TANK TO P / L WELL BLDG. Air Intake ROAD Dt Inlet NA Dt Bottom Dosing NA Header / Man. 7 , 2- 9�•/� Aerq Ion NA Dist. Pipe Y.27 O V Holding Bot. System 979 3 PUMP/ SIPHON INFORMATION Final Grade Manufacturer and S +.M«,w L_ Mode F GPM T H I Lift Friction stem TDH Ft Fo ai Dia. Dist. To well SOIL ABSORPTION SYSTEM F BE — D _ 7fRENCH Width / Length S�_ No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth 6flj I N DIMENSION SETBACK SYSTEM TO P / L BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION Typ y� i CHAMBER Mo Number: Sys em WA5 7 Q /��f �- OR UNIT DISTRIBUTION SYSTEM Header/Man old It Distribution Pipe(s) r x Hole Size x Hole Spacing Vent To Air Intake Length __&: Dia. Length 51 Dia. Spacing St N ^S 7 7 1p" 27Z7 - 74 - / "5- 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 E] Yes E] No ❑Yes ❑ No COMMENTS (Include code discrepancies, persons present, etc.) LOCAT SOMERSET 31.19 � ,� 1 �90T�AVENU T �Wt xar.� Hks�c� ' 'te r J � required? l ola -a-l�v Plan revision ❑ Yes M�N Use other side for additional information. r G /a� ? SBD -6710 (R.3/97) Date Inspector' ignature Cert. No. V iscons 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 Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8112 x 11 inches in size. • See reverse side for instructions for completing this application State sanitary Permit Number The information ou provide may be used b other g overnment agency programs l l Y P Y Y g 9 Y P 9 ❑Check if visi to previous application (Privacy Law, s. 15.04 (1) (m)]. ,(� (� State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION Prope O ner ame Property Location 1/4 t/4, S T , N, R ,e(or& P opert Owner's Mailing Address - Lot Number Block Numb City a Zip Codg Phone Numb pr Subdivisio Name or CSM Numb ( )a II. - TYPE OF BUILDING: (check one) ❑ State Owned ❑ Cit Nearer a 4 ❑ Village Public M 1 or 2 Family Dwelling - No. of bedrooms 5 of III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo ol 3 / • j j . 1 n 9A a_�u 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 rxNew 2 ❑ Replacement 3. ❑ Replacement of 4 ❑ Reconnection of 5 E] Repair of an - _____System ________System _____________ Tank Only______________ Existing System --------- Existing 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 [A 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 (sq. ft.) (Gals/day /sq. ft_) (Min. /' ch) Elevation A, 41 9 Feet Feet VII. TANK Capacity gallo s Total # of r Prefab. Site Fiber- Exper- INFORMATION Gallons Tanks Manufacturers Name Concrete Con Steel glass Plastic App New Existin strutted Tanks Tanks S tic Tank M ❑ ❑ ❑ ❑ ❑ Lift ft pTank /Siphon Chamber ❑ I ❑ 1 ❑ 1 ❑ 1 ❑ 1 ❑ VIII. RESPONSIBILITY STATEMENT I, the ndersigned, assume responsibility for ins lation of t nsite sewage system shown on the attached plans. Plum r' ame: Pr Plumb s ' hat St MP /MPRSW No.: Business Phone Number: 1 _ Plumber's A dress (Str t, City, State, Zip C ): Or ec, ZJZ IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate ssue ISsuin g t Signature (No Stamps) VA pp roved ❑Owner Given Initial CJX (i / ( /) n charge Fee) / /�� / Qd ` Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD -6398 (R.11/96) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber 5,Z4`� —SiJ -sue $ 7 //� rS� /q / a -ell ,kA 0 Wisconsin Department of Commerce SOIL AND SITE EVALUATION DMsion of tafety and Buildings page —L of S BuYeau of Integrated Services C b a n, with s . ILHR 83.09, Wis. Adm. Code Attach complete site pl an on paper n' es in size. ,Ian must County include, but not limited to: vertical arib t (BM), 4i ' and percent slope, scale or dimensions, n q an p d � distance t nearest road. pa el I D. # 997 CPA (I s�7 �� - � APPLICANT INFORMATION , L ormat�n:� Re 'awed Date Personal information you provide may Ge �r k�nA; 15.04 (1) s' Z 9 Property r S ,� Property Location _ £ Govt. Lot 1/ Gv 114,S T Z ,N,R E�(or 9 op rty ers ailing Address Lot # Block Subd (Name or CSM# x City Stat Zip Code Phone Number ❑ C ❑ VIlage ® 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 __.� bed, gpd/ft gpd/ft Absorption area required bed, ft 7,C_ trench, ft Maximum design loading rate , bed, gpd* _,_ tVench, gpd/ft Recommended infiltration surface elevation(s) It (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 Hol6ng Tank U = Unsuitable for system ®s ❑ u �1 s ❑ u ®s ❑ u l� s ❑ u ❑ s A ❑ S u SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Motiles Structure GPD/ft Texture Consistence Boundary Roots in. Munseil Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench ,• b/ S Ground elev. , Depth to limiting factor Remarks: Boring # 17�2 ei Ground L W - elev. Depth to limiting ,7� fact r in. Re rks: CST N e Signature Telephone No. 5 ` - 7L Address p� 9 Date > CST Number � G - I o -.5 71A/A"' /� . c ; I - t \. I I ST CROIX COUNTY s SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/B ickAer ' • L r1Sc L, e- ve r Mailing Address q /aS go " , 5�, So r►,ers� W I Syo a,S Property Address es — W 1 SyoaS (Verification required from Planning Department for new construction) l ip Cit3atate Sornecse� V 4 -T Parcel Identification Number D 3 - -1 10 S - 7 o LEGAL DESCRIPTION Property Location SF n, SW n,, See• 2 8 . T 3 N -R 19 W, Town of Sorr►erse -�- Subdivision Grac Fs 1 a tes Lot # 7 Certified Survey Map # Volume . Page # Warranty Deed # 56 A 7 y l Volume I a S 3 Page # 037 Spec house ❑yes 0 no Lot lines identifiable i� yes ❑. no SYSTEM yANCE 3mgmperme and maiadcna=of your sgdc syst=conld r=lt m its p ie. to handle wastes. mand=nm consists of pumping out the septic tads every throe years or Proper can affect the function of the if needed os a licensed pampa What y p rt into &e System tank a fieatmeat stage m the waste disposal_sysbem, . The property owner agrees to submit to St. CEO& Zoning Department a certification four, signext by the owner and by a 'P ] plambe� rrst<icxedphrmberor a Iioeasedp mperv�riag that (1) the oa -site v�rastewaterdisposat system u pupa Z condition and/or (Z) after iaspccton and pumpiog necesa &C septic -tank is I= than 113 full of sludge. YvIc. the tmdersignod have read the above requires and agree to maintain the private sewage disposal system with dw standards set forth, herein. as set by the Department of Commerce and the Department of Natural Reso urces, stating that You ups system has boen maintained must be completed and rotim d to &e St. (� oix.Cou�q Zoning Office �vithrn� 30 days &e three year expiration date. S LI TURE OF AP S / 7 / 9S DATE O R. RTIFI rO N 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 i 'bed abov b virtue of a warranty deed recorded in R egister of Deeds O Y ty offi PI: I DATE « «« informatio ia fti. nep reseated may result in the sanitary permit being revoked by the Zoning Department. «« Include with this application: a stamped warranty dad from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed + 4 &.0 Ne n, David Bracht Certified Residential Specialist - -- - -— Graduate REALTOR® Institute "s LOT 6 Sw s =- - 1 pT 4 �d7 g S.9'.3­E' 3ie 60 - 589'43']p'E 656. Of 3i>.e9 .9.39' 2N.0E )9).99• f = 7 5 LOT 5 LOT 3 ].¢ K�3 � I.F. K.ES 1)3 LOT 4 n ^ 3.00 K.tS EMC` FSrt. >$' 3.11 BC.EJ ExC. ESwT. l"1 E: 1M,)00 s0. ET. l.11 K11ES 1JS,.i1 z0. FT. � is IJ3,6.J SO.Ei. 3 m 01 O _OT _ .- 1u- a 10-T 041>Er.. , °� LOT 2 m /� _x.9 - F ® \ y >�' °3 Il9.eSe SG.111C. ESx1T. w.$ \ LOT I � 1w. »' -� \, o \ S,.;l s..•Srx n3.49' 1 '�- I._ iEp ... u�- of -lK "- \ .cso dil �Ee.so• e.gS,s io sE J R o$ '- 1 )' f 1.02 K.E6 wK. E6wT. I I d ? i - T / •$. 4-t• �• 131. i60 S4. FT. I I �y p, � , L 7 C9wT. aG. —. 341E NC. ES !J' � I q 589'5)2 - E 24296 300 a<4 Cx r. / _ -... �. �\ Q — eeY3>'32'T' - 2J9 ® / / � 'ylT •) h E 1 9i I `\ w -ROAD -7 - - ° E.1exa PUBLIC io — sw CO»1E4 ttnEw ab i_sw1 sa xb a c. - Cra1: r 11.1.: . __ - -_ —_ ___ 43..66'— } s99 N89'57'52_w 482.65' yyyIGGGIIII �s I LOT 8 - -- -- -- i m 1 G 1 , 3.0' LOT 9 FT 310 K° s r $. 8 v` 1- 'g, F _ 4 p { c m rv8957 '52 B>196 Q Rf/mw teaml realty - 103 Main St., Box 68 ® piss Somerset, Wisconsin 54025 © Office: (715) 247 -5900, Fax: 247 -3622 Residence: (800) 733 -9915 Each Office Independently Owned and Operated