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Home My WebLink About034-1019-50-050 ST. CROIX COUNTY ZONING DEPAIZ t,�T AS BUILT SANITARY REPORT' .�► Owner C Address t� ? / I ®+ !" " City /State .} !! ' / ST CROQX 01 3 4 , COUNTY ZONING OFFICE Legal Description: Lot Block Subdivision/CSM # ..V -E '/. -N ..?Sec. 9--, TAN -R — J-5 - V, Town of �5 L -' � � PIN # SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer 9� ) ter Size ST/PC —t -' S Pump manufacturer etback from: House Well 7oP /L S ' Alarm location Model (HOLDING TANKS ONLY) Setbacks: Service road ,y° y Vent to fresh air intake Meter location Water Line Alarm location SOIL ABSORPTION SYSTEM: Type of system: C'Ah Un„ �, r Width ,�' Setback from: House Well Length ---- Number of Trenches 2 P/L Vent to fresh air intake ELEVATIONS: Description of benchmar Description of alternate ben ark Elevation Elevation Building Sewer ST/HT Inlet ` �' ST Outlet -- "y PC Inlet - PC Bottom Header/Manifold r C`) �,. / Top of ST/PC Manhole Cover (� Distribution Lines TIZ f Bottom of System ( ) % , 6, 2 f ,. Final Grade ( ) ( ) Date of installation / 271 f &crmit number 3 S1 2/5 State plan number Plumber's si nature License number Date Inspector Completc plot plan �+ L 1Voconsin Impartment of Commerce PRIVATE SEWAGE SYSTEM Count Safety Buildings Division bT . CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitarlj�it21�.: Personal information you provice may be used for secondary purposes [Privacy L , s.15.04 (1)(m)]. SMITH, de�s 17 fokilal t f7.Town of: State Plan ID No.: CST BM Elev. Insp. BM Elev.: BM Description: Parcel &3 4' TANK INFORMATION ELEVATION DA A A9800297 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Se Ic kf tcseV— 5 Benchmark Aeration Bldg. Sewer & Holding St /Ht Inlet r 4. IZ 93. TANK SETBACK INFORMATION a/4911: Outlet TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake eptic �5' NA Dt Bottom sing NA Header /Man. ��.al ��q g3.dl Aeration NA Dist. Pipe -r t �: $� 9 IL S" Holding Bot. System T z 4 e q;: PUMP/ SIPHON INFORMATION Final Grade Manufacturer mand TO a I? `j Model umber GPM TDH L Friction S TD Forcemain Length Dia. Dist. To well SOIL ABSORPTION SYSTEM BED RE Width 3 1 Length No. Of nches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSI6 I DIMENSION SYSTEM TO SETBACK P/ L BLDG WELL LAKE /STREAM LEACHI G Manufacturer: INFORMATION Type f „� CHAMB er: Sy st MM 1 50 a Q 00 OR UNIT DISTRIBUTION SYSTEM Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing I Vent To Air Intake Length Dia. Length S °BTii `,/ Spacing x-- 16 e-ke SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over it 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: SPRINGFIELD 09.29.15.133,NE,NW 2947 110TH STREET t. 1 0C)S-(-� o ot,4W - �e V IM D om c l 44 OL AtrN^ f 1n a.( - 7 (oN-a Plan revision required? ❑ Yes 0 No Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Si ature i, SANITARY PERMIT APPLICATION 20 E VV��y�A Division ��risconsin In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Department of Commerce Madison, WI W707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 12 x 11 inches in size. St. Croix • See reverse side for instructions for completing this application State Sanitary Permit Number The information y ou p rovide maybe used b other overnm nt a c ro rams " " 48 Y P Y Y 9 9 17- z (Privacy Law, s. 15.04 (1) (m)J. � � 4/ � � � ❑ Check i revision to previous application y State Plan I.D. Nu mber I. APPLICATION INF RMATI N - PLEASE PRINT ALL INF RMATION Property Owner Name Property Location Dave Smith NE 1/4 NW 1/4,S 9 T 29 , N R 15 RAW) W Property Owner's Mailing Address Lot Number Block Number 14701 Kodiak Ave. W. City, State Zip Code Phone Number Subdivision Name or CSM Number Lakeville, MN 55044 (612 ) 435 -7011 II. TYPE OF ILDING: (check one) ❑ State Owned o itia Nearest Road vile Lj Public J3 1 or 2 Family Dwelling - No. of bedrooms 2 O Town OF Springfield 110th Ave. III. BUILDING USE (if building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 034- 0 50 -000; 09.29.15.133 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. ❑ New 2X)n 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 1 Zn Seepage Trench 22 ❑ In- Ground Pressure i a 1 42 ❑ Pit Privy 13 ❑ Seepage Pit 3 ��i� 43 ❑ Vault Privy 14 ❑ System -In -Fill ,, VI. ABSORPTION SYSTEM INFORMATION: I Q P+Weh fp 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade 300 Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) 91.5191.0190 Elevation 500 572.4 0.52 NA F ;et Feet VII. TANK Capacity INFORMATION in gallons Total # of Manufacturer's Name Prefab. Con- Fiber- Plastic Exper. New Existin Gallons Tanks Concrete structed Steel glass App. T nks Tanks Septic Tank 750 750 1 Wieser ® ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ I ❑ 1 ❑ 1 ❑ 1 ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumb s Signature: s) aP/MPRSW No.: Business Phone Number: Horace Hurlburt MP 222809 715- 283 -4851 Plumber's Address (Street, City, State, Zip Cod N 260 CTHW D, Eau Galle, WI 54737 IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee [Includes Groundwater D ate Issued ssui e t Signature (No Stamps) XA roved ❑ Owner Given Initial o Surcharge Fee) pp Adverse Determination - IWCA KOA�;ql�w� X. CONDITIONS OF APPROVAL tREASONSFOR DISAPPROVAL: SBD -6398 (R.11/96) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber -I �Jag Ck �2$ k+ 5 r- �►C� -t Litt }� �.. Z V 44 L.O. r Z �� l rr w QL � a.ot � o •�l /� /� C.i° �y�yo � � tJ" �OV .�.� �\ W Y►�►` i1 1..1w � I`�, �` �soA) u o I � u I - 'f1`, b .c 1t�. � � ; •L t eX f � ♦ a�-W `f.o �S3.to Zoi �J�MaL`i+.. f* tit `r ti [ 1 �t q o.�- 3 l� �+.... �,.( L. .Q CL � lL 1 o1�1 v c S _ V Wisconsw Department of Commerce SOIL AND SITE EVALUATION Page 1 of 3 .Divisign of Safety and Buildings .A i i1 arrt 0*0 Comm 83.05, Wis. Adm. Code Attach complete site plan on paper not less than WA i 41 Inc91d Elie. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and St. Croix percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I. D.# APPLICANT INFORMATION - Plea Rant all information 034 - 1010 - 50 - 000 (09.29.15.133) Date Personal information you provide may be used for pry purposes (Privacy Low, s. 15.04 (1) (m)). � r Property Owner r Property Location Smith Dave \ ` r Govt Lot NE 14 NW 1/4 S 9 T 29 N,R 15 W Property Owner's Mailing Address c. a E Lot # Block # S 14701 Kodiak Ave. W. -- _ City State a PhoneNumber City ❑Village ®Town Nearest Road Lakeville MN 5 4 672=435.7011 Springfield 110Th Ave. ❑ New Construction Use: ® Re rrtial / Number of bedrooms 2 ❑Addition to existing building ® Replacement ❑ Public or menial describe Code Derived daily flow 300 gpd Recommended design loading rate .5 bed, gpolfF .6 trench, gpd/ft' Absorption area required 600 bed, fF 500 trench, ft' Maximum design loading rate .5 bed, gpd/ft' .6 trench, gpd/ft' Recommended infiltration surface elevation(s) 91.5/91.0/90.5 ft (as referred to site plan benchmark) Additional design / site considerationsi 3 - Y x 36' Sidewinder, Hi- capacity "turtle- shell" trenches w/ extra backfill to give > 18" above system Parent material sandy /loamy outwash Flood plai n elevation, if applicable NA ft S= Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U= Unsuitable for system ® S❑ U ®S Q U ® S Q U ® S❑ U ❑ S ®U ❑ S® U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD/ftz Boring# Horizon in Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roofs Bed TTrench ................. .................. 1 1 0 -6 10YR 3/3 - sl 2 f sbk ds cs Him .5 .6 2 6 -64 10YR 3/3 - sl 2 m sbk mvfr cs lm .5 .6 Ground 3 64 -82 10YR 5/4 fld 7.SYR 4/6 s 0 sg ml - - 7 8 elev 93.0 ft Depth to limiting factor 64" Remarks: sl is very light- almost loamy sand; forms weak casts and textures as Is almost as often as sl _.... ................. .................. 2 1 0 -7 10YR 3/3 - s1 2 f sbk ds cs 2f1 m 5 6 2 7 -26 10YR 3/3 - sl 2 m sbk mvfr cw lm • .5 .6 Ground 3 26 -78 10YR 5/4 - s 0 sg ml - - 7 8 elev 94.0 ft Depth to limiting factor > 78• Remarks: 6 /6 OYR 3/4 sl (O,m) bands (a7 34-35,44 -45 52 -54 8r. 65-66" w/ weak high chroma pedogenic development below bands typically l OYR 6 CST Name (Please Print) Signature: Telephone No. Henry F. Grote 715 -665 -2681 Address P.O. Box 57, Knapp, W1 54749 Date CST Number Ref # 5/28/98 222774 295 (D 3 4 -I CIA - s-- . ") - o �•►•' Y� - ` o J 1 a.,. 7.Gt 4 11 O ti¢ oq, q,tr,li� hl L'- Nk, - -29 -I V �.. ,. �► S L► w ► 2 $ i ( Cu gb.c7 �tln o 4 L J4 " 0 , , F1 firms Q O..0) A J / �qy Q � � • a X ,� O 3 � 2v}j �a„L w .. � : ♦ �{� r o oe�l� V U ( �4•tt� �� rs b O-C Lt~ Cam. : 1 . 4 V lj 4 r» j AL,, Ito 4.&V4 Wisconsin Department of Commerce SOIL AND SITE EVALUATION Page 1 of 3 Divisidri of Safety and Buildings f m 83.05, Wis. Adm. Code ` Attach complete site plan on paper not less t I n s' Plan must County include, but not limited to: vertical and horizontal reference (BM), irection and $t. CIO1X percent slope, scale or dimemsions, north arrow, an distance to nearest road. , Parcel LD.# if APPLICANT INFORMATION - PI s@`j}i�t a informs on. 034 - 1010 -50 -000 (09.29.15.133) Personal information you provide may be used r dary purses (Privacy 1 qv�s, 15.04 (1) (m)). Re le '� D Property Owner Property Location Smith Dave Lot NE 14 NW 1/4 S 9 T 29 N,R 15 W Properly Owners Mailing Address ..; f , ; , " t # Block # Subd. Name or CSM# 14701 Kodiak Ave. W. : t OR.DX City State iP,(4pde P °`, Cily E] Village ®Town Nearest Road Lakeville MN - 044 zwft-c43 - L Springfield 110Th Ave. ❑ New Construction Use: ® Re ' " tidl /NNumber - o Brooms 2 []Addition to existing building ® Replacement Public or oo ial describe Code Derived daily flow 300 gpd Recommended design loading rate .5 bed, gpolftz .6 trench, gpd/ft= Absorption area required 600 bed, IF 500 trench, fP Maximum design loading rate .5 bed, gpdtfe .6 trench, gpd/ftz Recommended infiltration surface elevat 91.5/91.0/90.5 ft (as referred to site plan benchmark) Additional design / site considerationsi 3 - Y x 36' Sidewinder, Hi- capacity "turtle- shell" trenches w/ extra backfill to give > 18" above system Parent material sandy/loamy outwash Flood plai n elevation, if applicable NA ft S= Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U= Unsuitable for system ® S❑ U ® S❑ U I ® S❑ U ® S❑ U ❑ S® U ❑ S E U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD/ft Borin Horizon Texture Consistence Boundary Roots g# in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench ................. .................. i.. 1 0 -6 10YR 3/3 - sl 2 f sbk ds cs 2flm .5 .6 2 6-64 10YR 3/3 - sl 2 m sbk mvfr cs lm .5 .6 Ground 3 64 -82 10YR 5/4 fld 7.5YR 4/6 s 0 sg ml - - 7 8 elev 93.0 ft Depth to limiting factor 64" Remarks: sl_ is very light- almost loamy sand; forms weak casts and textures as is almost as often as sl ................. .................. ................. 2...I' 1 0 -7 10YR 3/3 - sl 2 f sbk ds cs 2fl m .5 6 2 7 -26 ' IOYR 3/3 - sl 2 in sbk mvfr cw Im • .5 .6 Ground 3 26 -78 IOYR 5/4 s 0 sg ml - - 7 8 elev 94.0 ft Depth to limiting factor > 78 Remarks: 10YR 3/4 A (O,m) bands @ 34-35,44-45 & 65-66" w/ weak high chroma pedogenic development below bands typically 10YR 6/6 CST Name (Please Print) Signature: Telephone No. Henry F. Grote _ 715 -665 -2681 Address P.O. Box 57, Knapp, Wl 54749 Date CST Number Ref # 5/28/98 222774 295 "co3 �ot9- se•v}o ��e. �,.,..'W�- 1 0� ,� ,�.,,, ICc4 -'� tto' p►..� oq, q, 1c ,13 N L' -N�.v -g - lq - tY Y's� wSNw ►28 �.a is Ir L� ai �o zo IL ice++► e\ i •�' q11 -.�� —� � g 7 C44 $S ;Zu A Ito A V. * q2.4 •r R •3 w L SO S . �A� Fl J TS `o ae 1 , , A.. 't ll. , i a]L.w ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer , 6o W V Mailing Address 7 / / 0 7t ..� Property Address _ o.*y 4,1 O 0 G/ I nv, G�� S� � O (Verification required from Planning Department for new construction) City /State Parcel Identification Number LEGAL DESCRIPTION L Property Location X 1 /4, Sec. , T 2 � N -R / W, Town of e � a -1 � ;� Subdivision , Lot # Certified Survey Map # Volume , Page # , 06 V)6 Warranty Deed # _ _ Z - 7 0 ;7 s t 2 / '7 , Volume )- Q Page # Spec house ❑ yes ® no Lot lines identifiable ❑ yes ❑ 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, 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, j ourneyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal 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 statin a our septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 day of th three year piri 'on date. SI ATURE OF APPLICANT ATI� E OWNER CERTIFICATION 1 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 th pro0erty descri bove, b virtue of a warranty deed recorded in Register of Deeds Office. C/ ATURE OF YPP 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 g. ` t E a IN IL � D 5' . DD DD r DDDD { DDD [I F] DD ry pi CA �p cr - n 3� cn i N ® � O o (' e N y I r — y j C 0 U) 6 f -C \ m rV'1 A - 1 d' z L - O - w o o i 4 en 1