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HomeMy WebLinkAbout036-1028-95-000 S'h. CROIX COUNTY ZONING DEl)Ain ;N r AS BUILT SANITARY R11,1 Owner Ea ih Address i 3o City/State Legal Description: - Lot Block -- Subdivision/CSM !t a �� Sec. 1L, T.,3/ N -R) Town of PIN # 0 3L SEPTIC TANK - DOSE CHAMBER - HOLDING TANK INFORMAT ON I 1 Tank manufacturer 6� ,51ze ST/PC Setback from: House � Well P/L /f! 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 101, Setback from: House a 6 ' Welly D p a pl�ngth � Number of Trenches .�_ Vent to fresh air intake ELEVATIONS: Description of benchmark IV Elevatio Description of alternate benchmark Elevation Building Sewer ST/HT Inlet -" ST Outlet S- 5 G PC Inlet PC Bottom Header/Manifold Top of ST/PC Manhole Cover 94' 7 Distribution Lines (l) S' 3 (a ) Bottom of System( L ( ) Final Grade { ) / 7 to ( ) Date of installation / mp / crmit number 3 219 ?-5 9"1 State plan number �— Plumber's signature License number a2 0 5 3 7 Date ? R 1 Inspector � j�`�}2Ol e, Complctc plot plan K W i sco nsin Department Commerce Safety Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count ST. CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary3202t$o: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: ❑ City Village Town of: State Plan ID No.: OOGHEEM, STEVE STANTON CST BM Elev.; Insp. BM Elev.: BM Description: Parcel Tax No.: 10 I All izr 40 11,E 036- 1038 -95 -000 TANK INFORMATION ELEVATION DATA A9800447 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. S pti hU Benchml 1d 1,, Z„ /6A Dosi ng Aeration Bldg. Sewer Holding Q /* Inlet TANK SETBACK INFORMATION St /49k Outlet P/L WELL BLDG. Air to i ntake ROAD Dt Inlet — ir Se NA Dt Bottom Dosing NA Header/ Man. Aera ' N Dist. Pipe �•/ G�S-�� Holding - Bot. System 0 PUMP / SIPHON INFORMATION Final Grade (Aq Manufacturer Model umber GPM TD Lift Fricti System TDH Ft Forcemain Length Dia. H Dist. To well SOIL ABSORPTION SYSTEM B TR N Width S Length /Z No_ Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSION SETBACK SYSTEM TO P/ L BLDG I WELL LAKE/STREAM LEACHIN - INFORMATION Ty p I /� r CHA R Model Nu Sy .A loo � - 7 �G17' OR U DISTRIBUTION SYSTEM Header/ Y Distribution Pipes) f x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length 170 Dia. Spacing 0 Se_ (f. f 272°7 — � 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 ❑ E] Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LO CCATION: STANTON_ 1684 210TH AVENUE �J I h�i�1►� V 51W GC rVHf� U / Plan revision required. / f r[: f ] Yes JK No Use other side for additional information. Zgj 7 SBD -6710 (R.3/97) Date Inspe is Signature CC ®No V i sconsin SANITARY PERMIT APPLICATION 01 E w s h n Ad� A ve lion Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 1/2 x 11 inches in size. • See reverse side for instructions for completing this application State sanitary Permit Number 3W2se 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)]. State Plan I.D. Nu I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATI N Property Owner Name Propert y Location v S0 1/4.5e- 1/4, S 16 T j � , N, R 12 or) W Pro pert O e 's Mailing Adtirsss Lot Number Block Number O 0-2 City, State Zip Code Phone Number Subdivision Name M Number .C�w.o "o l (n S) W 2 II. TYPE B DING: (check one) ❑ State Owned C it y � Nearest Roa Public 1 or 2 Family Dwelling - No. of bedrooms V ows oF2� ✓� t 111 BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 0 �<o — — Colo 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 2. Replacement 3 ❑ Replacement of 4_ E] Reconnection of 5 E] 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 r 42 ❑ Pit Privy 1 ❑ Seepage Pit C S ?� 113 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 r� Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation d �� / ��r+Z Feet Feet Ca acit VII. TANK in gallons Total # of Site INFORMATION Manufacturer's Name Prefab. Con- Fiber- Plastic Exper. New Existin Gallons Tanks Concrete Steel glass App. structed Tanks Tanks Septic Tank l w 1 ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber 1 ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attache plans. Plumber's Name: nt) Pl / uer�s Signatu : (N tamps EMP/IMPRSW No.: �y Business Phone Number: Plumber's , (Street, City, St e, Zip Code V\ t IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issue Issuin Agent Signature (No Stamps) %Approved ❑ Owner Given Initial Surcharge Fee) �� /^/ Adverse Determination l Ii,/ iqp / /O X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SB66M (at t =) DISTRIBUTION: Original to County. One copy To: safety & Buildings Division, Owner, Plumber I _� �1 Q► lf� I S v� ±rr•, s �'�, I I I I �� J � -� r , I I I it I I - ` T I _ I I ` I I I I I I i i I i ' I 1 I I I 1 i I I I I I I I I f I I � I i ' I f� I I I I ' I i I - - 1 i : I _ I I PAGE OF C rVSS J y STr= F(dlA Alt Inlels And Obsetvollon pip Lam-- Approrid Yonl Cap Minimum 12 Above Final Grada 20. 42' Above Popp 1' Coot Iron To final Grada Vant Pipe Ma►n Her Or S al, M 0 S B° Perlaoled Pips below o — Covpin0 Tarminellno AI Bollom 01 System SOIL FILL DISTRIBUTIOM PIPE APPROVED aS49PETIC COVER ^' r F-RIM- OR OF STRAW RAW 2 "oFl,, GG R� GATE MAT — "= OR MARSH HAy KIEV. oF �y�a EC .e ( OFl2'2 AGGREGATE �P i� Ile F T DI5 1- FtlI5'JTlr.:)N PIPE TO BE AT LEAST C QY _ INCHES BELOW ORIGINAL GRADE atilt/ AT LCAST t0 INCHES BUT 1.10 MORE. THAN 4Z IMCHES BELOW FINAL GRADE MAXIMUM DaPrij OF CIACAVATIO0 FROM OR16VJAL 6XADF_ WILL BE l� _ INCHES 111t1 9rPrN of I~ACAVAD,OM r-POl\ �161NAL I3RADF- WILL BE ! L_ INCHES SIGUED: LICEMSE IJUMBEIi: _- DATE E. — - -- — - - - - -.. 110 Wiscobsin Departmcdnt of ItAustry, SOIL AND SITE EVALUATION Labor and Human Relations Page of Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Attach complete site plan on paper not less than 8 1/2 x 11 inches in si Pf40 lar)si` ,f, County include, but not limited to: vertical and horizontal reference point (Bd�e,¢tion and ,.••�` .5 �� C r O � percent slope, scale or dimensions, north arrow, and location and d• tano� ton �rdel 1. D. # 3(� t ©3 —qS cod) Z) APPLICANT INFORMATION - Please print all info tion. , a qqQ RevieWe y Date Personal information you provide may be used for secondary purposes (Pri [w, s. 15.04 (1) Property Owner i �+ Pro L ation -l e VL' 1 7 i; -cICF �� Q, @. rY1 / ! Govl Lot }%4 1/4,S T 3 ,N,R f , �r) W Property Owner's Mailing Address i J 61� 4Igc #, f Subd. Name or CSM# City State Zip Code Phone Number Nearest Road �t Sy� (� /S�y _� ❑ City ❑ village own ❑ New Construction Use: XResidential / Number of bedrooms Addition to existing building Replacement ❑ Public or commercial - Describe: Code derived daily flow gpd Recommended design loading rate . 3 bed, gpd/ft gpd /ft Absorption area required bed, ft trench, ft Maximum design loading rate 3 bed, gpd/ft I _ trench, gpd/ft tr Recommended infiltration surface elevation(s) / 1 ft (as referred to site plan benchmark) Additional design /site considerations 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 rA S ❑ U [A s ❑ U ❑ s ER U ❑ s K U ❑ S ER U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench - 0 0 a — 5 r C 5 . 6a6 K 5/1 a SbK mfr CS am Q G � r j ou ) nd _9 5 I 5� i�Y 3 y e �ou- , ft. Depth to limiting factor , �in. Remarks: Boring # 0`1 - --' SV 3 3t, -A sbk Ground Depth to limiting factor in. Remarks: CST Nam (PI lase Print) jignature Telephone No. U t PC) We 2, - -" m6 - / Address Date CST Number i7 _ - te os.37 3 a� I I II � I , j I Z II I _ I 11 1 ! _ lo L - _I l j _ I i I I I I I : I ' t i ST. CROIX COUNTY OFFICE + CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that Ih�a inspected the septic tank presently serving the � � � �_ l� �.Q residence located at: .5 1/4, Sec. /�. , T 3� N R W, Town of a. Upon inspection, I certify that I have found the tank' and baffles to be in good condition, and it appears to be functioning properly. q Last time serviced i 1 G� Did flow back occur from absorption system? Yes No ,(if no, skip Approximate volume or length of-time: gallons next line) minutes Capacity: Construction: Prefab Concrete — Steel Other Manufacurer (if known): Age of T (if known): C�\ lQ (Signature) (Name) Please Print -AA�) -5 �T (Title); (License Number) (Date) Form to be completed by licensed plumber (x.145.06, Wisconsin Statutes.) or Licensed Disposer (NR 113 Wisconsin Administrative Code) Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank to the best of my knowledge will conform to the requirements of ILHR -83, Wis. Adm., Code (except for inspection open in over outlet baffle). Name 1. ` V\ R , - , V3 , - Q .c S Signature o7c� ®S 5/88 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer L & .Q C - yly ,� �► Mailing Address Property Address es -+ (Verification equired from Planning Department for new construction) City /State Parcel Identification Number LEGAL DESCRIPTION Property Location - ' /4, S"- '/4; Sec. �b , T 31 N - 12 _ Town of Subdivision , Lot # t Certified Survey Map # 3 �(� , Volume = Page # Warranty Deed # 5 3� y I , Volume Page # Spec house ❑ yes 1K 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, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal 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 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 days of the three year expiration date. SIGNATURE OF AOLICANT 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 property described above, by virtue of a warranty deed recorded in Register of Deeds Office. SIGNATURE OF APP CANT 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 l i ,3 314 CERTIFIED 8URVEY MAP I, Arthur L. Wegerer, registered land surveyor, hereby certify: That in full compliance with the provisions of Chapter 236.34 of the Wisconsin Statutes and the provisions of the St-Croix County Subdivision Ordinance and under the direction of Steven G. Hoogheem, owner of said land, I have'surveyed, divided, and mapped said parcel of land, that such plat correctly represents all exterior boundaries and the subdivision of the land surveyed; and that.this land is located in the SEw of the SEy of Section T 31 N, R 17 W, Town of Stanton, St.Croix CountZrner Wisco , o -tiri t: C i- :encing at the South of Section 16; then.^e East along the Section line 1331.63r to the point 'of beginning; thence North 660.00 ; 'thence East 330.00 ; thence South 6 0.00 to the Section line; thence West 330.0Q to the point of beginning. Contains 5.000 acres of land subject ,to Town Road Right -Of -Way .. over the Souther y 33 thereof. .Dated this 14th. day of April, 1976 ul7ti (V11L- �' h t.hur L. V,Qrer `,Wis. R.L.S. S - 9 3 EAST _. Sm. Ob - ♦ g o es. ` J ARTLI ` R VyErc�c • S_(1 S�{ ! 4 ire ift '� a ! ! !aB . , t i r i F i • ELLS"A'nRTH l o f �. Wis. ,. g 16 O c0 (D 0= I "X 24 IRON PIPE WEIGHING 1.13 LBS. /LINEAL FT. LOT o . � N 5.000 ACRES co ^..'. ' y N ORTH SCALE -1 ° :100 ~ 3 I-- APPROVAL OF THIS M!NOR SUBDIVISION o , z Fib � (n DOES NOT MEAN APPROVAL FOR SEPTIC MAY 2g ' SYSTEM. REFER TO H62.20 - in �s . 1976 APPR k+cw. rO NNEtt ft ST. CROIX COUNTY "'«,�� ' 1A 46 1 COMPREHENSIVE FARKS PLANNING PK. SET AT AND ZONING COMMIT ILE