HomeMy WebLinkAbout036-1044-95-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count
Safety and Buildings Division
INSPECTION REPORT ST. CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar y320271:
Personal information you provice may be used for secondary purposes [Privacy L , s.15.04 (1)(m)).
Permit Holder's Name: I ❑ Cit Town of: State Plan ID No.:
CICCHESE, BARRY STANTON
CST BM Elev.:- Insp. BM Elev.: BM Description: Parcel T��N�_: -95 -000
TANK INFORMATION ELEVATION DATA A9800459
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosi ng
Aeration Bldg. Sewer
Holding St /Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P/ L WELL BLDG. Air ir Intake ROAD Dt Inlet
Septic NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH I Lift Friction System TDH Ft
L oss Forcemain Length Dia. t f Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSION DIMENSION
SETBACK
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type Of CHAMBER Model Number:
System: OR UNIT
DISTRIBUTION SYSTEM
Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. _ Length Dia. Spacing
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 ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: STANTON 19.31.17.281D,NE,NW 1429 210TH AVENUE
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD -6710 (R.3/97) Date Inspector's Signature Cert. No.
Safety and Buildings Division
SA NITARY PERMIT APPLICATION 2 01 W. Washington Avenue
A f i sconsin
In accord with ILHR 83.05, Wis. Adm. Code P O Box 7302
Department of Commerce Madison, WI 53707 -7302
• 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. C
• See reverse side for instructions for completing this application state Sanitar Permit Number
Personal information you provide may be used for secondary purposes p Check if revision to previous application.
[Privacy Law, s. 15.04 (1) (m)]. (`a ' K� State Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N
Property
Owner Name �/ ti Pro4erty Loc 1�4 S T 3) , N, R E (Or)
Property Owneies Mailing Address Lot Number I Block Number
z/d
City, State Zip Code T P7/ hone Number Subdivision Name or CS Number
c -i Z 3 In
II. TYPE OF BUILDING: (check one) ❑ State Owned o it � Nearest Ro ad
p e �
Public 1 or 2 Family Dwelling - No_ of bedrooms T VII ag
own OF A cZI2 4 5—
III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 9S
(7
1 ❑ Apartment/ Condo / �' 3 7' a 8 D
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) `7�,rrw -A vie,
A) 1. ❑ New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5 Repair of an
______System ________ System _____________ Tank Only______________ Existing System Exlstfnc�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 E] Mound 30 [] Specify Type 41 C] Holding Tank
12 6 Seepage Trench 22 ❑ In- Ground Pressure 42 E] Pit Privy
13 E] Seepage Pit ^' I Y �1( 43 ❑ Vault Privy
14 ❑ System -In -Fill -L 0
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. /inch) Elevation
Feet , 1 Feet
Capacit
VII. TANK in allo Total # of Prefab. Site Fiber- Exper.
INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con- steel glass Plastic App
New Existin structed
Tanks Tanks
Septic Tank or Holding Tank 1 ) 606 1 -2 ❑ ❑ ❑ ❑ ❑
Lift Pump Tank %Siphon Chamber ❑ ❑ I ❑ I ❑ 1 ❑ 1 ❑ — E�
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for' stallation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plu er' i ni tur • (No Stamps) MP /MPRSW No.: Business Phone Number:
v 7r .�
Plumber's Address (Sfrebt, City, State, Zip Code >:
;! v /1✓r
IX. COUNTY / DEPARTMENT USE ONLY
❑Disapproved Sanitary Permit Fee (include$ A Groundwater ate Issued issuing Agent Signature (No Stamps)
roved Surcharge /� � ,•
pp []Owner Given Initial I�� o� / e Fee) � �}�25 8
Adverse Determination l
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD- 6398 (R.11/97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber -
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
This is to certify that I have inspected the septic tank presently serving
the ,�� / residence located at: _ 4, A/4 y
Sec. �� , T N, R - W, Town of St. Croix
County, Wisconsin. Upon inspection, I certify that I have found the tank and
baffles to be in good condition, and it appears to be functioning properly.
Last time serviced 9
Did flow back occur from absorption system? Yes, No (if no, skip next
line.
Approximate volume or length of time: gallons minutes
Capacity: "-
Construction: Prefab Concrete _� Steel Other
Manufacturer (if known):
Age of Tank (if known):
(/ 4 2,- /Z /) nature ��5
(Signature (Name) Plea6d Print
(License Number)
(Date)
Form to be completed by licensed plumber (s. 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 opening over
outlet baff
Name �iS /1� Signature
MP /MPRS
09/22/98 TUE 15:10 FAX 715 386 4686 ST CRX CO ZONING 002
ST. CROIX COUNTY
WISCONSIN
— ZONING OFFICE
'•+' ST. CROIX COUNTY (iOVERNMEN r CENTER
1101 CanrlduW Road
M .�._- - — ---- -- Hudson, WI 54016.7710
(715) 386.4680
AFFIDAVIT OF SYeTSM RL'dUBNATION
Property owner: /Y
Addre �6��
1 a—J 1A
Day time phone: (Rim) ZV - Z3
)areal I.D.# $
Ivagal Description of property: �k ad see T.3L_N.
R.W., Tn. of
St. Croix county, RI
.:a owner of the above described property, I acknowledg
-Vtic system serving this residence (is /is not) unersized t he
, urrent code standards. I understand that the issuance of a
anitary permit to allow the attempted rejuvenation of the septic
ystem does not imply that the system meets current code sizing
equirements, nor does it imply that the proposed procedure will be
%lecessful. I also acknowledge that I will make this information
vailable to any future parties interested in purchasing this
roperty.
R� y
ignature:
Date:
5/97
Wisconsin Department of commerce SOIL AND SITE EVALUATION
Division of Safety and Buildings Page __L of
Bureau of Integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code
Attach complete site plan on paper not less than 8 1/2 x 11 Inches in size. Plan must County
Include, but rat limited to: vertical and horizontal reference point (BM), direction and C O f
percent slops, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
. - c�" I o y g 4— Soo o
APPLICANT INFORMATION - Pl"se n> IYnf in'etlol:, Review by Date
Personal information you provide may used for
y r, 4 rjr�p o ryo8ss(fi,4vecytA s.,.1, . (1) (m)).
Property Owner perty Location NW
G _ .Lot w 1/4 0 1/4,S 19 T 3I N,R '7 E (ore
Property Owneile Mailing Address 1.,A Lot Block# Subd. Name or CSM#
14 a9 s1 cx v, 3 Pa S 3 3
City State Zip Code Phone I FI ` n City ❑ Village E] Town Nearest Road
rV w.e� w� SNo� r :7 -3 Q a a�d
L'
❑ New Construction Use: ® Residential / Num rooms _ Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
59 R4v.+aK4A;0V%
Code derived daily flow — gpd Recommended design loading rate " bed, gpdtft = trench, gpdit
Ab sorption area required bed, ft2 o / trench, ft Maximum design loading rate -- bed, gpd/ft trench, gpd/ft
awwwl�' "r = �1, ft as referred to site Ian benchmark
Aecoauaeade�4lntiitration surface elevation(s) � ( p )
Additional desigri/sfte considerations _� 2.., a — li,j n r i
Parent material AG'► (h 1 r) U+ w Q S G1 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 systerni WS El u CBS El u I ®S ❑ u 1 59 S E u I ❑ s [3 U [- CS U
SOIL DESCRIPTION REPORT
Boring Horizon Depth Dominant Color Mottles Structure GPD/ft
g in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed , Trenct
l
0 -16 1 4 3/
Ground L
-7. y y 5 <_
Depth to Yo-7 1 —
limiting ;
factor
Remarks: Y' S 60 t h' v *.I\
Boring #
.:rrS i4
Ground t t Q C V\ (� S E
slev.
n.
Depth to
limiting
factor
in. Remarks:
CST Name (Please Print) Signature Telephone No.
-�'arl� �. _ - 7 15 - �`l ?- 35$$
Address +� Date CST Number
a a St 5 ,r
Syoa
-
N E 'Iy � SC IQ o T Z1MJ, k1 S. 5 5 4er t \ r~
ruw4y ra ly
T � cs4 ►� as 17 y b
RoA I ro So : ,nn t,v� S'�b�
so
3 vv 4
d
k-I -
.i
V z
35 Q �
,p P °fie
hr. r -.'
er
h
Qm QcQ � �
d.e,:��:41� uey% +, t 4.x04
o
r' 1 � 0 C. r l r e fe c .e. Pf- .
ve.v.} P.�
Q bor �C (3� q$�12•
� w �1 I
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/B
<1
Mailing Address
Property Address _
(Verification required from Planning Department for new construction)
Ci /State
ty 1A A Parcel Identification Number 36:� -
LEGAL DESCRIPTION
Property Locatio �, ,� /, See. T ,3/ N -R2W, Town of 5"��
Subdivision
Lot # -
Certified Survey Map # _ 2 . ��� Volume � Page #
Warranty Deed # / Volume Page # 7 2,-S
Spec house ❑yes ❑ no Lot lines identifiable. ❑ yes ❑. no
DANCE
lwBropuwcand ofymscpdcsystemcouldresaltkits
consists of pumping oat the septic tank every three years or P��a+cfailuc+e to handle wastes. Propermaiateaaace
ooas
can fists Gf a �fuactioa of the if node by 9 Licensed pamper. What you pat into the system
septic tank as -a tmatmeatstage in the Vasbe disposai_system,
Tie PwPcr owner agrees to submit to St. Croix Zaubg Deportment a .certification form. signed by the -ow= and by a
P I apb= ber. rest <idadplumberoriti=sedpumM that(I) &e on-site wastewater 1system
is m Proper operating condition and/or (2) afftcr won ad pumping necessary the septiataak-is less .dm W fid of sludge.
Uwe, the undersigaod have read the above reqakcinents tad a to maintain the rivate
set forth. herek as set by the Dgmft eat of commerce and the t e � with the standards
stating 911 Your septic Department of Natural Resources State of Wisconsin.- Cert%frcation
system has been maintained mast b completed and
days-of throe year expiration date, rcb=cd to the St, t mix.Coumy Zoning Office within 30
X SIGNATURE OF APPLICANT / /
DATE
OWNER CER MCATION
I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner of
the described above, by virtue of a warranty deed recorded in Register of Deeds Office.
�1
SIGNATURE OF APPLICANT
DATE
« « « « «« Any iaforrnation that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. « « « « ««
«• Include with this applicatlon: a stamped warranty deed from the Register of Deeds office
a copy of the certified s=cy map if reference is made in the warranty deed
h ew FORM NO. 985 -A
H4Md.rrrCdp.ry®
5 , 9 549
CERTIFIED SURVEY MAP
I, Bradley J. Canaday, 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 Eva Smith 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 NE4 of the NW4 and
the NW4 of the NW4 of Section 19, T31N, R17W, Town of Stanton, St. Croix
County, Wisconsin, to-wit:
Commencing at the N4 corner of said section, thence West along the North
line of the NWT 820 to the point of beginning; thence South 333.50
thence West 725.00 thence North 333.501 to the North line of the NWT•,
thence East 725.00 to the point of beginning.
Said parcel contains 5.55 acres and is subject to an exiting Town Road
right -of -way over the Northerly 33 thereof
APPROVED
Dated this 23rd day of May 1979 JUL 11 1979
NORTH 1/4 CORNER o♦ ea� G o ��,0�i o
SEC 19, T31 N , R I7 W 7 COMP2EHENSIVX PARKS PLANNING
s J� AND ZOHING COMMITTEE
BRADLEY J. ii v
Z
CANADAY o APPROVAL. OF THIS MINOR SUBDIVISION
M = S -1 N... k M-AN APP;cOVAL FOR
U) • RIVER FALLS DOES
i WI S r : BUILDING �,I_ OR SEPTIC SYJEM.
! �i +. p�♦ ♦` REFER TO H62.1.0-
SU
c� osses
a3.00 Bra le . Ca nad
SOUTH 333.50' 3 g R.L.S. No. S -1462
I X91 300.50
O cy ,� is Dittloff Engineering Co.
I O
c „ z I F1 River Falls, Wis. 54022
m 1 JUL 24 1979 0)
W* °r . v
z o i D 00 :� oa•ly,
z i > > r of s
1 I °c o = 1" X 24" IRON PIPE WEIGHING
m (rn W 1.13 LBS /LINEAL FOOT SET
I I r
0 0 O — • = 1" X 24" IRON PIPE FOUND
I 1 �
I 1 zz
__J I N
n I __