HomeMy WebLinkAbout036-1051-80-000 ST. CROIX COUNTY ZONING DEPARTMEN `� .
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AS BUILT SANITARY REPORT
Owner l ". 14 L
Address
City /State -
Legal Description:
Lot Block ubdivision/CSM #
'/. ��'' /. 25�, Sec. / , T,LN -R_Z3V, Town of _S w/L PIN #
al- 3(l�• �a-3
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION:
Tank manufacturer Size ST/PC / �J� Setback from: House 9,5 Well/
Pump manufacture_ r. AQgdel
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 Length / Number of Trenches
Setback from: House Well /6 D P/ 5 _ Vent to fresh air intake ..2 5/(m
ELEVATIONS
Description of benchmark Elevation
Description of alternate benchmark ' '` ,-1 levation_T�(.__l
vI ,z
Building Sewer / - ST/HT Inlet ST Outlet 2 PC Inlet `—
PC Bottom T `" Header/Manifold Top of ST/PC Manhole Cover `
Distribution Lines
Bottom of System () () ( )
Final Grade
Date of installation 6'134?yl� Permit number 3/.5S,;O State plan number
Plumber's 'nature Licen se num Date 6 LWS
Inspector ®� I 1
Complete plot plan
Wisconsin Department of Commerce
Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count t . CROIX
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) SanitacnffeniW:
Personal information you provice may be used for secondary purposes [Privacy L s.15.04 (1)(m)].
Permit Holder's Na a e Town of: State Plan ID No.:
CNAMARA , RANK �'� (�� g E]
CST BM Elev.: Insp. BM Elev.: BM escriptio Parcel 6336 Q--1051-80-000
C
TANK INFORMATION ELEVATION DATA A9800210
PE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
T epti7 7 / ODD Benchm k 1
Dosi ng
Aeration Bldg. Sewer
Holding t/ Inlet 4 'N
TANK SETBACK INFORMATION n � St 4* Outlet 7C3 e-7
T P/L WELL BLDG. Airintake ROAD Dt Inlet
Septic C NA Dt Bottom
Dosing NA Header / Man.
7.� 3
Aeration NA Dist. Pipe ?3.
Holdin Bot. System 2 , c/ Z.�—
PUMP / SIPHON INFORMATION Final Grade S_-Q, IT(;
Manufacturer . e 77.q
Model Number GPM
TDH Lift Friction S TDH Ft
Forcemain Length Did. Dist. To Well
SOIL ABSORPTION SYSTEM
/ TRENCH Width I Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Dep
DIMENSIONS ( � DIMENSION
SETBACK
SYSTEM TO P/ L L G WELL LAKE /STREAM LEA anufacturer: INFORMATION Type O AMBER Model Num e
Syste ZC OR UNIT
DISTRIBUTION SYSTEM
Header / Manifold a Distribution Pi e(s) x Hoe Size x Hole Spacing Vent To Air Intake
Length LL Dia - Length Dia. — 1 — Spacing �1 I T f o - 6 q Q
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx M I hed
Bed /Trench Center Bed /Trench Edges o ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: STANTON 21.31.17.323,SW,SE 1664 200TH AVENUE
�; Gs V_L�
rim ho Iqb
Plan revision required. ❑ Yes ❑ No
Use other side for additional information. - W13
SBD -6710 (R.3197) Date Inspector's Si ature
Safety and Buildings Division
Vi scons i n SANITARY PERMIT APPLICATION 2 01 W. Washington Avenue
In d w acc o r t . P O Box 7302
Department of Commerce t LHR 83 05, Wi s . A dm Code Madison, WI 53707 -7302
• Attach complete plans (to the county copy only) for the system, on paper not less County pp
than 8 1/2 x11 inches in size. � i lv`vi
• See reverse side for instructions for completing this application State Sanitaa Permit Number
Personal information you provide may be used for secondary purposes ❑ check if revi�l6n fo previous application
[Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION I 1___�
Property Owner Name Property Location
/ rC,_ 1/4 SE 1 /4, S C� T l , N, R� _7E (o
Property Owner's Mailing Address Lot Number Block Number
City, State Zip Code Phone Numb Subdivision Name or CSM Number
(7!S
I1. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road
village
Public 1 or 2 Family Dwelling No. of bedrooms .3 E] village OF
III BUILDING USE: (if building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo
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 online B, if applicable)
A) 1. ❑ New 2..j4 Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an
- _____System ____- tem __ ____ _______ 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
1?,-0Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In- Ground Pressure r 42 ❑ Pit Privy
13 ❑ Seepage Pit 1 !7 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 (s . ft.) (Gals/ y /sq. ft.,) (Min. /inch) CJ� Elevation
r Jo/ ,
56 02 Feet • Feet
Capacity
VII. TANK in Ca allo s Total # of Prefab. Site Fiber- Exper.
INFORMATION g Gallons Tanks Manufacturer Name Concrete Con- steel glass Plastic App
New Exist in structed
Tanks Tanks
eptic ank Ing ank >< ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ I ❑ Ill I ❑ I ❑ ❑
VI11. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
P tuber's Name: (Print) Plum 's Signature: Stamp [ MP�/iMPRSW No.: Business Phone Number:
>. JJr _33 / `i< ?Is ,Q 6�
Plb �'s Address (St eet,Gty State, Zip Code):
r to 4L N-2— 1 A O
IX. COUNTY/ DEPARTMENT ONL
❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued Issu g ent Si nature (No Stamps)
D4 roved Surcharge Fee)
Adverse Determination p�l
pp ❑ Owner Given Initial Q'j� eo7 (, /
vV <r°�
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD- 6398 (R.11/97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
PLOT PLAN
PROJECT Frank McNamara ADDRESS 1664 200th Ave New Richmond Wi 54017
SW 1/4 SE 1 /4S 21 /T 31 N/R 17 W TOWN Stanton COUNTY ST. CROIX
MPRS BYRON BIRD JR. 3318 DATE 5/29/98 BEDROOM 3
CONVENTIONAL XXX IN -GR UND PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 Gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .4 ABSORPTION AREA 1 128 BED SIZE 12'X 94'
IL BENCHMARK V.R.P. Base of Window ASSUME ELEVATION 100'
❑ BOREHOLE O WELL *H. R. P. Same as Benchmark
SYSTEM ELEVATION 92.2
PL
Alt.
LB.M.
vEtrr
12" GRADE
' ii TYPAR COVERING
38 ft4 ,
BM 12" 3' 6' (a) 3'
42' 27' ALL i " SEWER R K
12'
DRIVEWAY
Insulated Line to
be used under 70'
Driveway
131, BARN
Line to be buried at a T
depth of >42" after PL
g30' from house 125' 60'
20'
> 20'
2 B -3
1
10 AL
BM 90,
36' 12' X 94' Bed
>500'
V 0 B -1 60 B -2
0 12'
PL Vent
Wiscongin Department of Commerce SOIL AND SITE EVALUATION
Division of Safety and Buildings Page of
Bureau of Integrated Services r a COJp ith S. ILHR 83.09, Wis. Adm. Code
"' `
Attach complete site plan on paper not les tAan t 1/2 x 1 Aches in size. I an must County
include, but not limited to: vertical and h izt, I refe BM), direotign and
IL . s Gym
percent slope, scale or dimensions, nort ar?pw, and location an distance to_r)earest road. Parcel LD. #
OJ� 400
APPLICANT INFORMATION - ��e prin!_fl1f fprrmatio#t ' Rev b Date
Personal information you provide may be used 5 ndary pufpiei� (ivac Law; s 1 .04 (1) (m)).
S �L
Property Owner' Property Location
?"a s. Govt. Lot 1/4 1 /4,S T N,R E (o
Property Owner's Mailing Address ` Lot # Bock# Subd. Name or CSM#
City State dip Code Phone Number ❑ City [:1 Village X Town Nearest Road
e/7 (71 j✓ 0 S f" �
❑ New Construction Use: 'Residential / Number of bedrooms �_ Addition to existing building
Q] Replacement ❑ Public or commercial - Describe:
Code derived daily flow gpd Recommended design loading rate _bed, gpd/ft gpd /ft
Absorption area required bed, ft 9DO trench, ft Maximum design loading rate _ bed, gpd/ft? trench, gpd /ft
Recommended infiltration surface elevation(s) 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 Ground Pressure AT -Grade System in Fill Holding Tank
U = Unsuitable for system I JAS ❑ U F5!rS ❑ U In p S ❑ U PT-8 ❑ U ❑ S 2rU ❑ S ',U
SOIL DESCRIPTION REPORT
Boring Horizon Depth Dominant Color Mottles Structure GPD /ft
9 Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
,
l o to �` r G • 5^
-i o _
Ground
� ellev
Depth to
limiting
factor
,--- in.
3- Remarks:
Boring #
l a -% lO 2 - �3 /v ®.� 02 n� .� -P r- 0-
Ground
elev.
3 DeA to
limiting
factor
in. Remarks:
T Name (Please Print) Signa a Telephone No.
Al
4 ��
Addre s/ c� Date CST Number
Soil Test Plot Plan
Project Name FRANK MCNAMARA Byron Bird Jr.
Address 1664 200TH AVE.
NEW RICHMOND, WI 5 4 0 17 C9fM #3479
Lot -- ---- Subdivision - ---- ------ Date 5 /1 9 /98
SW 1 /4 1/4S21 T 31 N/R 17 W TownshipSTANTON
E] Boring ()Well PL Property Line County ST. CROIX
BM or VRP Assume Elevation 100 ft.BASE OF WINDOWN
System Elevation 92.2 * H R P Sa as Benchmark
Alternate Benchmark NAII. IN ELM TREE / moo
PL
Alt.
B.M.
38'
BM ELI,
42' 27'
DRIVEWAY Q
L
BARN p
g 125'
20'
a 20'
� 20' B -3
io at
BM 90,
36'
500'
V
20' B -1 60' 12' B -2
0
0
PL
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
/ OWNERSHIP CERTIFICATION FORM
Owner /Buyer
Mailing Address ` n
Property Address
(Verification required from Planning Department for new construction) / l
City /State _SG --ems Parcel Identification Number
LE GAL DESCRIPTION
Property Location '/4, '/4, Sec. , T _5/ N _R_Z2W, Town of
Subdivision ��C12/S_/1l>' , Lot #
Certified Survey Map # �— , Volume Page #
Warranty Deed # / X , Volume 9/ V , Page # 6
Spec house ❑ ye ono Lot lines identifiable 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 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
stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
ays of a three year expira ' date. / / 1
u/- lL,U✓
IGNATURE O PLICANT 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
t e rope descri ed above, irtue,,,o�f�a warranty deed recorded in Register of Deeds Office. r L
Gv v ►� l 6 �^"' l ` rl
S GNATURE OF f PLICANT 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