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Home My WebLink About036-1065-90-000 ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT Owner - Property Address mss! City /State 1 Legal Description: Lot — Block Subdivision/CSM # %4 � t /a, Sec. TAN -RAW, Town of PIN _ SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION Tank manufacturer Size ST/P / Setback from: House Z-->? Well ,� PM/ac— Pump manufacturer Model Alarm location (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location I SOIL ABSORPTION SYSTEM Type of system: 'ko Width IS Length e5 Number of Trenches Setback from: House Well / /to P/L Vent to fresh air intake ELEVATIONS Description of benchmark S t Elevation Description of alternate benchmark Elevation 7 _ Building Sewer /� >.�v� ST/HT Inle ST Outlet ,is��i� PC Inlet PC Bottom Header/Manifold /��, y Top of ST/PC Manhole Cover L l Distribution Lines Bottom of System O Za.2_o Final Grade Date of installation 711,; 7P�r it n ber State plan number Plumber's signat re License number Date 1�?/ Inspector 416 Complete plot plan Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Buildings Division Count bT . CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar yn Personal information you provice may be used for secondary purposes [Privacy s.15.04 (1)(m)]. 4 LL 11 Permit Holder's ERGIN, DARREN D . 9�iiNTUNage Town of: State Plan ID No.: CST BM Elev.: l insp.BMElev.: BM Description: Parcel 8q; 90-000 TANK INFORMATION ELEVATION DATA A9800520 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Wee Benchrr Dosing k X J l=- Y""" �. ZY O Aeration X Bldg_ Sewer Holding ?� t t Inlet TANK SETBACK INFORMATION Outlet S TANKTO P/L WELL BLDG. Air to i ntake ROAD Dt Inlet ir X Septic �. �,, NA Dt Bottom )C Dosing Y NA Header / Man. Aeration NA Dist. Pipe �.� > 7 Holding - Bot. System PUMP / SIPHON INFORMATION Final Grade ' Manufacturer Demand Model Number GPM TDH Lift Lriction R _ System _ TDH Ft Head oss Forcemain Length Dia. Dist. To W,gu__ S IL ABSORPTION SYSTEM 1S g BENCH Width Length N Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIME N I N I DIMENSIONS ' SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION TypeO „ CHAMBER Model Number: System: 5 1 i 0 +:> OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length 12 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 28.31.17.427,SW W 1609 200TH AVENUE Ths {A1I-e_v ( 4ecamW e u ClCA,5n A wk. � ` — �f o o F bac I(_ �( � i II � �''! �� of 3 Z� 1 r !� , r ( '�'� V l�. t yt,a ,ka,,, '. uvf U � t I151�� Plan revision required? ❑ Yes ® No j Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Signiaure ert. Safety and Buildings Division 14 9consin SANITARY PERMIT APPLICATION 2 01 W. Washington Avenue 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 81/2 x 11 inches in size. s- • See reverse side for instructions for completing this application State Sanl ary Perrmi Number Personal information you provide may be used for secondary purposes E] Check it n to previous application [Privacy Law, s. 15.04 (1) (m)L State Plan I.D. Number - 1. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION Prop rty Owner Na a Property Location J" va, S T , N, R or Property Owner's Mailing Address j Lot Number Block Number rh' i — Cit , tate 1 zip Coe Phone Number Subdivision Name or CSM Number 7 ( ) I1. TYPE B IL ING: (check one) ❑ State Owned E] Ity Nearest Road ❑ Village -�s9 Public 1 or 2 Family Dwelling No. of bedrooms Town OF III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)r - 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 on line B, if applicable) A) 1. 13 New 2 ❑ Replacement 3 ❑ Replacement of 4 ❑ Reconnection of 5. ❑ Repair of an System ________ System_____________ Tank Onl�r______________ Existing System ________ Exlsth2q� yytem 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 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In-Fi[I VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3_ Absorp. Area 4. Loading Rate 5. Per Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/da /sq. ft.) (Min. rich) Elevation 5 �— Feet Feet Capacit VII. NFORMATION in g allo ns Total # of r Prefab. Site Fiber- Exper. g Gallons Tanks Manufacturer Name Concrete con- Steel glass Plastic App New Existing strurted Tanks Tanks Septic Tank or Holding Tank ❑ 1 ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ I ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for inst tion of th onsite sewage system shown on the attached plans. P�me Vt) Plumb 's Si t t ps MP /MPRSW No.: Business Phone Number: l 1 s I tuber s Addre sf (�� eet 11 City, St te, Code): 1 IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater D ate Issued Issuing Agent Signature (No Stamps) Ap proved /1 Surcharge Fee) pp ❑Owner Given �j � >��d Adverse Determination / d X . CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: 7) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division; Owner, Plumber � i - � � \---- � i �. �� b � � � � �' �. �� ° Z � , � �� z�� a � � � y � a Q w � � � �, �� k ' .� .°o ® � � � _ � ,� a �, � � � � N� _� �, �y � � �� .s�, g i �o \� � r, � � � t� n� � a� .� � � � � �� / -- --�- -. i Wi§gsnsn Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3 Labor and Human Relations Division bf Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less th 112,E 11 inches in size. Plan must include, but St. Croix not limited to vertical and horizontal refer cp, nj (8Iyl) ction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and locatio e d�¢istnce fist oad. 036- 1065 -80 APPLICANT INFORMATION -P 45�E IN ATION R VIEWED BY DATE tLe�� 12.3 •% PROPERTY OWNER: } PROPERTY LOCATION Darren & Lisa Ver n , ). 2 1997 (, r GOVT. LOT SW 1/4 NW 1/4,S28 T 31 N,R 17 for) IN PROPERTY OWNERS MAILING AD 4 1;T �;ROIX ' LOT # BLOCK # SUBD. NAME OR CSM # 887 E. 6th St. #3 Y .:- CUUNrY , i na na na CITY, STATE `�[P.QQDEZON ❑CITY ❑VILLAGE ®TOWN NEAREST ROAD New Richmond, WI. 54617, (715 . 032 Stanton 200th. ave. [x] New Construction Use [ ] ResideIitii bui i i Brooms 4 [ ] Addition to existing building I ] Replacement ( ] Public or commercial describe Code derived daily flow 600 gpd Recommended design loading rate • 4 bed, gpd /ft - 5 trench, gpd /ft Absorption area required 1500 bed, ft 1200 trench, ft Maximum design loading rate _ bed, gpd /ft gpd /ft Recommended infiltration surface elevation(s) 103.55 ft (as referred to site plan benchmark) Additional design / site considerations trenches 3/25 below surface grade spaced to code Parent material pitted glacial dtift Flood plain elevation, if applicable na ft S = Suitable for system CONVENTIONAL MOUND IN GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable fors stem 13 S ❑ U is S El 12 S ❑ U F0 S ❑ U ❑ S ®U ❑ S R1 U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft .................. in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench ................. .................. ................. .................. ................. .................. 1 0 -9 10 r 4/4 none Sil 2msbk mfr 2f .5 .6 2 9 -17 10 r4/4 none sicl 2msbk m Ground 3 17 -60 7.5yr 4/4 none is oSq mvfr aw if .7 elev. 1 4 60 -80 7.5yr 4/4 none sl lcsbk mfr na na .4� . Depth to limiting factor +80" Remarks: Boring # 1 0 -6 10 r 4 4 none sil 2msbk mfr 9.f -9i -6 2 ` <' 2 6 -22 7.5yr 4/4 none scl 2msbk mfr 3 22 -60 7.5yr 4/4 none lfs oSq mvfr CrW na .5 .6 Ground elev. 4 60 -84 5 r 4/4 none sl lcsb mfi na na -41 10 ft. Depth to limiting factor +84" Remarks: CST Name: -- Please Print Gary L. Steel Phone: 715 - 246 -6200 Address: 1554 209 New RidimoM, WI 54017 Signature: Date: 11 -12 -97 CST Number: m02298 STEELS SOIL SERVICE Gary L. Steel 1554 200th Ave CSTM2298 Darren vergin New Richmond, WI 54017 MPRSW 3254 SW4NWq S5- T31N -R17W (715) 246.6200 town of Stanton N 1"=40 - BI.= top of US Fish & Wildlife survey marker C el. 100' ,`� 1o 2 2'7 pp -I- YVA a ,z S pre -�- Gary L. Steel 11 -12 -97 •SEP -17 -98 04:04 AM BELISLE EXCAVATING 7152473038+ P.02 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address 7 1,1 0 ��' `� �-� 4� property Address (Verification required from Planning Department for new construction) _ Cit0tate Parcel Identification Number LE IUpT1oN 0--�) to — I D Property Location !aUj y y., Sec, 41r, T21N -RJ- —7W, Town of Subdivision , Lot # CertMed Survey Map # , Volume , Page # Warratity Deed # -- 1 00 Volume 9 9 Page # _ ?� 0 Spec house O yea % no Lot lines identifiable Er yes 0 no SYMM INTJ�N E I MmPer 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 afleet the function of the septic tank as a treatment stage in the waste disposal system. The Property owner agrees to submit to St, Croix Zoni and by a master plumber, Journeyman plumber, restricted plumber or a licet� al is in system f s proper operating condition and/or (2) a[icr inspection and pu 1 e. Uwe, the undersigned have mad the above requirements and agre, standards set forth, herein, as set by the Department of Commerce and the T, i tification stating that your septic system has been maintained must be comp \ vithin 30 days of three year expiration date, 1 ATURE OrApppc ANF J ASA QW tiER CLrtTI !:- N I (we) certify that all statements on this form are true to � -- � 1er(c) of • the property dese by v' a of a warranty decd record �• �� S! OF AP A * * ** Any information that is misrepresented 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 survey map if reference is made in the warranty deed 4k ( )> 7 E'X I s T T-, IG ni rTj N Z ql 2 4' (4 X