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HomeMy WebLinkAbout036-1097-70-000 O N p j 3 0 —1 ? c CD CD c 3 ;u z z O w o T o N o o b. � w` • °a a -4 a a o CCD co cn CD 9) N _ CD o N N a ; N O N 03 z tq 0 v CD O O - n CCD N 7 O W° A7 O CD ° D b CL a o y— fn w o r i a b D eo 4 CD (nz> so 4 CL A m U3 m N a co O W O. j . CD c O a c ° °° CD c _ PO ID ° L ..� Oo A A Z co N (00 O f�D f (D ! ( 0 c OD CO N O O fD 3 :'* C Z Z I po 000 000 :E No °: a 'a v a o I � m �� � o � A3 N CD N a ' o .. o o z o =i D (DD o D o c 0 O O m o !1 T ll�Vl • CD a �' m (D O CA CD C . CD �. C CD N C w a cp a n 3 3 CD CD c6 � N (n C N C J M a A z 0 d a G) 7 Z w a M (D z 3 c ° o c z H y v v p w m w m I a m � n c3�o CD _. CD - n 'm � D c co o z a v_. o a 00 CD CD rn N N N Qo O co CD c A m 3 I m CD o 3 M EP o C) ° V I I ti O O= Q A Co CD CD , w O o 0 w O O i O L ti Wisconsin Department of Health and Social Services Fjb.67 10/69 Division of Health PEitaT APPLICATION for ' PRIVATE DONIE'STIC SEWAGE SYSTEMS A. OWNTR OF PROPERTY TYP OR US_c, BLACK !NK [r Jr� Address (Streat, City, Zip Code) r B. LOCATION OF PROPERTY WE F.RE SYSTEM WILL BE CONSTRUCTED, AL T_EPED OR EXT FND ^U County Check One: CITY VILLAGE LEGAL DESCRIPTION; TOWNSHI� �� �c.'G ��LJ' ;S,Ci ✓ J �� C- X C. IS LOCAL PERAIT REQUIRED FOR THIS WORK? YES NO PERMIT NUMBER D. SEPTIC TANK CAPACITY Cii Gallons NEW INSTALLATION ' m) REPLACEMENT ADDITION MATERIALS; prefab Concrete _;, Poured in Place Steel Other NU.M ER OF TANKS TO BE INSTALI : 6 E. TYPE OF OCCUPANCY Check Ones One or Two Family Residence Commercial Industrial Other _ Specify Number of Persons to be Accommodated Number of Bedrooms _J F. APPLIANCES, ETC= Food Waste Grinder YES NO Automatic Clothes Washer YES NO Dishwasher YES �_ NO Automa.tio Potato Peeler YES _ X NO Other (Specify G. EFFLUENT DISPOSAL SYSTEM NEW EXTENSION ADDITION REPLACEMENT JC Tile Size NO.Lin.Feet Trench Width Depth Number of Lines Seepage Bedt Length Width Depth Tile Size No. Lines 2 Seepage Pitt Inside diameter -&.:Z Liquid Depth - P E R C 0 L A T I 0 N T E S T Test Depth Character of Soil Hours Water Test Time Dr in Wa ter Level Inc Finutes Number Inches Thickness in Inches Since Hole in Hole Interval Second to Next to Last To Fall lst Wetted Overnight in Minutes Last Period Last Perio Period (me In-,h K;Umple P- 0 36" T Soi 10" Clay 26" 25 yes or no 30 112 .1 2 1 2 60 2. r , a / -3 RECORD DA FROM MjqJ OF 3 TEST HOLES ompute size of absorption area in e.coord with H 62.20 Wis. Administrative Code. S O I L B O R I N G S- Minimum 36 Below Prop osed Absorption System oring Total Depth Depth to Ground Wat Depth to Bedrock _ _ 4umber Inches Observed Estimated Observed Estimated Character of Soil with Thickness in Inches xample i 0 72" 72" Black To2 Soil 12 "• Cle 18 "• Sand 18 Gravel 24�� RECORD DATA FROM MINIMUM OF 3 BORE HOLES e COMPLETE OTHER SIDE * -, I, the undersigned, hereby certify that the percolation tests reported on this form were made by me or under by supervision in accord with the procedures and method specified in Chapter H 62.20 (3), Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to the best of my knowlet' e and belief. NAME �; i+: r• 'v -�` V— TITLE Cy,�• � � y Type or Print) REGISTRATION N0, or MASTER PLU1 LICENSE No. ADDRESS ` DATE _ f ? : ? _ SIGNATURE MASTER PLUM -E'R MAKING APPLICATION MP Signature: !^ ✓t: _L c ., -t License Number: MP RSW i (To be Completed by Issuing Agent) Date of Application U — Za Fee Paid $ O Permit Issued (date) L - A - 76 Permit Number 1 Agent (name) �11�\ �? -� \J 1� For: Town, Village, City, tounty, etc. (Specify) Note: The application cannot be considered for filing until all of the above questions are answered and the fee paid. Agents will forward application, the fee of $10.00 and Copy (b) of the Permit (yellow copy) to the Division of Health. Checks and money orders should be made payable to the Division of Health. Do not write in space belay: — FOR DEPARTMENT USE ONLY DATE RECEIVED _` �� } L -_ ACCEPTED BY r r RETURNED (Initials) (Date) See Corres,) FEE RECEIVED VALID. NO. �i C� �� !J� P£:L`IIT NO. Yes or No) REVIEWED BY APPROVED DATE (Initials) (Yes or No) COMMENTS: f. ST. CROIX COUNTY ZONING DEPARTMEN V" AS BUILT SANITARY REPORT REC�i "�1�� Owner " - %f� � A,P 2 7 1998 Address 1 890 ST CROIX Y City /Stat d , J ,s� / COUNTY 2 " 6, L'� �`ONINGOFFf�E Z; j Legal Description: ' j , < Lot / Block Subdivision/CSM # �b �.✓ J � P.c.� '/. iV�A&2. Sec ,j_, T W, Town of PIN # -3 09 7 SEPTIC TANK — DOSE CHAMBER — HOLDING TANK INFORMATION: Tank manufacturer Size ST/P(f ' Setback from: House 3 o Well 6"'O p/L, &9 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 ooll l Type of system: Width 1 Length s `7 Number of Trenches / Setback from: House � Well 8 P/L j ! Vent to fresh air intake ;;/d ELEVATIONS Description of benchmark � l� C -) Elevation �� C Description of alternate benchmark 0&4 4 Elevation Building Sewer ST/HT Inlet ST Outlet 62- PC Inlet - loe PC Bottom Header/Manifold ��Top of ST/PC Manhole Cover Distribution Lines Bottom of System O 7 O ( ) Final Grade O Z O ( ) Date of installation // 9 ermit number 76 State plan number Plumber's signature Ak License number 5 Jv� _ Date Inspector ('omplete plot plan p Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County Safety and Buildings Division INSPECTION REPORT ' ST . CROIX GENERAL INFORMATION (ATTACH TO PERMIT) SanitarXP�r.IrL ll�� IN_: Personal information you provice maybe used for secondary purposes [Privacy L s.15.04 (1)(m)]. 3 �i // 44 FREDRl S�6 ; WILLARD Q t 4 +�j'}�ge Town of: State Plan ID No.: CST BM Elev.: � 66 Insp. BM Elev.: BM Description: Parcel Td V-�1097-70-000 TANK INFORMATION ELEVATION DATA A9800063 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchma l�_, .,S -? • 'IZ' 10 Dosing Aerati Bldg. Sewer 5 v Holding 1 °-� (Vkt Inlet . 5 7- 70 3 6 TANK SETBACK INFORMATION ors (9 hit Outlet O°) �'D. 99 TANK TO P / L WELL BLDG. Ai a ROAD Dt Inlet e t)0 ";o 3+' NA Dt Bottom Dosing NA Header / Man. g • ( �8 y� Aeration NA Dist. Pipe g�D g�'1-0 Holding Bot. System ©f. X7. -5 PUMP/ SIPHON INFORMATION Final Grade C- o .°j Manufacturer Demand�, Model Numb GPM TDH i Lift ' Friction S s TDH Ft Loss ad Forcemain Le Dia. Dist.Towell SOIL ABSORPTION SYSTEM B RENCH width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth EN I N IZ, I DIM N I N SYSTEM TO P / L BLDG WELL LAKE/STREAM LEAC ING =Nuum ctr SETBACK INFORMATION Type O � CHAM Syste ��V 5' 8� ?7 OR UNIT DISTRIBUTION SYSTEM Header/Manifold , Dia. Leng �_ Dia. Spacing Distribution Pipe(s) �J r A , 2 x Hole Size x Hole Spacing Vent T Air Intake Length t / � t g 9 —L— i W� ++ '? `t & Z � 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 31.31.17.593B,NW,NW 1890 142ND STREET T �XISk1l�tvy WL�( 14 �0c1,�-�LC� 1V1 ✓OV► -E c� - {/�� V pvc�e- �,in�1 � Plan revision required? [:]Yes Q No Use other side for additional information. TV i � Wj S i I SBD -6710 (R.3/97) Date Inspector's ignature rt. N >t { V iscons in SANITARY PERMIT APPLICATION 2 01 e E.W shn P.O. Box 7969 Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 vi x 11 inches in size. r • See reverse side for instructions for completing this application State Sanitary Permit Number The information you provide may be used by other government agency programs ❑ Check if revision to previous aication [Privacy Law, s. 15.04 (1) (m)]. C a ' `�/ J State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION Property Owner Name - Property Location C.(.) t `/a.r t 1/4 ,J1/4, S ) T3 , N, R E (or W Property Owner's Mailing Address - I Lot Number Block Number 0 I .5'T - . City, State Zip Code Phone Number Subdivision Namt or CSM Number II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ it Nearest Road ❑ Village Public 1 or 2 Family Dwelling- No. of bedrooms – Town oF N�T - 7 n) S III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) �1 1 E] Apartment/Condo ail. 31. / 7 • 5 / p m 3 6— 10 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. E] Replacementof 4. ❑ Reconnection of 5. [:],Repair of an System ystemTank 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;ET3eepage Bed ;21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure �Z X / 42 E] Pit Privy 13 E] Seepage Pit 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 Require (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min /inch) Elevation Feet Feet VII Capacit TANK in gall Total # Of Prefab. Site Fiber Exper. INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Exist in strutted Tanks Tanks epti ah J d (� El 11 El El 1:1 Lift Pump Tank /Siphon Chamber ❑ I ❑ 1 ❑ 1 1:1 El El Vill. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumbe 's 'gnature: (No S s) MP /MPRSW No.: Business Phone Number: .. Plumber's Ac dress (Street, City, State, Zip Code): 1 IX. COUNTY/ DEPARTMENT US NLY ❑Disapproved Sanitary Permit Fee (Includes Groundwater j D ate I ssued l issu Agent Signature (No Stamps) ��( / Approved ❑ Surcharge Fee) Owner Given Initial �' / / Adverse Determination 4 �i& X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: SBD -6398 (R.11/96) DISTRIBUTION: Original to county. One copy To: Safety & Buildings Division, Owner, Plumber - PLOT PLAN PROJECT Willard Frederickson ADDRESS 1890 142nd St. New Richmond Wi 54017 NW 1/4 NW 1/4s 31 /T -�,1 N /R - 17 W TOWN Stanton COUNTY ST. CROIX 1 3/16/98 3 MPRS Shaun Bird 3532 A DATE BED ROOM CONVENTIONAL XXX IN- GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 648 BED SIZE 12'X 54 bed I L BENCHMARK V.R.P. Base of Siding ASSUME ELEVATION 100' ❑ BOREHOLE O WELL *H.R.P. Same as Benchmark SYSTEM ELEVATION 87 142nd St. vENT 12" GRADE TYPAR COVERING Well * L1 9 69 1 SEWER R K J 8' 12' Existing 3 25' Bedroom House 10' B.M. 18' 30' 35' 7' tank T Shed All 40 Alt. measurements 8 ' 45' M. were measured off the centerof the Drywells 20' 15' 12' X 54' Bed 15' 6' B -2 259 > Drywells are B -1 \ _ 15' located below 5' 6% \ water table All old tanks Slope _ are to be B Vent collapsed 50' and buried Hart Lake i Wisconsin! Department ofCommerce SOIL-AND SITE EVALUATION Division of Safety and Buildings Page of Bureau of Integrated Services in ac got ance with s. ILHR \ 83.09, Wis. Adm. Code - r r n County Attach complete site plan on paper not less than 8 1/2 k I4'' lches must include, but not limited to: vertical and horizontal referpn point (BM), direction and C percent slope, scale or dimensions, north arrow, and I n aimm t Te o P9 road.` ` Parcel I.D. 3�- o �--�70 APPLICANT INFORMATION - Pleas rin for r { », Revi ed b Date i`. !... Personal information you provide may be used for secondary pu � Law, s. 15.04 (1) (m ». j tb Property Owner s r pro Location ovt. Lot 1/4 o1 /4,S 3 T ,N,R E (or) Property Owner's Mailing Address Lot # Block# I Subd. Name or CSM# City State Zip Code Phone Number N ❑ atly Village Town Nearest Road ❑ New Construction Use: ZResidental / Number of bedrooms 3 Addition to existing building g Replacement ❑ Public or commercial - Describe: Code derived daily flow gpd Recommended design loading rate • 7 bed, gpop . f trench, gpd Absorption area required 65 bed, ft S� t renc h , ft2 Maximum design loading rate — gpd* gpd4t? Recommended infiltration surface elevation(s) �? It (as referred to site plan benchmark) Additional design/site considerations Parent material © Flood plain elevation, if applicable 0 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 SI S ❑ U §d S ❑ U ❑ S U [IS Z U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench l Ground elev Depth to limiting in. Remarks: Boring # L1 ys$ C_5 MA Ground A))9 IV elev. Depth to limiting factor 98—in. Remarks: CST Name (Please Print) re Telephone No. / ,+ S !� ^1 • r �0 f76 Address Date CST Number S'24 6 CJ" S ` 0 4Z 6 - Soil Test Plot Plan Project Name W illard Frederickson Shaun Address 1890 142nd St. New Ric Wi 54017 C§fK4 #3922 Lot 17 Subdivision Tobin's Date 3/16/98 NW 1/4 NW 1/4S T 3 1 N /R W Township Stanton F - l Boring ()Well PL Property Line County S T. CROIX BM or VRP Assume Elevation 100 ft. Base of Siding System Elevation 87.3 * H R P Sa as B Alt, BM Base of Shed Siding @ 93.9 142nd St. Well 8 ' Existing 3 25' Bedroom House 0' B.M. 18' 35' 7' tank T Shed All Alt. measurements 8 45, M. were measured off the centerof the Drywells 20' 15' 15' Drywells are B-1 15' located below 5' 6% water table Slope 50' B- Hart Lake ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer fr fe1 ,A Mailing Address ` o /,7 Property Address JCcu-e.. Cs Cl (Verification required from Planning Department for new construction) City /State A- &,-,) /C C_X ^_Dn W "` rcel Identification Number S �,/2��/ LEGAL DESCRIPTION / Property Location �j u N c) ' /o, Sec. 1 , T,�? / N -R l 7 W, Town of �T�,,,4�1/ Subdivisio ,` � C,� l/i °��� ���i� ✓ , Lot # �. Certified Survey Map # 61 P/ , Volume , Page # Warranty Deed # 0 2 ,lq 3 L �� , �VGmme 7 , Page # 6 Spec house ❑ yes J( 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 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. 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. Z�e� L/ SIGNATURE OF APPLICANT 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 APPLICANT 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 r . A/ .89 ° i5 E. oS.3 10 853.00 O CO R►.1E72 `.AEG. 31� 97.2 O� ,t3 /�.o /UG E7•,6ACK A1�i N. P. l W. Cito►x Couw►YY W►5t. ° 'O�• 9 dot . oo . _ 1J• 84 v iS► 4o °►S.. 2 0 • loess . :)P of- 1;2o►'A SLAKE EL.1400.0 ►D e W I VV - 9 4. Z LCvEL Z 5!0 - 92.9 o�y1 20 ' S ►' O u 69 ° I a . 3 , aas a a V7 �g 4 Zo Q - 51 5 • N� � O 2 iiZ � � 7 %3o 0 6 )oo 4.0o �O 3 stakes e4eas to p stakes avo�s'e 3 �; N 92 1 5 c o V is, are measured to 2s o Q 0 in 1 of the Wisconsin ?s S&SIS' ling setback line shall S� I p or road line and 5 feet v� . X045• . O 40 °� y� • 6!t °/5 W. io c v � ° n /29e32. 1 p 0 � N w