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HomeMy WebLinkAbout038-1177-40-000 0 CA 0 3 n d T'— C m r/1 3 A. cp I � O 0 cn 0 0 a � w S d N 0 v M d j4 9D �I j d m n N N CD �'► OD m S 0 D 0 °° � N N n 7 (0 N ry 6D \ 1 CD O O c A W CO 0 O 4 rn o 0 3 ?; 0 ... g y c c o A ° O m cn D a CD (0 y U) a CD EC. m 0 i o o �r r co c 3 v m m m a °' h• I N v' = rs � N to �4 0 0. CD p O o v N 7 ur M A J N a 3 0 N �° o D D o N O CL (D N c C4 O. a 3 J O N A Z J T M v A Z 3 o. M m W M w -Fl A N Z a 3 Z 'o C m J N Z p� co CD I � w D CD � n C W T c O X � T O. N c co co Z a N Z O �: a o C Q � � y (D O. `N N cz 01 � A � b O A N (D D a CD CD- ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT 1 Owner Address a396 //p r City /State /U v✓ c /� �- Legal Description: �ou Lot / 7 Block Subdivision/CSM # INGOFF ...G— %, JV . Sec. - T N -R / L _ W, Town of 5- rAk T MIX I PI SEPTIC TANK -DOSE CHAMBER -- HOLDING TANK INFORMATION: 9 Tank manufacturer Size ST/PC /qDD� Setback from: House �� � Pump manufacturer GOUiDS Well p/L Ep '.�. Model 45 Pp y , Alarm location (HOLDING TANKS ONLY) Setbacks: Service road • 3 Vent to fresh air intake Water Line Meter location . Alarm location SOIL ABSORPTION SYSTEM: Type of system: Mo n A Width 8 Length 1 � 7 Number of Trenches Setback from: House Sar Well P2 Z O Vent to fresh air intake ELEVATIONS: Description of benchmark i u T H F A s r D arZU .5TA Elevation • ` Description of alternate benchmark Chorr 5 S 2 dove Elevation 1,02,36 Building Sewer __ 1 7. ST/HT Inlet q / ST Outlet PC Inlet PC Bottom 9 o. 37 Header/Manifold / Top of ST/PC Manhole Cover 35 Distribution Lines () /Ud. 03 ( ) Bottom of System Final Grade Date of installation / permit number �C277Zb State plan number 7/7.47 Plumber's signatur� S License number 22 o y 2, Date � /a / 9 _ Inspector complctc plot plan or Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM county: . Safe Buildings Division INSPECTION REPORT ST. CROIX GENERAL INFORMATION (ATTACH TO PERMIT) SanitarXP,g LL UU �t1uQ.: Personal information you provice may be used for secondary purposes [Privacy L s.15.04 (1)(m)]. 3 llJJ LUNDE,deAIN L ❑ a(i�ige T,4wn of: State Plan ID N o.: CST BM Elev.: Insp. BM Elev.: BM Description: Atc t•ttA L. Parcel ( T ) o c 1M 1177 40 - OUO � �, i , axNo_ : TANK INFORMATION ELEVATION DATA A9800109 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. /p00 Benchmark 7 /p / pp p g "tf'" !n r to ALI . R) 3 /oa .3 E, Aeration Bldg. Sewer g.7S '�7 c� Holding �j�t Inlet /2.7 o .q 7 TANK SETBACK INFORMATION / di Outlet TANKTO P/L WELL BLDG. Ae lntake ROAD Dt Inlet NA Dt Bottom / 6.33 90.3 - 7 NA Header / Man. Aeration NA Dist. Pipe Co (. /Ov • 03 Holding Bot. System - 35' � 3� PUMP/ SIPHON INFORMATION po� Final Grade Manufacturer Cloy G S Demand +�c +ahl� bs (,,,,�� �✓ `7•Zi 9q ,� Model Number e p ot( TDH Lift . -7 Friction I O System�2 TDH oss /3 Ft H Forcemain Length Dia. o t " Dist. To Well SOIL ABSORPTION SYSTEM D TREN Width Length , ! 7 No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth `� DIMENSION SETBACK SYSTEM TO P/ L BLDG WELL LAKE /STREAM HING Manu acturer: INFORMATION Type CHAMBER Mo m er: System: 2!7 j� t0�� DISTRIBUTION SYSTEM Header /Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake � , Length . , Dia. Length � Dia. f /Z Spacing _— 2 ' F1 i rr 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 �.� E] Yes E] No ❑Yes E] No COMMENTS: (Include code discrepancies, persons present, etc.) F.gST -, G�g,Z� ItSY 71S /. z s-- Z LOCATION: STAR PRAIRIE 4.31.18,E,NE 2396 110TH STREET / k{, &*i- �.� V► � v`n � ( �.,� '� nom, �c-c. ham. 1.s s of 7 Ir Plan revision required ?�❑ Yes [ No Use other side for additional information. f SBD -6710 (R.3/97) Date Inspector's Signat e SANITARY PERMIT APPLICATION 201E Wa ��gton O 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. b - , 4rre /A • See reverse side for instructions for completing this application State Sanitary Permit Number '3 0 - 7 72xz, The information you provide may be used by other government agency programs Q Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT AL INF RMATION 7/ 73 - 7 Property Owner Name Property L I.V01> 1�' 1*� )fP14, S y T 3/ r N, R B E (or) 10 Pro erty Owner's Mailing Address Lot Number Block Number R ot 17 City, State Zip Code Phon u er Subdivision Name or CS Number �.A (; ALt wl SYOz (?/ 3 -337,f2 MAID Q0 K.V IV II. TYPE F BUILDING: (check one) ❑ State Owned ❑ ity N earest�� [] Vil age Public 1 or 2 Family Dwelling - No. of bedrooms Town OF s R A046 //O 111. BUILDING USE (If building type is public, check all that apply) Parcel Tax N umber(s) 1 E] Apartment/ Condo 6 ` ) � _ 11 L /Q 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. XNew 2 E] Replacement 3_ ❑ Replacement of 4 E] Reconnection of 5. C] 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 XMound 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 -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 yS ., D Required (q. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) t� Elevation .?7-5 .775 1. 7— Feet DX q Feet VII. TANK Capacity in gallons Total # of Site INFORMATION Manufacturer's Name Prefab. Con- fiber- Plastic Exper. New Existin Gallons Tanks Concrete steel glass App. strutted Tanksl Tanks Septic Tank or Holding Tank /0 1600 ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber 1 6 &501 1 0 1 ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Sign Stamps) MP /MRR,SaALAID -: Business Phone Number: Plumber's AAdriss (S r t, Cit , State, Zip Code : n IX. COUNTY / DEPARTMENT USE ONLY [] Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issui Ag nt Signature (No Stamps) S charge Fee) Approved E] Owner Given Initial !J0 o W/ Adverse Determination ZXD Irtoo / X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: S8I16M (8.11/96) DISTBIBUT10111: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber Safety and Buildings 15837 USH 63 HAYWARD WI 54843 -8107 isconsin Tommy G. Thompson, Governor Department of Commerce William J. McCoshen, Secretary April 06, 1998 CUST ID No.223242 ATTN: POWTS INSPECTOR JEFFERY V FOX PO BOX 295 DRESSER WI 54009 RE: CONDITIONAL APPROVAL Transaction ID No. 71737 APPROVAL EXPIRES: 04/06/2000 SITE: Site ID: 4732 ST CROIX County, Town of STAR PRAIRIE E1 /2, NE 1/4, S4, T3 IN, RI 8W ALLEN LUNDE FOR: Description: NEW MOUND Object Type: POWT System Regulated Object ID No.: 11239 The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes listed in the regarding line above. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. The following conditions shall be met during construction or installation and prior to occupancy or use: A copy of the approved plans, specifications and this letter shall be on -site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of construction /installation/operation. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. When making an inquiry or submitting additional information, please refer to Transaction ID No. in the regarding line. Sincerely, DATE RECEIVED 04/01/1998 FEE REQUIRED $ 0.00 CARL J LIPPERT , WASTEWATER SPECIALIST FEE RECEIVED $ 180.00 Field Operations REFUND DUE $ 180.00 (715)634 -3484, CLIPPERT @COMMERCE. STATE. WI.US cc: RESIDENTIAL MOUND DESIGN INDEX AND TITLE SHEET Project Al Lunde Owner Address P.O. Box 385 St. Croix Falls Wi 54024 Legal Description E1I2 N/E1 /4 sec4 T31,N,R18W Township Star Prarie County St. Croix Subdivision Name Mallard Run Lot No. 17 Parcel ID Number Plan ID Number INDEX SHEET PAGE ONE = MOUND CALCULATIONS PAGE F - PAGE THREE -_ 0UND DRAWINGS PRES. DIST. CALCS. & LATERALS PAGE FOUR =-'P TANK DRAWINGS PAGE FIVE l P Ct1ARY t� Pt(,E 51� R T �I.API PI�(,� s E ✓ElJ SOIL lesT R R Ctt6p Designer k d A-1 License Number Z1 L ' :ature Phone No. - 7 Date P.O•WT• ']afice: Tampering with this file by unauthorized persons is ProhTbnditiouai` 1' F® �� PAP; � T OF COMMERCE -. ` - - E (R -�7) DEPARTMEN r ND BUILDINGS pI�IQN OF SA SEE C ONDENCE `�3'7 RESIDENTIAL MOUND DESIGN Eight Bedroom Maximum Complete information in red framed boxes as necessary. (y or n) n Is the system over creviced bedrock? Slope 8 % Number of bedrooms 3 Wastewater flow rate 450 gpd 1703.3 Lpd Depth to limiting factor 27 3in 68.6 1cm 24 In situ soil infiltration rate (code) 0.4 gpolft 16.3 L/m Contour line below the upslope edge of absorption cell .8ft 29.81 rn Use standard fill depths? x OR Designer speed depth in cm Place X in box to use standard depths (12, 24, A +4 inclusive) OR specify design fill depth. Center or end manifold E B (r ore) Estimated hole space 3.5 ft Not anal calculation. Lateral spacing ft Minimum dose >= 10 times void volume Use a o lateral spacing for trenches. Pump tank elevation 89 ft outside bottom of tank Number of laterals r__2__J Force main diameter 2 in Force main length f>5 ft Force main actual dia. 1 2.067 in SYSTEM SOLUTIONS Inch - pounds Metric Cell media "x" one only. Estimated daily flow 450 gpd 1703 Lpd x Aggregate and pipe Chamber and pipe Absorption cell Design load rate & area gpd /ft' 375.0 ft 34.84 m 1.2 Linear load rate 9.6 gpd/ft 119.0 Lpd /m Design width (A) 8 ft 2.44 m Cell length (B) 47.0 ft 14.33 m Depth of cell (F) r - 9 - 97 in 25.1 cm Sand filter Upslope fill depth (D) 12.0 in 30.5 cm Downslope fill depth (E) 19.7 in 50.0 cm Basal area required (gpd /infiltration rate) 1125 ft' 104.52 m Supporting components Topsoil depth 6.0 in 15.2 cm Subsoil depth at center 12.0 in 30.4 cm Subsoil depth at cell wall 6.0 in 15.2 cm End slope toe length (K) 10.9 ft 3.32 m Upslope toe length (J) 6.8 ft 2.07 m Downslope toe length (1) 15.9 ft 4.85 m includes basal adjustment Total mound length (L) 68.8 ft 20.97 m Total mound width (W) 30.7 ft 9.36 m Project: Al Lunde P Page 2 of Plan I.D. MOUND PLAN VIEW observation pipes (typical) p A= 8.0ft 2.44m W= 9 0.1 m _ p A� B= 47 ft 14.33m B K J= 7.2 ft 2.19 m I 1 = 15.9 ft 4.85 rn ,. K= LjP.Cjjft 3.26m 68.4 ft _ typ. obs. pipe 20.9 m A X B refers to absorption cell width and length (anchored secun*) J = upslope width I = downslope width �! K = end slope dimension 61 0 E M) T MOUND CROSS SECTION D = 12.0 in 30.5 cm T subsoil cap E = 19.8 in 45.2 cm lateral (, ft topsoil G F = 9.9 in 25.1 cm invert - -- see note G = 12.0 in 30.4 cm elev. H = 18.0 in 45.6 cm I D E ASTM CM Sand Fill sys. elev. . ft contour 6% M slope Note: Absorption cell media will D = upslope fill depth plowed layer consist of a ggregate and pipe E = downslope fill depth or leaching chambers and pipe F = absorption cell depth as specified Aggregate RICharnber G = subsoil + topsoil depth at cell wall at right H = subsoil + topsoil depth at cell center Designer notes: If aggregate is used, it is covered with code compliant material. -E T Yrl if � 1] PRESSURE DISTRIBUTION CALCULATIOIF Width (A) 8 ft 2.44 1 m Length (B) 47.0 ft 14.33 m Lateral specifications Number laterals 2 Holesllaterai 13 holes Lateral length 44.0 ft 13.4 m Perforation dia. 0.25 in 6.4 mrn Lat. dis. rate 15.15 gpm 1.0 Us Sys. dis. rate 30.30 gpm 1.9 Vs Hole spacing 44 in 111.8 cm Pipe diameter Design options Design choice Designer must 4 to 25 mm c ' # in r° "X" one c hoice 1 114nW mm X from the options 1 X x iar�3f, . provided. 2inFOmm X 3 mr/5 mm X - - meter Pipe diameter Design options Design choice Designer must 1 int25 mm "V one choice 1 1l4n/32 mm X Place X in re from the options 1 112in mm X box of chose:t provided. 2in150 mm X x ciiert: eta! 3iin175 mm X 41n[ioo mm X Distribution system contains 2 lateral(s). LATERAL O!A °_ "_•' _ END CONNECTION Place correct lateral diagram by clicking in one of Laterals centered ow the A tk B kmension Last hole driled r1oft t4 erd cad+ en cap �E P •� Ir i porce :awrei I X E H-�i45 ar ;ced or tr:t bvl' -n s6 t±te iararai S 1 equallg spaced • m ;onnec>ica t ee of ifi.�fiS LJ �Tioriitcid di ark �-ir, Laterals & fOfC4 • . peManantend marker (per cow, i iui2 4. a -P inch- pounds " = -- Lateral length (P) 44.0 ft 13.41 m Lateral spacing (S) 3 ft 0.91 m Manifold length 3 ft 0.91 m Hole diameter 0.25 in 6.35 mrn Lateral diameter 1.5 in 40 mm Number of holes per pipe 13 Invert elevation of laterals X93 fit 3220 m Project: Al Lunde _ - Total dynamic head System head = 3.25 ft 0.99 M Vertical lift = 1,0- tt 3.08 M SySterr?'� 'X" here. x Friction loss 1 0 3 _.ft 0.31 M ' f es here. lift i 4,38 if r .,. o ��hatis the highest e�ela I M fcr- - Dose Volume dawrist.realn of pimp? --- Lateral void volume = g. gat 35.2 L Minimum dose gal 4259 L Drain back = 11.3 -gal 42.8 L Yes at L EEI, No —ber Layout weather proof F wmeming WW padlock diock f7 -ade leels discorlect 3 a He f , a t .11� -S electric as outer 4' vent pipe Comm �ocation 4 sl r45 cm mir- approved gwaflofp t OuMet u chamber or joint combination tank A 1/4' weep Grade levels We as V� tank MwrkhC!e alarm on T pump on B mm _7 C 1 pump F 95.91ft off elev. 29.2 fn L) � ina under tank and anch3 tnnk 25necessary 9 ft pj.�7%.p -Ank eie�, 3 (75 mm ) o f bedd 29.0 m bott= Of E P Pump tank S -- Gallons Pump tank volume ; gal Capacities Inches A= 21.7 E 326.2 2 Pump m. anufacb-za'e-E. !ffo—ulds 8.3 F 'S C 123.8 Pump model numbe! 1 ,EPO4 D= F__8 1 2 -"-oject: Al Lunde M - 04 •C • • — • :• is - ' �i *} ,p i'. f 3 . ' f M EYE It3 FEET MODEL: 3871 C3 � 2 10 - -- - _ - =k- -- 0 U AD ^.D90 40 61 uS. fiM 0 Z a 13 ur 12 m'A,r CAPACITY Pump Specifications Features and Ben fits aho and 1 /2 HP • EPO4 impeller- semi -open design Up to 60 GPM with pump out vanes to protect Maximum head to 32' mechanical seat. Discharge size 1 WIT • EP05 impeller - enciosed design Solids: 1 /4 " maximum for improved performance. Motor • Rugged glass - filled thermoplastic casing and base design provides All motors feature ball superior strength and corrosion bearing construction- resistance. Single phase: 115U Materials of Construction • Cast iron motor housing for Cast iron efficient heat transfer, strength, Thermoplastic and durability. Stainless s steel • Corrosion resistant threaded stainless steel shaft. • Available for automatic and manual ooeration- AL,LPel 111A D- Ra t?ax (.8h F -Vt NE sic yTai, /8 s� S-r ezvX Fos k1 5 774 8 AAoA 7 ,�1✓s1�'JP SyvZY )o7 >7 .1/IALJ At.n Funl AL 7o bF S. E aWMU S7AA(, Q .S ay $a aj MG o Jl�DlL00 G,�L. �ESS�a L'oMg SCALE 1 1 0 � � a IM EA 1'ROP� b 3 B�rzoarn GHRJiG� HausE z 8 x'�7 Bea !D 2 T � IOtN Division of S and D of Commerce SOIL AND SITE EVALUATION .. Divisin of sety and Buildings Page of 3 Bureau of Integrated services in accordance with s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less than B 1/2 x 1 t inches in size. Plan must County include, but not [knited to: vertical and horizontal reference point (BM), direction and �- f Percent slope, scale or dimensions, north arrow, and location and distance to nearest road. C # APPLICANT INFORMATION - Please print all information. Parent I.D. Reviewed by D ate Personal k formaWn You Provide may b rxm e used for sedary Purposes (Privacq law, s. 16.04 (1) (m)). Property Owrwr / Z q.A1C1 E P►ope►hr Location . dry, 3 GovL Lot " % L /U61 /4,S T Sl ,N.R B E (or) W Property Ownegb meting Address Lot # Block# Subd. Name or CSM# Cit Sla Zrp Code Phone Number ❑ city. ❑ vi © Town Nearest Road (/S ) M'S 33 zP Sf� `y' oar %/D -4 , O New Construction Use Residential / Number of bedrooms Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow YS _qp Recommended design loading rate Z bed, gpd* 3 trench, gp&* Absorption area requined`t- 7 bed, ft trench, ft2 Maximum design loading rate 7-- bed, gpdO • 3 trench, gpd/ftz Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design/site considerations T S<s o� c C' , ' l Parent material r- Flood plain elevation, if applicable S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = unsuitable for system CIS [@ U 91 s El ❑ S ® u ❑ s ® U ❑ S ® u ❑ s Dr SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/R2 13 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bad , Trench Ground Depth to limiting factor Z—in. Remarks: Boring # + y S Ground S % P 511 7`i P N p �ev. 8 J' • tt Depth to limiting factor � Remarks: CST Na�) Please Print) Signature Telephone No. cs 9 uC - aW fS,'tiJ - - z -- 89y4 Address / v 0 Data CST Number /4� .240 -J `' aue _ ,L W - 8. 5 ,3 3d - 98 L3 76- PROPERTY OWNE / � - 44 - A--'d Page DESCRIPTION REPORT Page s�? of PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots M , g in. Munsell Qu. Sz. Cont. Color Gr. Sz, Sh. Bed ; Trench , 1,56X 7 .< c L,-) lUK ' .5� Ground 3 7-5 C f .m �� /� � c9� �— . Z Vey. 0 N. i.? Depth to limiting factor d(p n. Remarks: _ Boring # Ground elev. ft. Depth to limiting factor Remarks: -- - - Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPDMt in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # Ur Ground elev. Depth to limiting factor in. Remarks: Boring # [3 Ground elev. ft ' Depth to limiting factor in. Remarks: SBD4W0 (R. 07/96) Ll ICJ Qj b t 41 4 �� h o w Ou L„ p t : a XQ -� Z � r �. ur� Q 4j 4 E C l- T � q N I f I a e _ � o Z � Wisconsin Department of Industry SOIL AND SITE EVALUATION / Labor and Human Relations Page L of Division of Safety and Buildings in accordance s I is. Attach complete site plan on paper not less than S 1/2 x 11 inches in la us , include, but not limited to: vertical and horizontal reference point (B ), ` ectio UZ.I ' d / x percent slope, scale or dimensions, north arrow, and location and d' e t t road,'; Pa D. # a, APPLICANT INFORMATION - Please print all in for " ` n.�`' `j ie d by Date Personal information you provide may be used for secondary purposes (Privacy ', 5� 15.04 (1) (mj).Cr :t 1 w Property Owner a1 ' c / Rrope t oc V/04/4 y T N,R i8 E (or) W Property Ow er's Mailing Address Lot ock# Subd. Name or CSM# City State Zip Code Phone Number d 62 14 / 4C Nearest Roa k)J I SYa (7is )140-351-8 ED city Village LE Town �si /ZNew Construction Use: JaResidentiall / Number of bedrooms Addition to existing building ❑ Replacement � El Public or commercial - Describe: ) Code derived daily flow N ' � . gpd Recommended design loading rate bed, gpd/ft 's .3 trench, gpd /ft Absorption area required t�� �• bed, ft �� trench, ft Maximum design loading rate bed, gpd/ft • —3 trench, gpd /ft Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design /site considerations g-27 c-14 a6 4r s_Yo 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 V9 U 9S ❑ U ❑ S 4�1 u I ❑ S .�U EIS ad u ❑ S 'K 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 13 7 /O'I?f 3 -<J /;c e tj 1v - 5/ ; v S Gro elevund .3 '� 17/� �y S� ter» db� A— C c..J `� e L ' je Depth to limiting factor Remarks: Boring # . r-2 ,3 -- L Ground z7 ��� �Zl� r � ✓7` i ._ �" 'P ^4101 elev. AU � � ft. Depth to limiting factor 0Z Remarks: CST NaN lease Print) Signature Telephone No. Q 0 'C / 'NS s - Y 7Z -4f Y Silo Address Date CST Number UI �rzj,,o zz-,- -�,- --,z Q) ° ^� N\. rl q �, '�'� o Q ,j � NL Nrl 0 a Q o oa ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer kl e,J L,,/ J_ Mailing Address F0. 13OX 6%, 5Y. rRo in F.4 /11s zi i , xY_mz � N Property Address �� /�� - T VF'v 'Or/C y Nio 10 -7 OPP (Verification required from Planning Department for new construction) City/State 5 7n,e F2AiRje_ 1 1 Parcel Identification Number ��� — ///7_/0 LEGAL DESCRIPTION Property Location '/, A ),F ' /4, Sec. , T -3 J N -R /,T W, Town of 5_�tAA F9Ai e_ Subdivision ,d p IC u nJ , Lot # /7 Certified Survey Map # , Volume , Page # Warranty Deed # , Volume G , Page # Spec house IF yes ❑ no Lot lines identifiable N 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 masterplumber, journeyman plumber, restricted plumber or a licensedpumper 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 days of the three year expiration date. SICTNATURE 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 pro erty described above, by virtue of a warranty deed recorded in Register of Deeds Office. /Xi 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 JQ4:fi(ici UN NORTHEAST CORPIER rvorE ALL oFourLor SECTION 4. T31N. 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