HomeMy WebLinkAbout038-1049-55-300 ST. CROIX COUNTY TONING DEI ARTMEN
AS BUILT SANI'T'ARY REPORT k" /
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Owner L2 h Ny f� r
Address 3. c - J V '
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City /State u Q t h r+na►�el 11- R31
' 7_C)NIING0FRGE
Legal Description: 4P
Lot_ Block Subdivision/CSM #
'/• So ' /, 5C , Sec. fI--, TjN -RAW, Town of 57gr rC4LI w.I'e PIN # ddb – lU q--` 5• - d
SEPTIC TANK -- DOSE CHAMBER — HOLDING TANK INFORMATION:
Tank manufacturer (,t1 La"-- Size ST/PC./&o Setback from: House a/ ' Well P/L
Pump manufacturer Model
Alarm location
Setbacks: Service road Vent to fresh air intake Water Line
Meter location
Alarm location
SOIL ABSORPTION SYSTEM:
Type of system: &t0 Width Z Length G Number of Trenches
Setback from: House Well P/L 2D Vent to esh air intake �
ELEVATIONS:
Description of benchmark A) �
Elevation aD
Description of alternate benchmark Elevation
Building Sewer /DD, •Z ST/HT Inlet 2ai ST Outlet PC Inlet
PC Bottom Header/Manifold gs• Top of ST/PC Manhole Cover
i
Distribution Lines O - 21 1 , ' O O
Bottom of System ( ) 9
Final Grade
Date of installation �/ / /Perm' number State plan number
Plumber's si g nat ure License numbe - 03V Date 0' /V / 2 ,9' -
Inspector
Complete plot plan
• Wisconsin Department of Commerce '
Safe and Buildings Division PRIVATE SEWAGE SYSTEM Cou s INSPECTION REPORT ST. CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) SanitarITT"690:
Personal information you provice may be used for secondary purposes [Privacy Lay, s.15.04 (1)(m)]. 3 ttSS yy //
ftbi N NarleE Y E Ate' Villaae ff,n of: State Plan ID No.:
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel T d 325 1049 -55 -300
1 lfQ /ron �� 325
TANK INFORMATION ELEVATION DATA A9800287
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic tv fe SC I /- Bench a (0.0 /V&.0
Dosing /N' /•/ <o�•$C.
Aeration Bldg. Sewer jo -O j
Holding St /Ht Inlet
TANK SETBACK INFORMATION w� St/ Ht Outlet ? D6,
TANKTO P/L WELL BLDG. Air Intake ROAD Dt Inlet
Septic a-� �7 NA Dt Bottom
Dosing A Header / Man. qtr G�j. 05<
Aera ' NA Dist. Pipe 9 0 6 q(, ,. 4
Hol Bot.System IV - 4 7 5•,'q 95•
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer D and 5•�• —7. Z q'k- ?
Model er GPM
TDH ft Friction System TDH Ft
oss H
Forcemain Lengt Dist. To Well
S IL ABSORPTION SYSTEM
BE TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
EN I N a DIMENSION
SETBACK
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEAC M
INFORMATION Ty CH ER umber:
Sy a 2S� ��+� �`'1�-- '� OR UNIT
DISTRIBUTION SYSTEM
Header /Mani �� Distribution Pi (s) x Hole Size x Hole Spacing Vent To Air Intake
Length � Dia. Length i f0 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.) q•93
LOCATION: STAR PRAIRIE 11.31.18,SE,SE 1278 220TH AVENUE
AD , Fj& — Be, 4w- e S
JA/
<�
Plan revision requ red. ❑ Yes a No 7
Use other side for additional inforon. Z j
SBD -6710 (R.3/97) Date Inspector's ignature ert
14 6consin Safety and Buildings Division
SANITARY PERMIT APPLICATION �o �W Ave.
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 Count
than 8112 x 11 inches in size.
• See reverse side for instructions for completing this application State Sanitary Permit Numb
3 ts897
The information you provide may be used by other government agency programs ❑ Check if revision to previous application
[Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION
Property Ow r Name Property Location
s r E 1/4 E 1/4, S T , N, R e W
Property Owner's Maili Address Lot Number Block Numbed,_
City, State Zip Code Phone Number Subdivisio Namg or CSM Number
c.,, c) I (- 7 LS) 1 C j 3 Il Y 7 S '
11. TYPE OF BUILDING: (check one) ❑ State Owned it Nearest Road
❑ Village t
Public Z 1 or 2 Family Dwelling - No. of bedrooms 3 - Town of j :� �� S'l .
III. BUILDIN SE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo "' S_ - 30Z
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. 1�1 New 2 E] Replacement 3_ ❑ Replacement of 4_ ❑ Reconnection of 5_ E] 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 Qjseepage Bed 21 ❑ Mound 30 Q 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 S. Perc. Rate 6. System Elev. 7. Final Grade
Tc! b Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) El v tion
TcJ �j'�3 6 p —'�� Feet , Feet
Cap at
VII. FORMATION in gallons Total # of Manufacturers Name co Fiber- Plastic
Steel Prefab. astic Exper.
New Existin Gallons Tanks Concrete strutted glass App.
Tanksl Tanks
Septic Tank or Holding Tank
Lift Pump Tank /Siphon Chamber
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for instc3lLation of the onsite sewage system shown on the attached plans.
PI ber's Name: (Pr PI u is Signal ure o Stamps) MP /MPRSW No.: Business Phone Number:
Plumber's Address (Stre t, City, Sta e, Zip Code):
N.
IX. COUNTY / DEPARTMENT USE ONLY
(Includes Groundwater ate I ssu e d Issuing Age Sig Q Disapproved Sanitary Permit Fee 9 9
roved Surcharge fee)
pp []Owner Given Initial / �a4C �
Adverse Determination
X CONDITIO�N�S O��VAL /REASONS FOR DISAPPROV L:
� {� B - �Q.�.r►� sue' . �{?D �J. � �33G�� e.�,�?� -t � •e
SBD-6M (FL 1INS) DISTRIBUTION: Original to County. One copy To: Safety 8 Buildings Division, Owner, Number
_ OT pla
err �� ors � St- Y is' V S- l l T .31
N% A monk 43 �5(fQ 17
f
sy
9 g ®-
,
,/ CrvsS S �c�IOf, p Y A
/ter
Froin Air 1111614 And ObtdrroUon pi
( -- Approrld V4nl Cop
• " Ilinlmuwe 12' Above
Final Goad* ,
20- 42' Above Plpr 1' CoU Iron };
To final Orod4 V4n1 PIP$
►win
If Or SrniMlk Co .tin
win 2' Aypf4polo
Ova, PIp4 ' • ,
Olwlb�llon
Plpo 0 0 0 — Too
6'A legal
84n44tb
Pip o ° /`4 Pips 8410r
o — Coupllny T41fnin611np Al
8ollom Of S1614M
SOIL FILL
OISTRIBUTIOf.I PIPE
i APPROVED +7yJJT1 uric COVER
241 0F AGGREGAIE --�� `_ 9" OF STReW
OR MARIa O
f•
ELEV. O FcFEI; le - 2 1 /2 AGGRCGATE P
��V�
DISTRIDUTIOM PIPE TO BE AT LEAST 5 -- IAICHES BELOW ORIGIMkL GRADE
AUU AT LEASTZO WCHEL BUT LIO MORC THAN 4Z INCHES 13ELOW FIAIAL GRADE
MAXIMUM paprH OF EXCAVATIOP FROM ORIGWAL 6F ADR WILL BE _ IUC14ES
M MUM OEpni OF IFXCAVATImN r 0�14INAL GRADE WILL BE _ INCHCS
51GUED:
LICEIJSE ►JUMBE11: _ 2..053
DATE:
Wisconsin Department of Industry SOIL AND SITE EVALUATION
Labor and Human Relations Page of
Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis.
Attach complete site plan on paper not less than 8 1/2 x 11 inches, in size. Plan must County n
include, but not limited to: vertical and horizontal reference point (BM), direction and 4
percent slope, scale or dimensions, north arrow, and loeatiorfand distance to nearest road." 1 Parcel I.D. #
APPLICANT INFORMATION - Please pri4ta%I infbimbtibr �_ '( Reviewed by Date
Personal information you provide may be used for secondary (Privacy Law, i s 15.04 (>) (m)).
Property Owner P
ro e
=, t Y ation
ot� 1/4 35; 1/4,S T , ,N,R E (o W
Property Owner's Mailing A dress t Block# Subd. Name or CSM#
City pp State ' Zip Code Phone Number Nearest Roa 219' ik= A
ew Construction Use: [gResidential / Number of bedrooms Addition to existing building
eplacement ❑ Public or commercial - Describe:
Code derived daily flow —� gpd Recommended design loading rate � bed, gpdA ^ x I trench, gpd /ft
Absorption area required g!z 3 bed, ft 5 ' Z trench, ft nn Maximum cl@sign loading rate _ 7 bed, gpd /ft - V trench, gpd /ft
Recommended infiltration surface elevation(s) "A . � gw ` 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 In- Ground Pressure AT -Grade System in Fill Holding Tank
U = Unsuitable for system �S ❑ U ' X ❑ U WS El 0S ❑ U ❑ S �U ❑ S CK 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
/z
>r � z S �,... n 5
=f �
Ground 17,V
Y Depth to
limiting
Remarks:
Boring # /
14 V
Ground
i�
Depth to
limiting
fa r '
in. Remarks:
C T Name (P se Print) ig ure Telephone No.
Address Date CST Number
Soil Test Plot Plan
Project Name C l a y E Byron Bird Jr.
Address 2220 127th St.
New Richmond Wi 54017 M #3479
Lot 4 Subdivision --- - -- Date 5/4/96
SE 1 /4 SE 1/4S11 T 31 N/1318 W
Township Star Prairie
Boring O Well PL Property Line County ST. CROIX
IL BM or VRP Assume Elevation 100 ft T o f NE Property Stake
System Elevation 9 5.9/95.5 * H R p Same as Benchmark
312' Property Line 50' * B.M.
5' S'
B -5 80 ' -4
Rep A
B -3 40' 10'
20'
Pri A ` 10'
-1 N
B -2 80 v
2% Slope
0'
o 3 to 4
Bedroom
House
220th Ave
ST CROIx COUNTY
SEPTIC " 'ANK MANT]"ONANCE AGREEMENT
AM)
OWt ERSHIP CERTIFICATION FORM
Owner/Buyer
Mailing Address
Propetly Address Q.0 .. 4 �-
(Verification rcqtiirtd fron i Planning Dopartment for new construction)
city/state Identification Niunber
LEGAL DESCRIPTIQ
W, Town o f
Subdivision Lot #
Certified Survey Map # Volume
Page #
Warranty Deed # _S5 Volume Page #
Spec house 0 yes P no Lot lines identifiable JK yes 0 no
SYSIMM HAMENANCE
Improper use andmaintena=eof your Sri Xicwstom could result in its preruatkire failure handle wastes. Proper imAiAtrmnco
consists of pumping out the septic tank every tk(a Yea" or sooner, if ti6oAod by a licensed pumper. What you p ut into the system
can affect the function of the ceptie tank its a trea � stage it the waste disposal 9yatem.
The property owner agrees to submit to 3t Croix Zoning Department a i:arfification font, signed by the awner and by
a
rnasterplur6er, resttictedpl-� tr6er or a licetuedpwriper verifying th (1) th ors -site wastewater (Usposal system
is in proper operating condition and/or (2) after in.- �ectiOnk*d PUMPW (if neealsaty), the septic to is Wag than 1/3 full of alt)dge-
Vwe. the midersigued have read the above req.u=i hosts and arco to maintain, the private sewage disposal system with the standards
set forth, herein, asset by the Departmetttof Coin "rce ond the DeparttuentafNawul RwUNOA, State of WiSoonSfft. CI-XI 16466a
stating that your septic sy. stem a n maintainer 1 must be completed and stu=d to the St. Qtotx County Zoning Offtoe within 30
days of the three year exT icon —te.
(-Q 1231
SIONATUT17 XPPLIdA DATE
OWNER CERIMCATION
I (w) ceAtify l"Men that " 11 I ts on this irm are true to the best of my (our) Imowledge. I (wr,) am (are) the owt=(s) of
r
the property described abo -Y. 'Vvil�rtl of a warra ity deed recorded iu Register of Deeds 01' ice.
62
S GNA or P CANT' DATE
*1 •jay information that is rnis-represented ir BY result in the sanitary permit being revoked by the Zoning Department.
Include With this application - a stamped w=T xty deed from t6o Register of .Deeds office
a copy of the c, rtified survey in,ap if reference is &Lade in the warranty deed
FILED a APPROVED
'ju'' 1 21996 1r —
' M `� 54517
JUN 1.21.6'
a . f
CERTIFIED SURVEY MAP ST CROIX COUNTY
ocated in Part of the Southeast Quarter of the Southeast Quarter of Sectio Plannu
Range 18 West, Town of Star Prairie, St. Croix County, Wisconsin. F W j Zoning and
0 . & Committee
Prepared for and at the request of:
4-
Clay Edin Z DOUGLAS 1 I'
2220 - 127th Street co ZAHLE'ri I a recorded
New Richmond, WI 54017 Drafted by. James M. Braul * S-c r5 days of
H UDSJ:V, a al date
EAST 1/4 CORNER SEC. 11 { Wis. I at shag be
(1" IRON PIPE) UNPLA_TTED - LANDS / j�� 1, .•f A & void
-- - - -- 2624.52' S 00'51'13" W - - -- / $.i,JIFI -
^ ^ ,y S NER SEC. 11
EAST LINE OF THE SE 1/4 C.T.H, sCw R.O.W. LINE / \�
(COUNTY MONUMENT)
- - -- 656.13' - - -- ��
51_46'
�— — — — — — — — r 1 LOT 1 AREA
00'43'55" W 604.37' - S; i l i \� 653, 380 sq. ft.
a I 1 1 I 1 1 / 15.00 acres
I 11 R.O.W. LINE
(n T
C ... ... } ............................. �.A�.\ R. W.
a� c AREA EXCLUDING �
o :3 ` 1 583, 610 sq. ft.
~ a v 13.40 acres
c r Iss'
a 0 1
V) U !nl I
Y I I LOT 2 AREA
C 0 in Qi a : I 68,133 sq. ft.
a o �I m , 1.56 acres
ai ai �I w I I I v
N ' W AREA EXCLUDING R. 0. W.
c`n o °; I I I W 65, 340 sq. ft.
o - o'5 a I I __ _ ad i ' 1.50 acres
zl N 1 I 1
E DI n fO o °a n t o
E �° N I I z LOT 3AREA
. a v r7 rn I I i i 13 n 68,119 sq. ft.
> ° W i i O 3 I 1 i ;0 0 1.56 acres
o v om F I I O u,
N I I * AREA EXCLUDING R. 0. W.
a 3 0 : W o I N I
o - 65,340 sq. ft.
�' °
E 3 'o _ z .
Q; 1.50 acres
w z
a� o W I
00 I
+ t > � 3 I I I
o
a ° o V) w : n z a LOT 4AREA
c ° a `'' w �t Z I 77,328 sq. ft.
2 to
° ... � ,� W I I I I 1.78 acres
U) Q L :� 90' am r I <I AREA EXCLUDING R. 0. W.
00 65, 340 sq. ft.
o a o ir 1.50 acres
K o °' z ° vwi i �i� - -- S 00'55'12" W 655.W--
209.17''i��� I N
M r l 209.17' w 68.48 208.48;1 v Q i 26 O 1 z W
237.55
w I I I 9. I i �i 3
0 3 U o N ' U I N I � N 1 0 °
z NN M^ O -��,� �N I� N I`t COI N I HI J Z
N N J nU N O Z c_V O OI�I I Qj < 3
M M opN (nom rn N I M I I I z o
M zI N
I.........� ' N00'55'12 "E . .. ... ao MI I �I w M o
co
\ - - 209 - -- r� -- 628.21' -i r� - - -- I I I I I o = z
R.O.W. LINE — �\ — _17_ 209.17 / �_ 209_87' -� / I w o a
CENTERLINE O ' . w V) v or m
– —�\ – 209.17 ==-- 209.17 - :I -- 237.47''; Of W °
CENTERLINE OF 127TH ST. i / �
R.O.W. LINE — - - - - - W