HomeMy WebLinkAbout038-1171-40-000 ST. CROIX COUNTY ZONING DEPARTME S ��
! AS BUILT SANITARY REPORT I �F(
Owner '1✓ " Td' C RY EC?t� J -:: L1 98
Address fl .9 _,Y. t !71 , ST CROIX c
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COUNTY , ,+
City /State / � �'i� ��'`��,� ��:� o.� �' ' ���'/ � � ' zoNlroG'aFFlcE
Legal Description:
Lot 1 `7 Block Subdivision/CSM # C6 UNT MM EAgpvJS
'/, SE_ '/4 `�✓ Sec. ice T - R_L� W, Town of :`T ,'i�AiKj ty PIN # 4� ' 7 - 40
13 •31.18: 83�}
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION:
Tank manufacturer I~sK5 Size ST/PC / Setback from: House _10 Well P/L
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
Type of system: 2 E 0 Width Length S.� Number of Trenches
Setback from: House Well ' / n � P/L Vent to fresh air intake
ELEVATIONS
Description of benchmark Snz f s -r i Elevation
Description of alternate benchmark Tor or � � '.a�,; b ! o v NOh`�r pl Elevation
Building Sewer `/,� ST/HT Inlet ° ' ' ST Outlet PC Inlet
PC Bottom Header/Manifold 4 : ,�" Top of ST/PC Manhole Cover
Distribution Lines
Bottom of System ( ) ( ) ( )
( )
Final Grade
Date of installation /7 / C7 6 Permit number 2670.1 State plan number -
Plumber's (O�
sign u License number Date / /�
Inspector
Complete plot plan
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County
Safety and Buildings Division
INSPECTION REPORT .5-: Groin
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.o4 (1)(m)]. 3a7641(f
Permit Holder's Name: ❑ City ❑ Village ® Town of: State Plan ID No.:
V i ri P 0 Sfa va ri v
CST BM ev.: j Insp. BM Elev.: BM Description: c_ Parcel Tax No.:
r
loo " — p >rOK �a G�'� as
TANK INFORMATION ELEVATION DATA AWpinD33
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
6'e-pt � D AB'enchm
Dosing
�T( , 6m
Aerati Bldg. Sewer ) l ,,s )0.3-so
Holding MAt -t lnlet i S /D M.
TANK SETBACK INFORMATION C$k?W Outlet 5.3 /0 L•73
TANK TO P/ L WELL BLDG. t V en t ke ROA D �t Inlet � S.3 ` 8 /OL 68
9 NA L �S7 107, 5
Dosing NA Header /Man. 0!.10,8
A ation NA Dist. Pipe 6•St 1 /•S
Holding Bot. System 7•� /OD •�(o
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Xemand 51A 1-f, 6 WC4-' 1 4 3
M umber GPM
ift Friction ystem Ft L ead
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
D RENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
EN I N 1 Z 53 DIMENSION
SETBACK
SYSTEM TO P/ L BLDG WELL LAKE / STREAM AEACHING Manua er:
INFORMATION T yp e G6� ��� N p -- OR UNIT R um er:
S
Y tem p
DISTRIBUTION SYSTEM
Header / Manifold 2
�_ Distribution Pipe(s) I x ST n/b !� Hole Size x Hole Spacing Vent To Air Intake
Length
` Dia Length � Dia. Spacing A l
- 7
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over ver ee a /Sodded xx Mulched
Bed /Trench CE DteU rench Edges Topsoil ❑Yes ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) 1331 L ovn - fv-� . f.
6M
�, wl✓�( way MY 1 r44(W a+ -ftll,1 I "
�• V 5� 2 (�rObOj (4 l► DK5, W wkh t2 4zwvk� _ k4t& 4 � - tkr �fa�asr.� Gda y
Plan revision required? El Yes No
Use other side for additional information.
SBD -6710 (R.3/97) Date Inspector's ignature ert. N
Safety and Buildings Division
*
A sconsin SANITARY PERMIT APPLICATION p0 Box796 ngtonAve.
Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI W707 -7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 112 x 11 inches in size. S T C e- 0 I
• 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 application
[Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION —
Property Owner Name - Lo
to 4,.TF, i R N SE 1/4 S 1/4, S 13 T 31 , N, R /8 E (or)
Propgrty Ow M Ads] ss - ��� Lot Nub �r Block Number
C + it�ySta U t �j G+ Zi Code Phone Number Su ivision Name or CSM Number I -
II. TYPE ILDING: (check one) ❑ State Owned E] C] Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms C] o age
own oFS-Fa✓ Praifif-. Cou
111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo l - • I g • 9 3 � % �/ 7 � - �� ��
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. Pq New 2 Q Replacement 3 ❑ Replacement of 4_ ❑ Reconnection of 5_ Q 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 ZSeepage Bed /L X S/•S 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 Q 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.) Prop sed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation
y50 /S 8 1 Feet / Feet
VII. TANK Capacit gallons Total # of Prefab. Site Fiber- plastic Exper-
INFORMATION Gallons Tanks Manufacturers Name Concrete con Steel glass App.
New Existing structed
Tanks Tanks
eptic Tank ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamberl I ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) PMPRSW No.: Business Phone Number:
AtI � ?F AIJIJ S ? /S- 755-3267-
PI 's Address (Street, Cit , State, Zip Code):
352, 3.7c -R . Mme. S`10
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued Issuing Agent Signature (No Stamps)
A roved Surcharge Fee)
Adverse Determination
® pp ❑Owner Given Initial & �`�
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD -6399 IRA 1/96) DISTRIBUTION: Original to County, One copy To: Safety a Buildings Division. Owner, Plumber
1
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DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY &BUILDINGS
INDUSTRY, DIVISION
LABOR AND CC P.O. BOX 7969
HUMAN RELATIONS PERCOLATION TESTS (11J MADISON, WI 53707
5w„ - '5w% C'_. (ILHR 83.09(1) & Chapter 145)
LOCATION: SECTION: TOWNSHIP /MUNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME:
56. y3w �/ 13 /T N /RIg (or► W &,., ,� ' 1 �
C(ZUN TY: MAILING ADDRESS: �'�' - Z4, j
� ' (� l,� J3 ep 1�t . tj I J Sao z
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
Residence XfNew ❑Replace Z/ �� �.� Z L
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN- GROUND- PRESSURE: SYSTE� IN- FILLHOLDIING TANK: RECOMMENDED SYSTEM: (optional)
Ki J cc 0U 1XI ou ZS OU OS X U EIS ®U C
require DESIGN RATE:
q - / If any portion of the tested area is in the
under s. ILHR 83.09(5)(b), indicate: Floodplain, indicate Floodplain elevation:
If Percolation Tests are NOT re
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
l Z �/ `2'.ars;, /� anJ'.'�
B L 83 °�` ` e-3 ,�, e / -Lo' e. /3,7 3,t
a 7 /o�! 8 - 0 3 ° �/, /3 - 3 Z 3 2- - 5 1 6 " 1Z.
B- `� 9 2--.10 ,
B- 0
�- ,� /O "mil /, !li - >�i�/ - y- 3 ° /1. 'ellj "/ 3 5�
7g X05! , �9 .� � L
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL -MIN. PERIOD 1 PER IOD2 PER PER INCH
P -� %v '
P
P_ 3 S'o
P-
P-
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope-
e X �
uogonjlsuoo Aue to Deis ayi of joud palsod pue peurelgo eq lsnw liwiad
Aiepues a141 liwiad a uielgo of japio ui Aluoylne Ieool eleudoidde 8141 of pauiwgns aq lsnw uoileoildde 1lwied a pug
walsAs a6emas aleAud ayi jot sueld to las elaldwoo V aouenssi 1!wjad of joud plait 8141 u} Isal llos S1141 uopeoyueA
lsonbai Aew luawUedaQ aUl jo Alunoo ayi 1!wjad Aiepues a 6uunoes ui dais Isiq ayi s! UodaJ lsal 1!02 slyl
:U3NMO 3H101
STC- 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER _ Doug 4- T R2t Pe'eQSGP
MAILING ADDRESS FqQ �i�,�t x' st. Ap , 5. /Jetj Kfc{,j Lj *..5"
PROPERTY ADDMS /33 (O u A 4
(location of septic system) Please o tain from the Planning Dept.
CITY /STATE /('eW k; a h M oryc t . GJ 1 . J` gol'7
PROPERTY LOCATION _�� 1/4, 3' 1/4, Section T _j_�_ -R _1_7 _ W
TOWN OF OA PkPi2ie ST. CROIX COUNTY, WI
SUBDIVISION (�ou�'�KY e�C01.�S LOT NUMBER
CERTIFIED SURVEY MAP , VOLUME pF , PAGE 311 , LOT NUMBER
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 licensed septic tank pumper. What you put into the system can affect the function of the septic tank
as a treatment stage in the. waste disposal system. it
St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost
of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that owners of all new systems agree to
keep their system properly maintained.
The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner
and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1)
the on -site wastewater disposal system is in proper operating condition and (2) after inspection and
pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum.
I/We, the undersigned have read the above requirements and agree to maintain the private sewage
disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR.
Certification stating that your septic has been maintained must bepleted and 7eturned to the St. Croix
County Zoning Officer within 30 days of the three expiratfib / n ; d te. /
SIGNE
DATE: l
X3,1 X98`
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
S T C - 100
This application form is to be completed in full and signed by the
owner(s) of the property being developed. Any inadequacies will
only result in delays of the permit issuance.., Should this
development be intended for resale by owner /contractor, (spec
house), then a second form should be retained and completed when
the property is sold and submitted to this office with the
appropriate deed recording.
-------------------------------------------------------------------
Owner of property �oug T �Rt Pcf�eIZSoJJ
Location of property _ 1 /4 SW 1/4, Section , T 5/ N -
Township fi&z fZAi2i� Mailing address 5"V0 nth •5+t
of��_IUec� �ia)1rhON��Li 5!JD/ 7 -
Address of site ,j�/ l - fie -. G'�` .ClPw r;nX A a'/a/ A/,,
Subdivision name _o�,� i!J(Adoajs - Irt Adgi - Upt no. __JZ_
Other homes on property? Yes C No
Previous owner of property ind Fin -ry
Total size of property �, 57 A cret
Total size of parcel
Date parcel was created C:
Are all corners and lot lines identifiable? k Yes No
Is this property being developed for (spec house)? Yes X No
Volume 10? and Page Number ff// as recorded with the Register
of Deeds.
------------------------------------------------------------
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a
certified survey, if available, would be helpful so as to avoid
delays of the reviewing process. If the deed description
references to a Certified Survey Map, the Certified Survey Map
shall also be required.
PROPERTY OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the
best of my (our) knowledge that I (we) am (are) the owner(s) of the
property described in this information form, by virtue of a
warranty deed recorded in the office of the County Register of Deeds as Document No. o J and that I (we) presently
own the proposed site for the sewage disposal system or I (we)
obtained an easement, to run the above described property, for the
construction of said system, and the same been duly recorded in
the office of the County of / 'Deeds as Do ument No.
3/8
Sig a re of Applicant Co- pplicant
Date of SiQnat re n:,tP of q;nr,a „ra
l 2 lu 1'6 MO N 16.11 FAX 1 715 380 6560 ZILZ & E41'REEh LZJij0
STATE BAR OF WISCONSIN FORM z -1982 i
573383 WARRANTY DEED 'I
DOCUMENT NO. l
. -
FAw ard S vast .a „ A r lsae I Fn }
REGIS 01•FICE
h „ sban�l anr3 uzife li ST. CR IIX� W1
i FEB 18 1998
conveys and warrants to Douglas � J. Peterson and
Terri A. Paterson, bUShand anA w; few 11:10 AM
i' Ra later of Daadp
y
'' THIS SPACE R ESERVED FOR WORDING DATA
, NAME ANO RETURN ADDRESS
Lhc following described Teal estate in St. Croix County,
State of Wisconsin! First National BAnk
PO Box C
New Richmond, WI 54017
038- 1171 -40
PARCEL. IDENTIFIOA N NUMBER
Lot,,17, .Country Meadows First Addition in the Town of Star
Prairie, St. Croix County, Wisconsin.
RA SFER
$ EE
This is not homestead property.
X§tkX (is not)
Exception to warranties: Easements, restrictions and rights -of -way of record,
if any.
Dated this � day of February , A.D., 19
(SEAL oaf�� (SEAL)
• Edward B. fast
(SEAL) (SEAL)
• Arlene R. Fast
AUTHENTICATION ACKNOWLEDGMENT
5ignature(s) Edward B. Fast, State of Wisconsin,
Arlene R. Fast
ss. '
County.
authensica d this day of _February ]9 _ 2B Penonally came before me this day of
19 , the above named
Kristina ocland
1 \
ADD-T
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ITY EASEMENTS lIFVVFt'� Fes.
STATES PONEA COMPANY)' 4',
• POzm.r, PA3VArLr DRI YENAYS
AOXX TELEPHOW COMPANYI
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NE SCALES 1 j! .am
NE SW —SW 6 SE —SW
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49. 759 SO. FT. cn
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