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HomeMy WebLinkAbout038-1185-60-000 ST. CROIX COUNTY ZONING DEI'ARTMENT AS QUILT SANI'T'ARY RET'OR'T' Owner _.., Address 3 7 2 City /State W� Syoi r air;; Legal Description: Lot l0 Block Subdivision/CSM ' /./, = , Sec J , T,?/ N -R /,r W, Town of ���_ PIN # 039- G v SEPTIC AN -- DOSE MBER — HOLDING TANK INFORMATION: Tank manufacturer Size ST/PC ' / Setback from: House 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: Width /S' Length ,3 Number of Trenched Setback from: House , Well P/L /o d Vent to fresh air intake o ELEVATIONS: Description of benchmark /o z o� file- Elevation /0 6 Description of alternate benchmark Elevation Building Sewer �'.� for ST/HT Inlet `�� S Z ST Outlet • 9 So 7 PC Inlet PC Bottom _ Header/Manifold S `/ S Top of ST/PC Manhole Cover Distribution Lines ( ) ' K Y 7 ( ) ( ) Bottom of System ( ) c� 4/. D 3 ( ) ( ) Final Grade ( ) 1�7 $', � ( ) ( ) Date of installation °/ /if /5g Permi number 2/ State plan number Plumber's signat re License number 2Z/ y7 / Date Inspector complctc plot plan K Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count Safety and Buildings Division y: ST. CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Pe Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)j. Permit Holder's Name: ❑ Cit p Vi llage Town of: State Plan ID No.: SWANSON, BRENT STAR PRAIRIE CST BM Elev.:- Insp. BM Elev.: BM Descriptiori: Parcel Tax No.: to w 03 1185 -60 -000 TANK INFORMATION ELEVATION DATA A9800364 TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV. Sep lc �(il.�� �DG?� Benc a Dosing d, � Aeration Bldg. Sewer �•�i ys, 6 8' Holding S Inlet TANK SETBACK INFORMATION tE Outlet TANK TO P/ L WELL BLDG. vent to ROAD Dt Inlet Airintake Septic I�O� G� 2,' A,,& NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System 1.1 '7 p PUMP/ SIPHON INFORMATION Final Grade Manufacturer emand S Vvy 4 Model Nu er GPM TDH Lift Friction Syste TDH Ft Forcemain I Length Dia. H Dist. To well SOIL ABSORPTION SYSTEM B RENCH Width i Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth EN I N I� DIMENSION SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEA HING anuacturer: INFORMATION Type rr '' CHA m er: Syst �uAv'rrUj Jbp� N OR UNIT DISTRIBUTION SYSTEM Header/Manifold r/ N Distribution Pipe(s), x Hole Size x Hole Spacing Vent To Air Intake Length _ l_ Dia. T Length —3 Dia. �� � Spacing t% ,'�Wi rjG( 2 GD 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 ❑ No ❑Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: STAR PRAIRIE 13.31.18,SW,SE�1378 211TH AVENUE A c f .01M -- 7,rp q w l , osr 4 Gaysf�� -�"�{ Plan revision required? Yes o . Use other side for additional inforrMtion. SBD -6710 (R.3/97) Date Inspector's Signature Cert No. Safety and Buildings Division Vi scons i n SANITARY PERMIT APPLICATION 201 E. Washington Ave. Ina r I P.O. Box 7969 Department of Commerce ac with t IL HR 83 O5, Wi s . A d m. Code Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County k than 8 vi x 11 inches in size. ST 04ote • See reverse side for instructions for completing this application State Sanitary Permit Number 315 -7 The information you provide may be used by other government agency programs El Check if revision to pre loos application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION Propert O wner Name Property Location r 2n T" S U&P S va s 1/4, S /$ T3 / , N, R $' E (or)a Property Owner's Mailing dress Lot Number Block Number t% /k- City, State Zip Code Phone Number Subdivisi Name or CS umber GS Ceo /� �� ( ) co i T II. TYPE OF BUILDING: (check one) ❑ State Owned 0 ✓ Vil it�r Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms � 0 Town oF9 C. S� III. BUILDING USE (If building type is public, check all that apply Parcel Tax Number(s) • 1 E] Apartment/ Condo ' 3 �' lg � ! 3 � ©3 D — 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. tg New 2. [:] Replacement 3, Q Replacement of 4_ ❑ Reconnection of 5_ ❑ 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.fSeepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 [:]Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit /?X 3 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABS ORPTION 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.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) c Elevation ��o G f 7 / Feet Vex__Feet Capacit VII. TANK in Ca gallo s Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Co Steel glass Plastic App New Exist in strutted Tanks Tanks Septic Tan fQldd /Odd '7 &6 e u jT B ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber El 1:1 1:1 El 13 1:1 VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) PI er's Signature: (N mps) MP /MPRSW No.: Business Phone Number: ,P , % I C V / 7/1= 2 ? Plumber's Address (Strei, City, State, Zip Code): 2 7 Z ,0 S % ih e S�`/Caa IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date ssue Iss ng A ture (No Stamps) (Approved []Owner Given Initial ov Surcharge Fee) o �o Adverse Determination O I °� X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6M (Rt 1496) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber Ad e`en T 41� 5'ys rL S/3 T3 AIAI �� ✓ �/.� — � Cis, .e 36 ` y — -- -- i i7v [�2J (' At Iti o.�eD I I c . Vo � W G41 I Wisconsin Department of Commerce SOIL AND SITE EVALUATION Page 1 of •" Divisionof Safety and Buildings in accord with Comm 83.05, Wis. Adm. Code Gil T rucking & E xcav a t ing, In c. Attach complete site plan on paper not less than 81/2x f 1 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and St. Croix percent slope, scale or dimensions, north arr , an$ loci d distance to nearest road. -- -- / y Parcel I.D.# APPLICANT INFORMATION - lda$e print au Lion. - Persona information you provide may be u Second P ` O ua�ses (Pri s. 15.04 1 m evi B , ( )) Property Owner ( Property Location _ Case , Dan J Govt. Lot _SW 1/4 SE im,S 13 T 31 N,R 18 �W) Property O wn er's Mailing Address C ,.9 7 Lot # Block # I Subd. Name or CSM# 3 23 Sawmill Lane _ 4 - , °' �,Ot. 6 Prairie Flats _ City State "gip ("iAi l umber [� City ❑ Village ZTown Nearest Road New Richmond WI S 17 71 C Star Prairie Hwy 65 New Construction Use: �n6a of bedrooms 3 ❑Addition to existing building El Replacement ❑ Public or commercial describe Code Derived daily flow 450 gpd Recommended design loading rate .7 bed, gpd/ft .8 trench, gpd/ft Absorption area required 643 bed, ft 562 trench,,ft Maximum design loading rate .7 bed, gpdfW .8 tr ench, gpd/ft Recommended infiltration surface elevation(s) y ft (as referred to site plan benchmark) Additional design / site considerations t material out -wash Flood plain elevation, if applicable ---- ft ble for system Conventional Mound In - Ground Pressure AT - Grade System in Fill Holding Tank uitable for system ®S ❑ U ❑ S❑ U X S❑ U ❑ S❑ U ❑ S❑ U ❑ S E U SOIL DESCRIPTION REPORT Horizon Depth Dominant Color Mottles Structure GPD/f Boring# in. Munsell Qu. Sz. Cont Color Texture Gr. Sz. Sh. C Boundary Roots Bed Trench 1 0 -10 7.5YR2.5/1 -- - - - - -- SIL 1FABK MVFR AW 1VF 1 .2 .3 2 10 -30 7.5YR4/6 - - - - - -- CL 1FA BK MVFR AS 1 VF .2 .3 Ground 3 30 -98 7.5YR5 ---- - - - - -- S O -GR ML - - -- - -- 7 .8 ele -- -- - -- - -- - -- -- gg 4' - — Depth to limiting - -- factor _ 98 in - - -- - - -- - -- -- � - -- Remarks: — _ 2 _ 1 0 -10 7.5YR2. - ------ - SIL 1 FA13K MVFR AW 1VF .2 .3 2 10 -28 7 .5YR4/ 6 -- ------- CL 1FABK MV AS 1VF 2 3 .3 - - Ground 3 28 -96 7.5 YR5/3 ---- - - - - -- S O - ML - - -- - -- 7 ' 8 ele — - - - - V9$ Depth to �---- - - - - -- -- -- - - - - -- - - -- -- limiting - - - — - I - factor 96 in. Remarks: CST Name (Please Print) ignature: Telephone No. DENNIS GILLE ..�!> _ _ �f S" , ?_G 8 i(' 3' 7 Address i� „� t CST Number Ref # Z S/ s !n a� l�J S` yov / W6/97 3 4/0 q 106 PROPERLY OWNER: Cas Dan SOIL DESCRIPTION REPORT Page 2 of 'PARCEL" I.D.# _ — Gille Trucking & Excavating, Inc. Horizon Depth Dominant Color Mottles Text Structure onsistence' Boundary Roots - � in. Munsell Qu. Sz. Cont Color ure Gr. Sz. Sh. Bed Trench 3 I 0 -12 7.5YR2.5 /1 -- - - - - -- SIL IF MVFR AW 1VF .2 . 2 12 -26 7. -------- CL IFABK MVFR AS 1VF — 2 -- .3 Ground - - - }-- - - - -.- elev 3 26 -96 7.5YR5/3 - - - - - - -- S O -GR ML -- -- - -- 7 8 Depth to limiting - - factor 96 in. - -- -- - - - Remarks: 4 0 -14 7.5YR2.5/1 -- - - - - -- SIL IF MV FR AW IVF .2 .3 F2 14-34 7.5YR4/6 --- - - - - -- CL lFABK MVFR AS IVF .2 3 Ground - eleu 3 34 -99 7.SYR5 /3 ---- - - - - -- S Ot R ML - - -- - -- .7 .8 c 7T. Zs Depth to limiting — -- -- - -- factor 99 in. - - -- -- - - - - - - -- -- - - - -- - - - -- - -- Remarks: 5 1 0 -15 7. 5YR2.5 /1 -- - - - - -- SIL IFABK I MVFR AW 1VF .2 .3 2 15 -36 7.5YR4/6 --- - - - - -- CL 1 MVFR AS 1VF .2 .3 Ground -- - -- - -- -- - elev 3 36 -96 7.SYR5 /3 ---- - - - - -- S O-b ML - - -- - -- .7 .8 1 V5 -- - -- Depth to -- - - -- limiting - -- factor 96 in _ Remarks: Ground - - elev Depth to limiting -- -- - -- factor Remarks: S'�✓y Shy S i3 3 > Alll $ t c) l��P e, ni, El x , 0 S, 160 z OT/4-e 33' 3 y3 — I I '7a, I I IJ YS' � 30 � yo' I I f 307. 63 i ST CROIh CovN'TV SEPTIC ';'ANK MA NTENANCE AGREEML-?NT M41) OWP, ERSHIP CERTIFICATION FORM Mailing Address 3 3� Z,1C C 7 Propetly Address (Ve3rifioatkon required fron i Planning Dopaxt n City /State ©SC 2a A A" Parcel Identification Ntamber - LEGAL DES IPTIQ Property z.octzoaa SG/ x / , , Town o f SZ71, �a r ✓ Subdivision / —ter, - Lot # Certified Survey Map # _ Volume -- �._ Page # _ - -- Warranty Deed # 7 �/ . ,� ............. , Volume / 3 i_'_� Page # Spec house, 0 yes: M no Lot limes identifiable U yes 0 no SySnM MAINTENANCE Improper use and xnaintenanceof your sei pc system could result in its premature failure to handle wastes. Proper znaizttcnancr cousists of pwxtping out the septic tank every ft . 6 years or soorter, if needed by a licensed pumper, W}aat you rut into the system rely affect the function of the septic tank as a ft3 �neut stage in the wa ste disposal system. The property owner agroes to subuxit to St, Croix Zoxdng Deparbacut a cottit?catxon form, signed by the awacr and by a rnasterplumbar, journeymanp1mber, restrictedpl trnber or a licensedp,unper verifying that (1) the on -site wastewaterdisposal system is in proper operatitug condition and/or (2) after iv ipection and purapftQ (if necessary), the septic =k is less than 113 full of alud.ge. i Uwe, the undersigned have read the above requnti hants and agxeo to maintain the private sewage disposal system with the standards set forth, laereiza, as set by the Dep artment of Can ame and the Departsuent of Nawmi ResotuceA, State of Wisconsin. Oxtifieation stating that your Septic system has been maintainer I must be completed and teturnod to the St. Croix County Zoning bffi -e v+uithin Y day the three ye r e gyration date. SIGNATM OF ICAN1 OATS O VV? 'VER CERIM T4.� ION I (we) cexti..fy that sy statements on this ; irxn are true tt) the best of my (our) kvowtedge. I (we) am (are) the owner(s) of tb petty dawritwd abo , by virtue of a warm zty deed recorded irk Rtgister of Deeds Office, MNATUT URr ap • p CANT � � L�r DA.T>1? A,my iat' lion that is mis- represented u ay result in the sanitary permit being revolted by the Zoning Department.' *•" *s *' Include with this application, a stamped wan -.xity deed from toe Register of .Deeds office a copy of the c4 rtified survey tntp if reference is made in the warranty deed W M 00 00.00 N I ; N U- 6C'GLZ cr- Z_ [� O I = _ W � Z i rf cV — j o— O � r . 3 „oo,00.oc ui N I u ,00'89Z N o ¢� I . 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