HomeMy WebLinkAbout038-1187-00-000 ST. CROIX COUNTY ZONING DEPARTMENT
• AS BUILT SANITARY REPORT
Owner
Property Address
City /State „, Ow � � ` � S
Legal Description: f f . -
Lot 1 0 Block Subdivision/CSM # & 6t, y'r' l
t /a _-jjr t /a, Sec. d TAN -R,ZLW, Town of _ PIN # 0 3 , t - ;1 as -aav
5 ' 7 Q✓' /fi ` r G � �, 3(, l �' . �$'
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION
Tank manufacturer ,,j, e Size ST/PC Setback from: House Well 50Z P/L SDI
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: 60,d Width Length Number of Trenches -
Setback from: House a7` Well SO4' PAL JL Vent to fresh air intake
ELEVATIONS
Description of benchmark /-o7 4,'e-r— Elevation Idig, ` 4
Description of alternate benchmark Elevation Oc. 33
Building Sewer. , 3 i' ST/HT Inlet �l� 9 7 ST Outlet y PC Inlet
PC Bottom Header/Manifold 9C ` /"F Top of ST/PC Manhole Cover t
Distribution Lines
Bottom of System
Final Grade
Date of installatio /S - / O / Iermit number State plan number
Plumber's signature e / License number Date
Inspector
Complete plot plan
NOTICE Please provide the following:
• A plan view sk*ch showing everything within 100 feet of the system.
• Two horizontal reference points to center of septic tank manhole cover.
• Show alternate benchmark, if applicable.
PL AN VIEW
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INDICATE NORTH ARROW
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count y:
Safetyand Buildings Division
INSPECTION REPORT ST. CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Personal information you provice may be used for secondary purposes (Privacy Law, s.15.04 (1)(m)]. 324701
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
CASEY, DANIEL STAR PRAIRIE
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
,' 038 - 1187 -00 -000
TANK INFORMATION ELEVATION DATA g �S X1 0
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic �/l�t�.U� 'rQ�s,, f ---- Benchmark
� I
Dosing -- k U.
Aeration _ Bldg. Sewer L
7
Holding St /Ht Inlet Sil
TANK SETBACK INFORMATION t 4 St/ Ht Outlet
TANK TO P/ L WELL BLDG. A I nta tO ke ROAD Dt Inlet 'ry
NA Dt Bottom - --
Dosing NA Header / Man.
Aeration �.. - NA Dist. Pipe
Holdin _ Bot. System -7 Cl (o.Yl (y
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer D and
Model Numb GPM
TDH Lif,� Friction S sterfri TDH Ft
oss 1d
Forcemain Length Dia. Dist. To Well
SOIL ABSO PTION SYSTEM
BED / RE CH.. Width / Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS °.J .:✓ DIMENSION
SETBACK
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION Type O } r / CHAM Mo Numb
System: , �,,���,_ / f /"- ' OR UNIT
DISTRIBUTION SYSTEM
Header / Mani old M Distribution Pipe(s) r x Hole Size x Hole Spacing Vent To Air Intake
6 t
Length _! Dia. Length Dia. ` Spacing `'� �"• f
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: STAR PRAIRIE 13.31.18, SW, SE 1393 211TH AVENUE — PRAIRIE FLATS
LOT 20
"L d �, . •+� fJJG t. t n el l %' ✓�/ yT �''C f; ". ;i) 4;'
V a
Plan revision fecluired? �0 Yes [XNo L, N
Use other side for additional information. �j
SBD -6710 (R.3/97) Date Inspector's Si6Aature Cert. No.
ASafety and Buildings Division
SANITARY PERMIT APPLICATION 201 W. Washington Avenue
ftconsin In accord with ILHR 83.05, Wis. Adm. Code P O Box 7302
Departmentof Commerce Madison, WI 53707 -7302
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 112 x 11 inches in size. --rrya 1�
• See reverse side for instructions for completing this application state sanitary Permit umber
Personal information you provide may be used for secondary purposes ❑ Check if re, to rev- us c lication
P PP
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION
Property Owner Name Property Location
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Property Owner's Mailing Address z Lot Number Block Number
City, State Zip Code T hone Number Subdivision Name or CSM Number
e6J E1 .S ) ,. /—.e TS
11. TYPE BUILDING: (check one) ❑ State Owned It Nearest Road V 0_v%
❑ Village r
Public 1 or 2 Family Dwelling - No. of bedrooms Town OF - , y ;
111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/Condo & 3 y 11?7 - ° `' Or` *6s
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, t&New 2_ ❑ Replacement 3 ❑ Replacement of 4_ ❑ Reconnettion of 5. ❑ Repair of an
______System ________ System_____________ Tank Only ___ ________ Existing System ___ -____ Existing System
8) ❑ 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 g,Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In- Ground Pressure / r—/ [ 42 ❑ Pit Privy
13 [] Seepage Pit � "� xE I 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
Required (sq. ft.) Proposed (sq. ft.) (Gals/da /sq. ft.) (Min. /inch) "3 Elevation
5 D' r Feet 70 Feet
VII. TANK Capacity
in gallons Total # Of Prefab. Site Fiber- Ex per.
INFORMATION New Existin Gallons Tanks Manufacturers Name Concrete Con Steel glass Plastic App
strut
Tanks Tanks
Septic a ank dd d l d zJ e e>- ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite se age system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: (No tamps) P PRSW No.: Business Phone Number:
7v4o - �15 -3�'G - 31.21
Plumber's Address (Street, City, State ip Code):
d S , ,,'
. COUNTY/ DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate I ssued Is sui n 'gnat a (No Stamps)
Surcharge Fee)
Approved ❑ Owner Given Initial 1 /6 0C� 99
Adverse Determination �V/
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD- 6398 (R.11/97) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
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Wisconsin Department of Commerce SOIL AND SITE EVALUATION Page 1 of
Division of Safety and Buildings in accord with Comm 83.05, Wis. Adm. Code
Gille Truckin & Excavating, Inc.
Attach complete site plan on paper not less than 8% x I I inches in size. Plan must County
if Nt
include, but not limited to: vertical and horizontal reference -po), direction and St. Croix
percent slope, scale or dimensions, north arrow „aOd location and dMance to nearest road. Parcel LD.#
APPLICANT INFORMATION - P /¢ate print all ' forrtiaticq. -- P — 8r1 —� O _
Personal information you provide may be used for secondary pu rivacy Law, $. 04 (1) (m)). R Dat
J
Property Owner i? perty Location
C asey, Dan _ ( s,�" M do4 Lot SW U4 SE im,S 13 T 31 ,N, 18 QW �
Property Ownees Mailing Address ; t # BloA# Subd. Name or CSM#
323 Sawmill L ane 9 : d 20 Prairie Flats
City State Z' Code - „ fie City ❑ Vdlage Town Nearest Road
New Richmond WI 54 7 7,15 - Star Prairie Hwy 65
New Construction Use: F1 Residehl.-l.{Stlip6be edrooms 3 [_)Addition to existing building
1 Replacement E] 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, gpd/ft .8 tr ench, gpd/ft
Recommended infiltration surface elevation(s) r 1 S', 3 ft (as referred to site plan benchmark)
Additional design / site considerations
t Parent material Out - wash Flood plain elevation, if applicable ft
ble for system Conventional Mound In - Ground Pressure AT - Grade System in Fill Holding Tank
itable for system MS D U ® S U ❑ S U ❑ S 2 U ❑ S N U ❑ S N U
SOIL DESCRIPTION REPORT
Horizon Depth Dominant Color Mottles Texture Structure Consistenc Bound Roots GPDIft2
Boring# in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
1 1 0 -11 7.5YR2.5/1 ---- - - - - -- SIL 1FABK M VFR AW 1VF .2 .3
2 11 -24 7.5YR4/6 ---- - - - - -- CL IFABK MVFR AS 1VF . .3
Ground 3 24 -96 7.5YR ---- - - - - -- S 0 -GR ML - - -- - - -- 7 8
ele v
Depth to _
limiting --
factor __ - — -- - -- - --
96 in. - - � - --
Remarks:
2 1 0 -10 7.5YR2.5/1 ---- - - - - -- SIL 1FABK MVF AW 1VF .2 .3
2 10 -28 7.5YR4/6 - - - - - -- — C 1FA MVFR AS 1VF .2 3
Ground 3 28 -96 7.5YR5/3 ---- - - - - -- S 0 -GR ML - - -- - - -- 7 8
el - -- - - - -- - -- - - - --
Depth to
--- - - - - -- - - - - --
limiting - -- - -- --------- .. - - --
- -�
factor _
96 in.
Remarks: _ -- —
CST Name (Please Print) Signatu e Telephone No.
Denni C 715- 268 -6637
Address p t CST Number Ref #
372 140th Street Amery, WI 54001 9 N97 3409 107
PROPERTY OWNER _ Casey , Dan — SOIL DESCRIPTION REPORT Page 2 of
APARCEti1.D.#- Gille Tnicking & Excavating, Inc.
Horizon bepth Dominant Color Mottles Texture Structure onsistence Boundary Roots �D
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench
3 1 0 -11 7.SYR2.5/1 ---- - - - - -- SIL 1FABK MVFR AW 1VF .2 3
- —r-
2 11 -35 7.5YR4/6 ---- - - - - -- CL 1FABK MVFR AS 1 VF
.2 .3
Ground
elev
3 35 -96 7.5YR5/3 ---- - - - - -- S 0 -GR <�- ML - - -- - - -- .7 .8
9F. 5r - - -- -- -- : _� - - -- - - - - - -- —
Depth to
limiting
factor
96 in. - -- - - -- - - -- —
Remarks:
4 0 -13 7.5YR2.5/1 ---- - - - - -- SIL 1FABK MVFR AW 1VF .2 .3
2 13 -35 7.5YR4/6 ---- - - - - -- CL 1FABK MVFR AS 1VF .2 .3
1 3
Ground -
elev 3 35 -97 7.5YR5/3 ---- - - - - -- S 0 -GR �� ML - - -- - - -- .7 .8
(I •
Depth to
limiting
factor
97 in. — -- -- —
Remarks:
5 1 0 -11 7.5Y R2.5/1 ---- - - - - -- SIL 1FABK M VFR AW 1VF .2 .3
2 11 -32 7.5 CL 1FA MVFR AS 1 2 .3
round
elev 3 32 -96 7.5YR5/3 ---- - - - - -- S 0 -GR ; ML - - -- - - -- .7 .8
Depth to
limiting -- — — -- - --
factor
96 m. — - - -- -- —� -- - -- - - -- - - - -� - -- -- j — -
Remarks:
Ground - - -- - -- —
elev
- - - -- -- - - - - - -- - - - - -- - - - - - -- - -- - -- -
Depth to
limiting — — - -- — —
factor
Remarks: —- — -- -___ —.
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• ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
_ AND
OWNERSHIP CERTIFICATION - FORM
Owner/Buyer _ 491, f� � �� � � f� S�Y r � ,C�� c �i' 4
Mailing Address .P3 1A A— e 4ilD &cW, 4v 6 X °17
Property Address a
(Verification required from Planning Department for new construction)
City/State Parcel Identification Number 0,9r— 11?7-ao 0 d
LEGAL DESCRIPTION
Property Location 5W _ 1 /4, :5F 1 /4, Sec. (3 , T3 LN -R 1 9 W, Town of 61aa 1QI
Subdivision ��A'� �, ��
LATS Lot #
Certified Survey Map # Volume . Page #
Warranty Deed # ` ` Volume 7 , Page #
Spec house A yes ❑ no Lot lines identifiable ,X( 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, restrictedplumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal 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
that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
'days f the three ear a piration date.
r
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SIGNATURE ANT DATE
OWNER CERTMCA ON
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
perry desc ' ed ove, b e of a warranty deed recorded in Register of Deeds Office.
c L �
SIGNATURE PLICANT DATE
* * * * ** Any information 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
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UNPLA LANDS
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