HomeMy WebLinkAbout038-1173-30-000 ST. CROIX COUNTY ZONING DEPARTMENT �I` 4
AS BUILT SANITARY REPORT
Owner I�)��
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Address - '`ti`wj� cc RO
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City /State ;, z 1 OFF►c,
Legal Description: j
Lot _ Block �_ Subdivision/CSM #
+,, '- %4,�, Sec - /5— . TAN -R,1Y_W, Town of _ XL' PIN #
SEPTIC TANK -- DOSE CHAMBER -- 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: r Width ,/R Length - sue Numb of Trenches —
Setback from: House Well P/L Vent to fresh air intake
ELEVATIONS
Description of benchmark
Description of alternate benchmark Elevation /DD,
f� °� Elevation
Building Sewer " ,72 ST/HT Inlet ST Outlet PC Inlet
PC Bottom Header/Manifold 9 2/ , 2 Top of ST/PC Manhole Cover
Distribution Lines
Bottom of System
Final Grade O /'L 2 G O ( )
Date of installation Pe mit a er ,��� State plan number
Plumber's signatur License number ,�7_ Dat
Inspector 1 1 - M
Complete plot plan
NOTICE Please provide the following:
• A plan view sketch showing everything within 100 feet of the system.
• Two horizontal reference points to center of septic tank manhole cover.
• Show alternate benchmark, if applicable.
•
PLAN VIEW
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���•�'' a use
INDICATE NORTH ARROW
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM y'
Safety 4nd Buildings Division Count
ST . CROIX
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitarxv"tijq.:
Personal information you provice may be used for secondary purposes (Privacy L , s.15.04 (1)(m)]. 3 t1 , / �G �y
PE Holder's f+La k E E1lii y lLi YKE� t �wn of: State Plan ID No.:
CST BM Elev.: MM /l1lC Insp. BM Elev.: BM Description: Parcel Parcel IMI1�_:1173- 30-000
TANK INFORMATION ELEVATION DATA A9800119
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic S �; �/� Benchmark
Dosing
Aeration Bldg. Sewer p , /de, - 2 X �
Holding St/#t Inlet "o -/,Y"'
TANK SETBACK INFORMATION St/ VOutlet
to
TANK TO P/ L WELL BLDG. geintake ROAD Dt Inlet
Septic - (8 �,� NA Dt Bottom
Dosing NA Heade
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model umber G
TDH I Lift F ' Ion System Ft
oss H ead
Forcemain ngth Dia. Dist. Towel
SOIL A ORPTION SYSTEM
BED / RENCH Width , Length No. Of Tr nches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS / S� � DIMEN I
SYSTEM TO P/ L BLDG WELL LAKE / STREAM LEA Manufacturer:
SETBACK --
INFORMATION TypeO n - CHAMBER Model Numb _
System: ��- OR UNIT
DISTRIBUTION SYSTEM
Headerj_Man4eld- Distribution Pipe(s) /� / x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. �F Length 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.) �o 3
LOCATION: STAR PRAIRIE 15.31.18,NW,SW 109 212TH AVENUE
C z;r
Plan revision required? ❑ Yes 2 S
Use other side for additional information. p
SBD -6710 (R.3/97) Date Inspector's Signature Cert. No.
N)L consin Safety and Buildings Division
SANITARY PERMIT APPLICATION 2 01 E. Washington Ave.
In r P.O. Box 7969
Department of Commerce acco d with ILHR 83.05, W IS. Adm Code Madison, WI 53707 -7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 1/2 x 11 inches in size.
• See reverse side for instructions for completing this application State Sanitary Permit Number
. ( :1
The information you provide may be used by other government agency programs ❑ Check if revision to previous a6plication
[Privacy Law, s. 15.04 (1) (m)).
State Plan I.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION �—
Prope ner N e Property Location (Or�
1 1/4 1/4, S — T , N, R ft
Property Owner's Mailing Address of Number - Block Number
City, Ftate Zip Code Phone Number Subdivisi N me or C Number
n. PE F B ILDIN : (check one) ❑ State Owned ❑ city Nearest Road
Public 1 or 2 Famil Dwelling - No. of bedrooms _ E] Village of fg
111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo I S • 3�
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. 4 New 2 _ ❑ Replacement 3_ ❑ 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 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 E] 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
Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. inch) Elevation
4�L I Rm f Feet Feet
Ca aclt
VII. TANK in ga llons Total # of Prefab. Site Fiber- Exper
INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existin structed
Tanks Tanks
Septic Tank ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, thp undersigned, assume responsibility for in allatiQn of #e onsite sewage system shown on the attached plans.
P e: (Print) Plumb gna a s) MP /MPRSW No.: Business Phone Number:
Plumbe s A( dress (Street, "ty, State, Z' Code):
IX. COUNTY / DEPARTMENT USE ONLY
❑Disapproved Sanitary Permit Fee (includes Groundwater ate ssue Issuin entSignature(NoStamps)
A rOVed f 01 0 %
Adverse arge Fee) j/ �`
I� pp ❑ Owner Given Initial c vV
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD•6398 (R.11/96) DISTRIBUTION: Original to county. One copy To: Safety & Buildings Division, Owner, Plumber
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WscvrglnDepa bons stry SOIL AND SITE EVALUATION REPORT P of -3
labor ^::� Human Relations � _
Division of Safety & Buildings in accord with ILHR 83.05, Wis. o
/J OUN1Y
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. P C� includ4,but s r . C R o I X
not limited to vertical and horizontal reference point (BM), direction and % e, scs -, �Ft1 L I.D. #
dimensioned, north arrow, and location and distance to nearest road. CID 'L'Ck •- UU
r J
APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATIO J U i 3 j 96 R DBY DATE
PROPERTY OWNER: PERTY 14 ti
Vi'G h 4 /?D 5 To o T 0 L( OF L S /� T 3/ ,N.R / E
PROPERTY OWNER':S MAILING ADDRESS LOCK fl CSM
353 4 w,4 T U ems= 7 , � ; /
CITY, STATE ��s ZIP CODE PHONE NUMBER CITY W
tFu Sow Syof(o �fq ika t 1 �ywy. CC
[pr�ew Construction Use [ 4-fiesidential / Number of b6drooms 3 +0 4 (] Addition to existing building
[ J Replacement (] Public or commercial describe
Code derived daily flow T gpd Recommended design loading rate bed, gpd/ft • S trench, gpd/ t
Absorption area required N/� bed, 11 /y trench, ft Maximum design loading rate �/� bed, gpdAt � trench, gpol(t
Recommended infiltration surface elevation(s) SEW }t .3 ft (as referred to site plan benchmark)
Additional design / site cons rations ZISE L ova Cv 44,e5 — Ga 41e42 -f& Cow "[-ov RS
Parent material SCS I 1 13VR e4,g RD % j Clu-/e Flood plain elevation, if applicable ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE I AT -GRADE SYSTEM IN FILL I HOLDING TANK
U= Unsuitable fors stem [IS O U [IS ❑ U I us ❑ U EIS ❑ U 0S ❑ U [IS O U
SOIL DESCRIPTION REPORT 41 IR = No/
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boalnd3ry Roots GPD /ft
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed itinch
:.. /:.: /o y,Q 3 1a- s/ f s b,� nh, f / 2 5 3 f s c�
2 5- z� /o ye 314?' /144 fe s i f s
Ground 3 1 �-�o /o ye ylf� 13 /f S/fe iw, f /� C �✓- _ �/ , S
elev.
/00. 73 ft. 15 61A of R • S , G
Depth to
limiting
fact f
Remarks:
Boring #
2 L
7 ,/o ye 3 1.;-- 2 f 5 6k i- ,-6
GrOUnd V Z3 mad /� y� y /� W/' 5 ��Sa/� /Yv, T/� CC �C r S i • b
el? v. U 7
Depth to
limiting
factor „
Remarks:
ST Name: — Please Print R n IB IE R T V L (3 R l C (n T- phone. 7 3 a�
Address: /0 /o
Signature: / — Ulb richt & ASSOCIates Date: // CST Number:
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer
Mailing Address 22c/, L ,/Ze
Prop Address
(Veri cation requ 1 ired from Planning Department for new construction �—
City /State Parcel Identification Number — /L7�-
LE GAL DESCRIPTION
Property Location !+l ' /4, _Sirs '/4, Sec. /,7 T .�% N- R,),f_W, Town of ��<Ijer
Subdivision Lot #
Certified Survey Map # , Volume , Page #
Warranty Deed # _ �7� / , Volume /_T / S , Page # 7n
Spec house ❑ yes ❑ no Lot lines identifiable 0 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, restricted plumber or a licensed pumper 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.
I/we, 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.
STGNATURE11 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 property describe above, by virtue of a warranty deed recorded in Register of Deeds Office.
SIG TURF Iq APPLICANT DATE
* * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department.
** Inclurte 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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ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
ST. CROIX COUNTY GOVERNMENT CENTER
urr� 1101 Carmichael Road
Hudson, WI 54016 -7710
(715) 386 -4680
June 30, 1998
Re /Max Team 1 Realty
Attn: Mike Germain
103 Main
Somerset, WI 54025
RE: Septic Inspection for Mike Germain located at 1109 212th Avenue, Lot 3 of Apple
River Bend, Town of Star Prairie, St. Croix County, Wisconsin
Dear Mike:
A septic inspection of the above referenced property was conducted on May 20, 1998. This
property is located in the NW %4 of the SWA of Section 15, T31 N -R1 8W, Lot 3 of Apple
River Bend, Town of Star Prairie, St. Croix County, Wisconsin. At the time of the
inspection, this septic system was found to be code compliant for a three (3) bedroom
home.
If you have any questions regarding this, please contact our office at (715) 3864680.
; rely,
K. Thompson
Zoning Specialist
/sm