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HomeMy WebLinkAbout038-1173-40-000 CROIX COUN'T'Y ZONIN EI M i G D � � AR'1' � rN� �� AS BUILT SANITARY REI'OR 'l' I Owner D 1z G-_ Address City/State Legal Description: Lot Block Subdivision/CSM if L ," v '/. W Sec. , T N -R �.�. J&W. Town of PIN tl SEPTIC TANK — DOSE CHAMBER — FOLDING TANK INFORMATION ' (a S8 Tank manufacturer Size ST/PCJ — Setback from: House 'O` Well Sd-� /L Pump manufacturer Model Alarm location (HOLDING TANKS ONLY) Setbacks: Service road _ Ve air intake r Line Meter location Alarm location SOIL ABSORPTION SYSTEM: Type of system: <zg rw,A Width 67 Setback from: House � �S Number of Trenches �_ Well P/L -Fo ' Vent to fresh air intake ELEVATIONS Description of benchmark _ l p, p� Elevation / e z - 7 , ` Description of alternate benchmark Ta,r? G ,� `, o Elevation Z,,g;?,� Building Sewer ST/HT Inlet ST Outlet PC Inlet PC Bottom _ Header/Manifold Top of ST/PC Manhole Cover 9? 5- 7 Distribution Lines Bottom of System Final Grade Date of installation/ Permit number ))LZ (05> tate plan number Plumber's signature �� - License number ?, Date/O Inspector Complete 1110( plan K 1 Wisc*nsin Department of Commerce PRIVATE SEWAGE SYSTEM Sg Count ST. CROIX fe and Buildings Division INSPECTION REPORT S GENERAL INFORMATION (ATTACH TO PERMIT) Sanita!y2%g8V.: Personal information you provice may be used for secondary purposes [Privacy L s.15.04 (1)(m)]. PP. C Hnlde,�'IM BUILDERS 6 3 t' #9 IU - to o : State Plan ID No.: CST BM Elev.: UV Insp. BM Elev.: BM Description: Parcel mao- 1173-40 -000 Ito j S TANK INFORMATION J LEVATI N DATA A9800490 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Se tic u C Bench f s8 2.7Z 102, 72— Dosing I j11/` .'7 O,Z • 0 Aeration Bldg. Sewer , rN Holding �* Inlet Gj0- S TANK SETBACK INFORMATION St Outlet TANK TO P/ L WELL BLDG. entto ROAD D Inlet Air Intake eptic tv S Z S NA Dt Bottom Dosing NA Header / Man. 7,72— Aeratio NA Dist. Pipe 7IS*' 77 Holding Bot. System q CIL t v PUMP/ SIPHON INFORMATION Final Grade y2L I F Manufacturer emand 4-A um W rim V 7 5-7 Model NdM T Lift Friction System TDH Ft Force la. I f Dist. To Well SOIL ABS PTION SYSTEM BED /(rRrNCW Width . Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIME 7 DIMENSION SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING, Manufacturer: INFORMATION Type( CHAMBER Moe Number: Syste v 7� A-If OR UNIT DISTRIBUTION SYSTEM Header /Manifold q Distribution Pipe , / a x Hole Size x Hole Spacing Vent To Air Inta � ke Length _ Dia. `S Length — 7 S Dia. N Spacing Cy SG I� � Z77� 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 g p El Yes E] No El Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: STAR PRAIRIE 15.31.18,NW,SW 1111 212TH AVENUE �. A li• 13 ty\� ?gyp bl k �'vpn' I�av�d -� n � r � � � � �D � .� �I'"r'�'I P� e, / h'a/�eczlt�t, �j / RI Q� (:�Giv1IZ G!�f an revision required? es o 1 IZ Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Fignat.re Vi sionsin Safety and Buildings Division SANITARY PERMIT APPLICATION 2 1 B Washington Avenue Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 -7302 • 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. 5 .A • See reverse side for instructions for completing this application State Sanitary �� oo Per it Number Personal information you provide may be used for secondary purposes ❑ Check if revision to previous pplication [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 v .I YS ,kW 1/4 _51,j 1/4, S is T3l , N, RAF' E (orko Ffroperty Owner's Maili�A ress / Lot Number Block Number City State Zip Code Phone Number Subdivision Name or CSM Number f e Qi.' lJ � Y 4m Q 11. TYPE F BUILDING: (check one) ❑ State Owned it 7 a rest Road Village Public 1 or 2 Famil Dwellin - No. of bedrooms 3 Town OF ar ?�� G� C III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(sl 1 ❑ Apartment/ Condo 03? 11 — lvd — 0 ea 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. X 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 U4 Seepage Trench 22 ❑ In- Ground Pressure _ s / f 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill 6 5 " 75 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 Al Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation G _1 �e G�— �y� 2 Feet 9 7S Feet VII. TANK Capacity in gallons Total # of Prefab. Site Fiber- Ex er. INFORMATION Gallons Tanks Manufacturer s Name Con- Steel Plastic p New Existin Concrete strutted glass App. Tanks Tanks epticTa !� �� G k 19. ❑ ❑ ❑ E] 1:1 Lift Pump Tank /Siphon Chamber 1 13 ❑ ❑ 1 ❑ 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: (Up Stamps) PRSW No.: Business Phone Number: M :�F - 7 Plumber's Address (Street, City, State, Zi Code): IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater D ate Issued Issuing-Agent Signature (No Stamps) �Ap Surcharge Fee) []Owner Given Initial / y/) � �� Adverse Determination l 00 l X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.11 /97) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber �f S � � 1 a op �r tD p e ( 5� S•` 1`' c 61- 1 9 ye ck- 1 fro m X5 0/- j �c5� I A5 8�f i Wisconsin Department of Commerce SOIL, A -SITE EVALUATION Division of Safety and Buildings ,, , s , ;- 1 Page I of Bureau of Integrated Services in acc ordance -with s. ILHR 83.09, Wis. Adm. Code i Attach complete site plan on paper not less than 8 112 11 inches irf4 !P. %Cmust County include, but not limited to: vertical and horizontal reference point (BM)',' difkt6q and `' S-} ' percent slope, scale or dimensions, north arrow, and location arad distanpe,,to nearest road_ - e- t Parcel I.D. # APPLICANT INFORMATION - Please print all inform" ; ,�,J Revi wed by Date Personal information you provide maybe used for secondary purposes (Pnvari:; hi0 tJrf6jW1) �- Property Owner Pie ocation ' 1 F r.. owr Lot tj()1 /4 5U) 1/4,S 1 5 T 3 N, R g E (or) Property Owner's Mailing Address Lot # Block# I Subd. Name or CSM# 135 3 A kte_ q GPPIC R; ue .. Be no( City State Zip Code Phone Number ❑ City ❑ Village Fj] Town Nearest Road r'jJ oe ❑ ew Construction Use: © Residential / Number of bedrooms �_ Addition to existing building Replacement ❑ Public or commercial - Describe: I' Code derived daily flow ' SO gpd Recommended design loading rate . S g g bed, gpd /ft gpd /fie Absorption area required 900 bed, ft 7 50 _-_trench, ft2 Maximum design loading rate . 5 bed, gpd/ft gpd /ft Recommended infiltration surface elevation(s) rtRENtht��� 1._ _6cl_� 9y,-2-$ ft (as referred to site plan benchmark) Additional design /site considerations Q p_h 1_ S',� t a dA PA5�• Oor ye a w+ I I -M -9 S Parent material Q IO a � a I O V:t w _ 5 L-% _ Flood plain elevation, if applicable ft F: u Suitable for system Conventional Mound In- Ground Pressure AT Grade System in Fill Holding Tank Unsuitable for system ®, S E:1 U � S El U ® S El U ®S ❑ U ❑ S ®U ❑ S 159 U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench 9'•1 6 101R y/ --- - ---- -� 5 L_ IF S6 k m F C w I F y 5 J Ntwv ^ / ale v. Ground J - 7. 5 L Ot M 5 6 k Yv% r. t.2 1 J F • J� . 1D 97 ft. q .3 � h 5 O -_ � � w iof 7 Depth to 5 7 ' S `19, 4/� - - -�� 5 �. M M F il` , to limiting factor $in. Remarks: 5 So, % -aa ►, b0.hg e. D, w : A- - 7.64 9 - 2 /g L!5 Boring # I 0 -9 y /y - - — 5 L- 01 MCC r 015 a IF , a o 9 -I� I LdA. y/3 c_w I F 3 y -a8 IS yl _ ---- -- Sc c, a m Sb k mfri y Ground a 9 -37 �. s YJ2 y l s� aMsbk �,� La F , 9 7,�ft. 5 37-y T$ `I R - -- t_ :5 O - 5 ML __ C w , 7 elev. y • Depth to 7 ,S `iR y /y limiting factor m in. Remarks: (1 �0rl3o 4-Q -7 .s4JZyly L.5 CST Name (Please Print) Signature Telephone No. �, - �'ar _— 1Is - -3588 Address Date CST Number a l0 06+ + aar a 4, c 1 � -31 -9 8 Ala 117 9 LP R► G n L r cX 5-t Q fi Pa SJ._—_.._Ll_._.. ___.__ sw %, sec i s, T 3 1 v R tg Li A Don h i4 'T,�r tG. " -Y0 cstm aai7 y(�, f O W Gocttic.� U Y 1.9 S a cres 3 3% E . a s o +- c 1 n c�ytibor S I y 349 -a1' q Q AS rc -17 -45 f VC- �) 17, 1 , �- 98.ao t7 bo rein a l s ® Lo C-1 l b -,� 17.75' Wisconsin Department Industry "Labor and Human Relations SOIL AND SITE EVALUATION REPORT Page of 3 ti Division of safety a BuOkings in accord with ILHR 83.05, Wis. Adm. Cod ou sT; cRo r K Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan not limited to vertical and horizontal reference point (BM), direction and % of slo a or ,A D. dimensioned, north arrow, and location and distance to nearest road. i' T ,t APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION ;; REVI _ Y DATE y PROPERTY OWNER: P RTY LOCATJOH, , Vi' CkARD 5"7'00 T GqVT APT N �v1/ W 1/4, f 3� ,N,R 11V E("'1L�J PROPERTY OWNERS MAILING ADDRESS L �, X 353 � W,4 CITY, STATE ZIP CODE PHONE NUMBER I! ,' E Ifs So..� /pis 5 y 01(0, (715)5 4q-(v731 N AD NEAREST NEAREST RO AD ( ew Construction Use I & f*fiesidential / Number of b6drooms 3 + o q () Addition to existing building ( ] Replacement ( ) Public or commercial describe Code derived daily flow '& v gpd 0 Recommended design loading rate _! f Z bed, gpd /ft • S trench, gpdjft2 ..//` Absorption area required bed, ft trench, 1 Maximum design loading rate A1 1,R _bed, gpd$ 'S trench, gpolft Recommended infiltration surface elevation(s) 5'4�5 .3 ft (as referred to site plan benchmark) Additional design /site cons rations LfsE 60.E N/f �P Ro w cvfff : — V 70 Parent material .5C-5 11 'BOR k L, .A i>- T - G Flood plain elevation, if applicable ft S = Suitable for System COr rTIONAL MWyD ❑ U IN- GF�kiN U PRESSURE A -G SYSTEM M FDA H Slip TA U = Unsuitable for stem l S ❑ U [�'$ R'$ 19 5 O U ❑ S M Ej SOIL DESCRIPTION REPORT N1/2 = Nei 46e- vA►1'Lc"AV A q Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Y Roots GPD /ft In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Ground 75 `S . D S �Q _ , 7 elev. Depth to limiting factor a 1� Remarks: Boring# y 6& Ground 3 3 7,5 y R —?/4/ elev. 75 yle Y` '-M ioW 7S YR •�r:,�, ,,c 51 1 140 ' �;Ae 44-1 f R �.c " — Depth to limiting f ac t or Remarks: T Name: — Please Print R t'C In ,�,— Phone' Address: C � C.STA Signature: �� L' r c It .. _ w_�.. -�� - .___ f+w..�. b—te Date: CST Number: tit ' y R Lq c 1 v ofl . w w w � / kn w m n O � O N Al `_ 4 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Q wne Buyer R C LL,bVA- ��VS Mailing Address 70 � �d • �� �_ Property Address fl l c>2 f Alf A l (Verification required from Planning Department for new construction) City /State / u IC EW (C W Mo' ZS Parcel Identification Number N D ( ' N G LEGAL DESCRIPTION Property Location V kJ %., .S'GrJ %., Sec. / S , TAN - R / W, Town of Subdivision L K y Gq'k- E/j t Lot #. Certified Survey Map # , Volume , Page # Warranty Deed # 3 3 / Volume , Page # 39" 7 Spec house ❑ yes )Kno Lot lines identifiable 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 fimction 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 masterplumber, journeyman plumber, restrictedplumberor 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. Itwe, 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 year expiry ' n date. SZNATURE OF 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 described abov , by virtue of a warranty deed recorded in Register of Deeds Office. / GNATURE OF APPLICANT DATE * * * * ** Any information that 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 OHMS 08:19 2 7152487839 SUPERIOR Mi O jT 004 ,' „'""^ _1..: ,08'5'1 ._.. • _:')•.,.a,r 1 _ • �. ---- _ ___ -- - - - -- •---- ....,. _ � to / «, w ...r .....Y.. ..•r. ••w -mow � a 0 O c� Lij Vi j �M `� • ,�8'bb� i ti 1 N 1 ff ,�i� dl� M „66 At,C!AN I I f v N ` o 4 N K) t 1 �t M„41,.J.Cyr,!'� ;)N L) i ' a n qJ, ,ti r w tt! i I 4 N i f.) I m h Q. N I '`. N U Li: IL LL �• 6 fN In C �- N M M I �v r W�w N w N a c7 rx iQ 4, N i u, ell � Safety and Buildings Division SANITARY PERMIT APPLICATION 201 Box Washington Avenue Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 -7302 • 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. C Z • See reverse side for instructions for completing this application State Sanitary Permit Number 9l5 g Personal information you provide may be used for secondary purposes ❑ 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 wner Name Property Location C Co /lo &&_ /dins W 1/a s � Zia, S s T f / , N, R /8'E (or p! Property Owner's Mailing Address Lot Number Block Number City, State Zip Code Phone Number Subdivision Name or CSM Number 1 vala 11. TYPE BUILDING: (check one) ❑ State Owned it Nearest Road Public 1 or 2 Famil Dwellin - No. of bedrooms 3 vo n OF trr-e V JO r oll, : r� 111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 03 r — a 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. WLNew 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 N Seepage Trench 22 ❑ In- Ground Pressure 42 Q 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. Pere. Rate 6. S stem Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) gf.;lS EI alr D� 4d r �� Q•s• �d Feet Feet VII. TANK Capacity in gallons Total # of Prefab. Site Fiber- Exper- INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Exist in structed Tanks Tan ks Septic Tank or Holding Tank �l 7 VV ❑ Lift Pump Tank /Siphon Chamber I I I ❑ I ❑ ❑ I ❑ I ❑ I ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sew ge system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature:( ostamps) P PRSWNo.: Business Phone Number: I —Y101 Plumber's Address (Street, City, State, Zip Code): Sc- , 4'4 d IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued Issuing Agent Signature (No Stamps) Approved E] Owner Given Initial Surcharge Fee) Adverse Determination ��.�� X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: VV SBD- 6398 (R.11/97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber a 0 Y + J l\ Ilk ` 10 4 M l D Cl. 0 ca ft V e � V1