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HomeMy WebLinkAbout038-1174-30-000 P _ ST. CROIX COUNTY ZONING DEPARTMEN �)� ! :; "•, • AS BUILT SANITARY REPORT Owner i e Addres Y Cit /Sta Legal Description: Lot _/ -? Block — Subdivision/CSM # vrr c, '/+ 5,6 '/, SW Seca ,TAN -R W, Town o IP e PIN # SEPTIC TANK — DOSE CHAMBER — HOLDING TANK INFORMATION: Tank manufacturer lc J Size ST/PCI � / -- Setback from: House Zlv Well/ &tP/L, Pump manufacturer Alarm location (HOLDING TANKS ONLY) Setbacks: Service road nt to fresh er intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM: Type of system: Wid = Length �5� Number of Trenches Z Setback from: House Zia 'Well P/L -- Veat to fresh air intake T �� ELEVATIONS Description of benchmark •� w Elevation /t'r Description of alternate benc Elevation Building Sewer ST/HT Inlet o ST Outlet to y X d PC Inlet PC Bottom Header/Manifold /D /, 0 Top of ST/PC Manhole Cover /D Distribution Lines O /oo • O loo •�_' ( ) Bottom of System () Final Grade Date of installation 6 / / FPermit ber �' 0 77YI State plan number Plumber's si ur License number Date / / Inspector complete plot plan or . Wisconshin Department of Commerce /190 Safety and Buildings Division PRIVATE SEWAGESYSTEM County CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) SanitarMu "_: Personal information you provice may be used for secondary purposes [Privacy L s.15.04 (1)(m)]. 33 / / Permit RESIDENTIAL BUILDING SERVICES�1� Yi� T�gwn of: State Plan ID N o.: CST BM Elev.: Insp. BM Elev.: BM Description: Parcel IMF'— :1174 -30 -000 loci loo T� TANK INFORMATION ELEVATION DATA A9800130 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic 1� Zvv Benchmark q« 10 r o v Dosing Aeration Bldg. Sewer / ga /a7, ?D Holding St Inlet TANK SETBACK INFORMATION N _ St IA Outlet TANK TO P/ L WELL BLDG. Air Intake ROAD Dt Inlet �SePtic / 7-6 34/ NA Dt Bottom Dosing A Header /Man. Aeration NA Dist. Pipe g',I /o c. 07 Holding Bot. System $ lad, C PUMP/ SIPHON INFORMATION Final Grade q / 5/, o/ Manufacturer Dema Model Nu � TDH Lift Friction S TDH Ft Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED / Width r Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS S 5 c DIMENSION SYSTEM TO P / L BLDG WELL LAKE / STREA LEACHIN M au f a cturer: SETBACK AMBER INFORMATION TypeO r ( � / i/ Mo er: SystemCoy>,,(6-4 V U OR U DISTRIBUTION SYSTEM Header / Mani f old Distribution Pipe(s)r x Hole Size x Hole Spacing Vent To Air intake Length Dia. � Length 7 5 Dia. a n � Spacing4 A s - r?A 1 .x / S SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over // �_ h Depth Over xx Depth Of xx Seeded /Sodded xx Mulched Bed /Trench Cente(p Bed/ Tren h ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: ST AR PRAIRI 1129 212TH AVENUE[ / __ i � > 1/ 5" ""'mil I S - 72-,C - + 5 +, Plan revision reAuir d. [ s No Use other side for additional information. G( IV SBD -6710 (R.3/97) Date nspedor's nature . Nc f Safety and Buildings Division SANITARY PERMIT APPLICATION 201 E. Washington Ave. Vis In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Department of Commerce Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 vi x 11 inches in size. . e;�P/` • See reverse side for instructions for completing this application State sanitary ermiit � The information you provide may be used by other government agency programs heck if revi� 0 7 previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION - PLEASVPRINT ALL INF RMATION Pro rtyOw rierNa 7m Property Locatio S T , N R E (or /Y � s .� operty Owner's ailing d re .� Lot Number Block Number 7 W ho — City, to Zip Code Phone Number p Subdivis n Na e o Nu ber 11. TYPE OF BUILDING: (check one) ❑ State Owned t / ° v't Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms 7 ° own ofi/"� III. BUILDING USE (If building type is public, check all that apply) arcel Tax Number(s) 1 ❑ Apartment/ Condo 15. 19. SSl D 3J — / /75- 3 400 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. fy1 New 2. E] Replacement 3_ ❑ Replacement of 4. E] Reconnection of 5_ ❑ Repair of an _____System ________System _____________ Tank Only______________ Exi sting 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 Seepage Trench 22 ❑ In- Ground Pressure r 42 ❑ Pit Privy 13 E] Seepage Pit 57 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 16. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) / ; v Elevation S 7,sd Feet 1/,4/" Feet Ca acit VII. TANK in allon Total # of Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con- steel glass Plastic App New Existin structed Tanks Tanks Septic Ta — J El El 1:1 1:1 1:1 Lift Pump Tank /Siphon Chamber El 1:1 ❑ ❑ 1 ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation 94he onsite sewage system shown on the attached plans. PI en's Name: (Print) ._, Plu ber's Sigp m atwe -Mo ps) WWMPRSW No.: Business Phone Number: t/�d lC� u r reet it tate Zip Code): IX. C U T / DEP TMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate sue Issuing / Q nt Si tune (No Stamps) Surcharge Fee) /�_ ) Approved []Owner Given Initial / y ( �c / Adverse Determination X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: SBD -6398 (R.11/96) DisTRtwmox: Original to county, One coq To: Safety 8 Buildings Division, Owner, Plumber DAVE FOGERTY PLUMBING uoMW Pork TW 1 r f ��,ts Rosa ROSE VyISCONSIN 54023 Phone 749 -3656 I L > iio " I I Q W / Sc a �c /•r Yo . v? of s/ v X 3 � O - 2od �� s.T #� ° �j(/tt7f Ldp �GT fi'/CE/�� i n e �fy1 �r/ J, >133' r rJrrrvT ED Ta /Z DAVE FOWTY PL.UNONG Ucensepa�3ark Test lu Pmber OM ROBEft , V CANSIN 5423 Phone 749 -3656 I L i I' i �c B-3 b L x #2 o w�sf /1 17 /9-/Z 67W) C /9 t l r rrvrvs�us,� tET /1�`C'�'j �r�r�awrED �iZ , 4 • Dave Fogerty Plumbing SEWER SYSTEMS & PERK TESTING FOGERTY HEIGHTS ROAD ROBERTS, WISCONSIN 54023 (715) 749 -3656 wil lo e� "t? e s /oyc ,�ld -7 Safety and Buildings Division SANITARY PERMIT APPLICATION Ascons 20 1 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Department of Commerce Madison, WI 53707 -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. • See reverse side for instructions for completing this application State Sanitary Permit er Num 3 o ��3 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 - PLEAM PRINT ALL INF RMATI N Ir.operty Owner Na a Property Location G r r 5 1 w 1 /sue T , N, R p' E (o r6p rty owneerM ailin Add Lot Number Block Number / City_, tate Zip Code Phone Number Subdivision Nam r CSM Nu r II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ Nearest Road Public V 1 or 2 Family Dwelling - No. of bedrooms Town OF III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s 1 ❑ Apartment/ Condo 4 - - 7 y — ,710 --pOo 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. 0 New 2 ❑ Replacement 3 ❑ Replacement of 4_ ❑ Reconnection 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 ❑ Seepage Bed 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 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3_ Absorp. Area 4. Loading Rate 5. Perc. Rate 16. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min./inch) / 16A D 3 , 2. IPA v Feet m.?. Feet VII. TANK Capacity INFORMATION in gallons Total # of Manufacturer's Name Prefab. Site Fiber- Plastic Exper. New Existing Gallons Tanks Concrete Con- Steel glass App. Tanks Tanks structed Septic Tank or Holding Tank 6 �' 1:1 El El ❑ ❑ Lift Pump Tank /Siphon Chamber -- ❑ El El 0 ❑ ❑ Vill. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation the onsite sewage system shown on the attached plans. Plu er's Name: (Print) Plumber's Signature: (N tamps) jWrMPRSW No.: Business Phone Number: ;E // jW 7 P e9r's Address (Street, City, Stat p Code): I d I ,r 5 .t 3 IX. COUNTY/ DEPARTM NT USE ONLY [] Disapproved Sanitary Permit Fee (Includes Groundwater ate slue Issu g gent Signature (No Stamps) pA roved. Surcharge Fee) pp ❑ Owner Given Initial Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- M (R.11/96) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber DAVE TY P LUMO � W SC4NS�o ROBE phone 7443556 L > lie' ,i art", 10 x 4 x �/° x = /ABe,H� o 40 = wad�csct / x FLEA /00. y ' JA 2 70 �l�c vG� rvT E 9 �p /Z Dave Fogerty Plumbing SEWER SYSTEMS & PERK TESTING FOGERTY HEIGHTS ROAD ROBERTS, WISCONSIN 54023 (715) 749 -3656 La Witconsin bor and, Department ti Industry SOIL AND SITE E V A L U N REPORT P � of 3 Labor end, Human Rela age _ Division of safety & Buildings In accord with ILH d de COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inc s ize. PI,Q l incl d ST: 1 C R O • K not limited to vertical and horizontal reference point (BM), dire i n nd Y., of sib �� or �� PARCEL I.D. # dimensioned, north arrow, and location and distance to nears this d. a j I APPLICANT INFORMATION PLEASE PRINT ALL IN ATION ?Gr, REVIEWED BY DATE PROPERTY OW NER: RTY LOCIIQ ki'c h A RD STo U T ' =W Y T /4 s4; 1/4,S 1-'6r T 3� ,N,FI /� E (o Wio PROPERTY OWNER':S MAILING ADDRESS ! SUBD. NAM ,. 1 55 - 3 w , 4 7 v k�> T.P. CITY, STATE ZIP CODE PHONE NU CITY []VILLAGE WN NEAREST ROAD f�U so..� lots, Syol(a (7i5 )s�Fq- 31 j31 r PRhtRtE �y�v Cc (pt<ew Construction Use [ residential / Number of b6drooms 3 + o q () Addition to existing building I ) Replacement ( ) Public or commercial describe Code derived daily flow y ° c[� gpd Recommended design loading rate bed, gDO trench, gpd/(t Absorption area required bed, ft _7 trench, ft Maximum design loading rate 7 bed, gpd/ft _ trench, trench, gpol(t Recommended infiltration surface elevations) SEA j .3 ft (as referred to site plan benchmark) Additional design / site cons rations Parent material SCS I t 60 R 1, A R OT Flood plain elevation, if applicable ft S - Suitable for system coNY.FM M_ U IN S - GRO PRESSURE AT-GRADE S IN FILL HOLDING TANK U = Unsuitable for O U stem as !• $ ©-S 0 U 01 ❑ U 0.5 0 U EIS SOIL DESCRIPTION REPORT 41 I R : NO �PEco�+rL� Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bou dsly Roots GPD /ft In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed tench 13 1 1 0-4 YR 3la as s /f L - �2 �0 Y& 3/c� e4 V y / .>~, �� cs /f 7 Ground -3 ' A; 1 YR 316 �.P y S Q C s 7 elev. /0 "1 . o ft. 10 i /R S/& S. o S cQ - 2 Depth to limiting factor „ I Remarks: Boring # ( lo y e 3 /1- /S /.� s�i,� GP c.S f , 7 Z 2 y - /jL io YR 31y Ground 3 /.a - 3g- /o vR 3 — y O sq d Q- cs 7 . elev. C IO /o YR 5 1& 5. O S � .7 � /&:)L • /D ft. Depth to limiting facto > r n ' Remarks: T Name: — Please Print R d Q t R T 2A L Q R t 1 T- Phone. 71!5�-- 3 Q& _ S 65 Address: /GO - //, - — C�CSTA AT /�� Signature: Ulbricht & A 580clates f+wn�ullenle Date: CST Number: 0 L y w O 0 " o d N p • G y H - v ti � IN O� Q �J N A l l rn • t� u � D f T I ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer .dam 1 -/ . A Mailing Address 7,38' Property Address /1.;L ; � t* Ay • , (Verification required from Planning Department for new construction) Cit 1 tY � �o� ar ;l': -�. Parcel Identification Number 14 3P- LEGAL DESCRIPTION Property Location ,sue %., Xt %4, S /r . T �/ N -R 1 W, Town of 'G Subdivision eA54�t 4!! a - l "l Lot # .13 Certified Survey Map # Volume . Page # Warranty Deed # <- 7 7 99 Z Volume 131 Y . Page # L- f � Spec house Cf yes ❑ no Lot lines identifiable IT yes ❑ no SYSTEM MAINTENANCE Improper use and maintenanceof your septic system could result in its prematumfailure 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 fomr, signed by the owner. and by a masterplumber, joumeymanplumber, 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. 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 stating that your ptic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of n date. S TUBE LI 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 p escnbed a", by virtue of a warranty deed recorded in Register of Deeds Office. NATURE Of APPLI 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 � - / °t e W l i j ,tom x' 4t' t�l N _jj ,.Es iS��O'S 0l:FICE, T "' I ST. CROIX CO., WIS, AC. 1 I W Aemm fm Record till dt( 90 S0. FT. I M L DJi Y.Rewded in CM N o 0 Q I Z Lul p I— I 13 i I r �Dlft _JI I CLI I 1 I 11 N89 I 249.81' 14 T ® y ' 0 N 7 3; .$ CD FT 1 c0 v 0 O N p 5 Z 1 N, IS 11 6 7'27 "W 389.20' T 8 X16\ AC. 9 S0. FT. -------- 21 V / / 3 QJ 288.90, 17 3/33, \`ai', h 18 O�Q /pti / . Z 9 FT. 1 \ �OO ` 19 ^�� � LOT 13 N O �� / a O f/ A ® � ul 1.90 AC. ~ N 'NN 82,937 S0. FT. 3 of e- M L / ° 0 Z LOT 12 N 'N -� P c` 1.74 AC. t� ON T l0 a 75,887 S0. FT. .. �'