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• ST. CROIX COUNTY ZONING DEPARTN%1ti T ~
AS BUILT SANITARY REPORT
Owner j
Address 1 /5'S Z/L
City /State
Legal Description:
Lot 21 Block _Subdivision/CSM #
'V 'V4 Sec. /1 T -LN -RAW, Town of Ics-4 •f me PIN # oZr=
SEPTIC TANK - DOSE CHAMBER -- HOLDING TANK INFORMATION:
Tank manufacturer Size ST/PC /Z60 / 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: 4e-P Width / 8' Length yV' Number of Trenches
Setback from: Mouse _ Well 7 5-6 P/L 7 S Vent to fresh air intake
ELEVATIONS
Description of benchmark 1i� S \
Elevation
Description of alternate benchinarg Elevation
Building Sewer ST/HT Inlet /02.0 3 ST Outlet /D /, PC Inlet
PC Bottom Header/Manifold Top of ST/PC Manhole Cover /C 3- S 7
Distribution Lines
Bottom of System
Final Grade
Date of installation y /761 permiLtAnumber d 7 6 , S - Y State plan number
Plumber's si na ur // License number /ll / Date `1 / B/ W8 -
Inspector Ll' 61 �
Complete plot plan R
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County:
Safety and Buildings Division INSPECTION REPORT ST. CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar
Personal information you provice may be used for secondary purposes [Privacy L , s.15.04 (1)(m)].
���iiN,gl�{Qis N�r�,�, City.,.❑ yjJlAge T�gwn of: State Plan ID No.:
CST BM Nev.: Insp. BM Elev.: BM Description: 1EEiittCC YYttcCt�� Parcel In V-;-1175
(0- <> / — Te v won «_ U3
TANK INFORMATION LEVATION DATA A9800043
TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV.
)Z,o a Benchmar v
�j,Z /C>0
Dosing
Aeration Bldg. Sewer
Holding Q6D>A1nlet 3 17� to7-
TANK SETBACK INFORMATION I� } i e � W outlet ?j. �1S lot-
TANKTO P/L WELL BLDG. Air Intake ROAD Dt Inlet
Septic Cp�'j
1 90' NA Dt Bottom
Dosing NA Header / Man.
Aeratio NA Dist. Pipe 7 L. I' 97 S`j
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade 5- 1 5' / too 05
Manufacturer Demand 4.2-5 / 03 97
Model Num GPM
TDH Lift Lriction SY TDH Ft
Forcemain Length -Bi- H Dist. To Welf
SOIL ABSORPTION SYSTEM PIT E RENCH Width 1 �! Length No. Of Trenches DIMEN I N f Pits de Dia. iquid Depth
DIMENSIONS 1 Manu ac e.
SYSTEM TO P / L BLDG WELL LAKE / STRE M LEACHING
SETBACK CHAMBER Num er:
INFORMATION Type O � 150 h J /_
System
DISTRIBUTION SYSTEM
Header / Manifold Distribution Pipe(s)
I Distri� , x Hole Size x Hole Spacing Vent To r Int1ke
' Spacing _( ( ,St •�n 2 1 7®
Length Dia. Length � Dia.
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over i� Depth Over Ix ed / S -
2
Yes No No ❑ Yes ❑ No
Bed /Trench Center 1 i Bed /Trench Edges $tea
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: STAR PRAIRIE 15.31.18,NW,SW 1145 212TH AVENUE t
4b6 n_ j r,
Z) q 0
l
A14- F�-M — T O� p L SC Pty L �4AA. kC Law l 7 6 /
4. �5aI0UI f. cr ( Ilrl I VI 5�
Plan revision required? ❑ Yes [] No 7 c
Use other side for additional information. G
SBD -6710 (R.3/97)
Date Inspector's Signature ert.
'
Safety and Buildings Division
SANITARY PERMIT APPLICATION 20 E. Washington Ave.
10 6cons i n 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 Coun
than 8 1/2 x 11 inches in size. S I.
• See reverse side for instructions for completing this application State Sanitary Permit Number
3 of osz/
The information you provide may be used by other government agency programs ❑ Check it revision to previous application
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION
Prope r Na Property Location
rt w 15
�M11143W 1/4,S IV T , N R E (or)�
Prope O er's Mailing A dress Lot Nu { r Block Number
2 8' ac
City to Zip Code Phone Number Subdivision a e or CSM umber
(� S/7 Z (, o/Y - 133 38 /r
I1. TY E B IL ING: (check one) E] State V l State Owned o Nearest Road �� tl_ v
age
Public qn 1 or 2 Family Dwelling - No. of bedrooms R Town OFSTm1 !`a
111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo OZ — // 7
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. g 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 R) 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 6. System Elev. 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation
D o 13� , '7 /6 7 Feet fGYJ. Feet
Capacit VII. TANK in allon Total # of Prefab. Site Fiber- Exper.
INFORMATION g Gallons Tanks manufacturer's Name Concrete Con- Steel glass Plastic App
New Existing strutted
Tanks Tanks
Septic Tank ! Zoo JZ a ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plpp;r ' , P rint Plum s Sig ture: ( o S a ps) MP /MPPRSW No.: 1 )/51. Business Phone Number:
/ , 7 5J�T6 .74 I' • C 1 ) 9' S
Plumber's Address (Str et, City, State, Zip Code):
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate slue Issuing Agent Signature (No Stamps)
Surcharge Fee)
Approved ❑ Owner Given Initial c y4� 7 C q 6 Lod
Adverse Determination Od
X. CONDITIONS OF APPROVAL / REASONS FOK DISAPPROVAL:
SBD-6M (R.11/96) DISTRIBUTION: Original to County. One copy To: Safety 6 Buildings Division, Owner. Plumber
I �
ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
✓'� w..
_ __ , , �• Hudson, WI 54016 -7710
- (715) 386 -4680
May 26, 1998
Jeff Geitner
1145 212th Ave.
Star Prairie, WI 54026
RE: Lot 21, Apple River Bend Addition
Legal NW 1 /, SW 1 /, Sec. 15, T31N -R18W, Town of Star Prairie,
St. Croix County, Wisconsin
Dear Mr. Geitner:
I recently observed your property from an adjoining lot during a
septic inspection in the Apple River Bend subdivision. I'm
specifically concerned about the construction of the volleyball
court over your drain field. The construction of the volleyball
court over the drain field may be detrimental to life expectancy of
the system. Compacting the soil beneath the surface could effect
the infiltration ability of the soil. In addition, it appeared
that the post to hold the net was dug into the system. This
excavation could cause damage to the distribution network in the
system.
To prolong the life of your septic system I recommend relocating
your volleyball court. I have enclosed a copy of the as -built for
the septic system, please use this as a guide to relocate your
volleyball court elsewhere on your property. After removing the
volleyball court, establish this area with grass as soon as
possible.
Please call if you have any questions regarding this matter.
Sincerely,
Rod Zi n err
Assistant Zoning Administrator
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'. La bo r and Department ti ons Indus", AND SITE EVALUATION REPORT Page Of 3
L abo r end Human Rela Division of safety A Buildings in accord with ILHR 83.05, Wis. Ad
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan ude4lt
not limited to vertical and horizontal reference point (BM), direction and % of s ale or i ,'_ "���� PAR
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION L DATE
�REVIE Y
T
PROPERTY OWNER: P
;V /C h A RD 5 V 7— G G 1 1 T �� ,N,R /9
PROPERTY OWN R':S MAILING ADDRESS
i
53_3 I w.4 7"0 A-�C LQT t o kiv��° l3�•��z,
CITY, STATE ZIP CODE PHONE NUMBER ILLAG NEAREST ROAD
Sow PRA 1F1E'.,,
Construction Use 14 I Number of b6drooms 3 +C 4 Addition lo existing build - Ing
(� Replacement Public or commercial describe Zt , , /g t to w
Code derived daily flow T - gpd Recommended design loading rate 7 bed, gpolA • trench, gpolR '
Absorption area required bed, 11 7y trench, 11 Maximum design loading rate 7 bed, gpdRl • ? trench, gpd/4
Recommended Infiltration surface elevalion(s) SEA }0. ft (as referred to site plan benchmark)
Additional design / site consjdqtaflons
Parent material SCS 11 /3y ,�,��, ,q� p Flood plain elevation, if applicable
1t
P U = Unsuitable for stem 3'S Suitable for System u0 U L MOIL U IN_ 0'$ �tM ESSURE E AT� F�BE SYSQ [Ell S q�p TMA( = Ltd$ 9,S ❑ U
SOIL 1)ESCRIPT10N RPORT N�� = /V T / �PEcoHr�,vf�Ef�
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Y Roots GPD /ft
In. Munseil Qu. Sz. Cont Color Gr. Sz. Sh. Bed Tlench
z 3z /oyR 3/3 l ? 'U'4 x1X- , 7
Ground 3 /0 e s. o S �,e — — . 7 g
Lieu.
/a0 , � tt.
Depth to
limiting
factor
n
? f - a - L —
Remarks:
Boring #
/ 99 /09 2 /3 — /s /,m ,e s /f .7-
. 8
�'..... �l Zo /o rP 3 3 /s / ,P /* f c� lvf , 7 g
:.:..nd 3 0 . 3 /0 31 � S/ IfsA.e � �,2 Cs . • s
Ground
elev.
100. 3( ft. - 7 S' R - s �f �� �ls �s s
Depth to yr�
li mi ting ( p - S� S . �, S i '7 8
factor
>—
Remarks:
ST Name: — Please Print R d B t R r V L Q R i'C I^ 7 — Phone: 71S
Address: 'J C �
Signature: r c ✓' _ '/1 Y�P CSTA
,. Dale: CST Number:
- ��l /_ _ p.twta sewaes Consultants
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FEB -27 -98 FRI 16:09 HALLE BUILDERS 2462034 P.03
STC -105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNF•RBUYER
MAILING ADD S J .;'.L
PROPERTY ADDRESS
(location of septic system) Please obtain from tKe Planning Dept.
CITY /STATE
ICY
PROPERTY LOCATION_ 1/4 1/4, Section 3 T �l N -R l0 W
TOWN OF ST. CROIX COUNTY, WI
SUBDIVISION tip- LOT NUMBER 2
CERTIFIED SURVEY MA1P. - 7 3 6 S 3, VOLUME [J, PAGE 2 Z 3 , LOT NUMBER 21
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 licensed septic tank pumper. What you put into the system can affect the function of the septic tank
as a treatment stage in the waste disposal system.
St. Croix County residents may be eligible to receive a grant for a maximum of 60 of the cost
of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that owners of all new systems agree to
keep their system properly maintained.
The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner
and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1)
the on -site wastewater disposal system is in proper operating condition and (2) after inspection and
pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum.
I/We, the undersigned have read the above requirements and agree to maintain the private sewage
disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR.
Certification stating that your septic has been maintained must be completed and turned to the St. Croix
County Zoning Officer within 30 days of the three y n date.
SIGNED: /�"
DATE: ✓ ��
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
,FEE -27-98 FRI 15:08 HALLE BUILDERS 2462034 F•
S T C - 100
This application form is to be completed in full and signed by the
owner(s) of the pro erty being developed. Any inadequacies will
only result in de
ay of the permit issuance. Should this
development be intended for resale by owner /contractor, (spec
house), then a second form should be retained and completed when
the property is sold and submitted to this office with the
appropriate deed recording.
----------------------------- -----------------------------------
Owner of property L,21Z
Location of prope t 1 /4 J�c/ 1/4, Section - RJ?
Township5%G_ /. a4 Mailing address z
S' < 7 z.
Address of site � 5 � Q l
Subdivision name Lot no.
other homes on prop rty? es No
Previous owner of property
Total size of property
Total size of parcel 1, u✓�
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house) ? Yes G� . No
Volume and Page Number as recorded with the Register
of Deeds.
------------------- ----------------------------------------------
INCLUDE VITH THIS APPLICATION THE FOLLOWING:
A WARRANTY•:DEED whi h includes a DOCUMENT NUMBER, VOLUME AND PAGE
NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a
certified survey, if available, would be helpful so as to avoid
delays of the reviewing process. If the deed description
references to a Certified Survey Map, the Certified Survey Map
shall also be required.
P ROPERTY OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the
best of my (our) knowledge that I (we) am (are) the owner(s) of the
property described in this information form, by virtue of a
warranty deed recorded in the office of the County Register of
Deeds as Document N). , and that I (we) presently
own the proposed s to for the sewage disposal system or I (we)
obtained an easement, to run the above described property, for the
construction of said system, and the same has been duly recorded in
the office of the C unty Register of Deeds as Document No.
Si n App cant ��� /�� Co- Applicant
FROM :EDINR REALTY HUDSON 19_ .01 -21 17:10 #100 P.02 /0S
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