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HomeMy WebLinkAbout038-1179-10-000 ` - O O o a> o 0 x •� I p ° I a ~ y = o I N, o , l i O z a z c `1 c a I Q I a� co U) ° _ L n M i a CO � z G O C b O z :!t c U o N p a) F- ,* ° F- z E -o I °� a) 0 m m I n m v I . N (D o 0 s o 0 @ N i Q i! � O w o O z m - N 'a (D Ln .. N m L 0 0 0 d U N N °` t H F H �.- w o o It It Q N II I E0 0 0 0 a m z o o N a z •• ' ° N au fA J V > rn rn } (O C,4 $= O O O r- 0 N 0 0 - N N O O .� "t1 E O r7 N d . to aJ O CD . o ►� c 0 3 o c O O 0 L) M (O o o a) ca n o 0 0 0 0 0 L �� m m N 0 M O N_ C N 3 r N W W in O O *0 r c C a 7 N • � @ O 0 O (n O O U O C/) M O z NC� w fn it `m m a a L D w • ci Q .2 ° E u c c ° r A o 0. E 1 0 ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT Owner Address City /State % Legal Description: Lot Block ` Subdivision/CSM # / /•J Sec:,, 'N_�r W� Town of PIN # ��- SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer �40- Si Pump manufacturer Size ST/PC Setback from: House � Well PAL r Model p/ 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: C � • Width 1 0 2 Length Number of Trenche Setback from: House 2r Well t p/L Vent to fresh air intake x_7:5 ELEVATIONS: Description of benchmark o �C Elevation Description of alternate benchmark ��� �r Elevation Building Sewer ST/HT Inlet 1o `f /ST Outlet 7 r PC Inlet PC Bottom Header/Manifold fo 3 Top of ST/PC Manhole Cover O 6r -7 , , 5r — Distribution Lines Bottom of System Final Grade Date of installation S5 // -2/ permit number 2 7 / State plan number Plumber's signature License number 3 .3 1 Dated /k) I Y Inspector Complete plot plan Or Safety and Buildings Division VL consin SANITARY PERMIT APPLICATION 201 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 1/2 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Number 3o `77/ — The information you provide may be used by other government agency programs E] Check it revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION Propert y Owner am Propert Location — N W1 /4ZW 1/4, S j!S T'S , N, R J E (or nW Prope � ner's Mailing Lot Number Block Number % G Z 7 0 A Q_ � Ci , State ^ r Zip Code Phone Numb r Subdivision Na a or CSM Number kjQ I 14 /) ( I) 1 ; II. TYPE OF BUILDING: (check one) ❑ State Owned 0 C Nearest Road Public .1 or 2 Family Dwelling No_ of bedrooms Ej row OF c ,, F� -_�_A AL,�,_ C_ C, III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 2 1 ❑ Apartment/ Condo J �^ j /6-00o 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 online B, if applicable) A) 1.ONew 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 Seepage Trench 22 ❑ In- Ground Pressure , 42 ❑ Pit Privy 13 E] Seepage Pit — I2 - 72 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 Re red (s . ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) J Elevation 6 d `� ,�) q fi 6 / Feet ,3, .7 Feet VII. TANK Capacity in gallons Total # of Prefab. Site Fiber- plastic Exper_ INFORMATION New Existin Gallons Tanks Manufacturers Name Concrete Con- Steel glass App. structed Tanks[ Tanks � eritotdRfJTank � 1 ,200 J iG! ❑ ❑ ❑ ❑ ❑ Lift Pump Tauk /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation oft . bq onsite sewage system shown on the attached plans. Plumb is Name: (Print) Plumber' g t=(NoSt rMf7if yV No.: Business Phone Number: — 6 P ZZ � er's Address �Strggt, Cit ,State, Zip C e): , X 1 IX. COUNTY / DEPARTMENT USE O Y /vJ/ E] Disapproved Sanitary Permit iF �(includesGroundwater at Issued Issui Signature (No Stamps) Appro [:]Owner Given Initial J ved Surcharge Fee) �D C�� Adverse Determination / X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: 4 k-af s�vk vm n&XA t�-" 5' 4 a t/4d 4 sa K l oa w► (s -, c�) vl o �1 �o v► Loot ( r SBD-6M (R.11/96) DISTRIBUTION: original to County. One copy To: Safety i Buildings Division, Owner, Plumber Vy isconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count Safety and Buildings Division INSPECTION REPORT County: . CROIX GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary,Puly1ylo.: Personal information you provice may be used for secondary purposes [Privacy La , s.15.04 (1)(m)]. S U Permit Holder's Name: ❑ n of: State Plan ID No.: MONTGOMERY, TODD S`A Wxi CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tff ft-. -1179- 10-000 100 100 1 7 - p �� 5�cva TANK INFORMATION ELEVATION DATA A9800101 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic �CG S l p Benchmar Dosing Aeration Bldg. ewer g� l� - 2 - L4 l l6 -6 Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Air �ake ROAD Dt Inlet ,- Sept 6L 3, - . J NA Dt Bottom Dosing NA Header/ Man. n� 13 7 Z S•a5 Ifl? Aeration NA Dist. Pipe o � , G.i /oz.7 Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade q o 0 /off o S Manufacturer mand A L - F Model N GPM TDH ft Fricti System TDH Ft Forcemain Length Dia. I f Dist. To well SOIL ABSORPTION SYSTEM ED /TRENCH Width i No. Of Trenches PIT No. Of Pits Inside Dia. Li d Depth DIMENSIONS t Z — DIMENSION SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEAC141ING Manufact INFORMATION Type Of CHAMBE � -ha I �I' o e Number: System �4 h-J � l Zc� � OR UNIT DISTRIBUTION SYSTEM Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length 6" Dia. length _7j Dia. Spacing �� '&STIV\ Sc 'L ZP I 0c)/ SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over „ 1 Depth Over xx Depth Of xx See So dde d Bed/Tr nch Center Bed /Trench Edges Topso ❑Yes ❑ No ❑Yes ❑ No COMMENTS (Include code discrepancies, persons present, etc.) LOCATION $TAk P RAIRIE 15.31.18,NW,SW 1147 212TH AVENUE \ 1)53s+e.� va's'In�I(ec I& P> 2-1 P> ids Z) fib w( 1 a 4 I ^-Spce -fj / ,, 3) lop o� sg4z, ww �c cove -e l irp(� 121°► j � S�s was 1 As.. \l -d * iK R, Z' ,13q, � Plan revision r 5 mired? © No Use other side for additional information. S I ty °18 Oc� s � / SBD -6710 (R.3/97) Date Inspe 's Signature ert No. PLOT PLAN PROJECT Todd Montaomery ADDRESS 912 170th Ave New Richmond Wi 54017 NW 1/4 SW' 1 /4S 15 /T 1 N/R 18 W TOWN Star Prairie COUNTY St. Croix MPRS Shaun Bird 3532 DATE4/15/98 BEDROOM 4 CONVENTIONAL XXX IN- GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1200 Gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 858 BED SIZE 12'X 72' BENCHMARK V.R.P. Top of 1" IP ASSUME ELEVATION 100' ❑ BOREHOLE O WELL IH.R.P. Same as Benchmark VENT SYSTEM ELEVATION 101.85 12" GRADE M VERING T 12" 3' K 339' Property Line 54' M. 3 ' 20' 70' B -2 32' 25' _ T 04 I Bedroom 136' House 50' I I Property 12' X 72' Bed I 100' Line I II (n B -5 o — I Vent 0 a o B -4 B -3 n 0 0 f7 n Wisc D ertmen t of a a bons In dustry, SOIL AND SITE EVALUATION REPORT P / of 3 • labor a nd H Rel 8Qe Division or safety a Buildings in accord with ILHR 83.05, W' . ' COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in siz st i ude, but /�� ST C R o (' X not limited to vertical and horizontal reference point (SM), direction and o lop RARCEL I.D. A dmensioned, north arrow, and location and distance to nearest road. CM0 APPLICANT INFORMATION- PLEASE PRINT ALL INFORMA L ,' REVIEWED BY DATE PROPERTY OWNER: PROPEMV TION /�G k /4 RD STOUT OVT rr - /4 � 1 /4,S /5 T 3/ ,N,R / E (o Wi� PROPERTY OWNER':S MAILING ADDRESS BLOCK k100 OR CSM A 1 353 1 4 w.4 TO )e�� T,P, ;-, : \ ;. X illE j3E�c.'Di CITY, STATE ZIP CODE PHONE NUMBER C - ROAD 5yor� (��5)5�fq-�731 P..Rht IE r EAREST S'�vy. cc (pt' ew Construction Use 14- tesidential / Number of b6drooms 3 to q [) Addition to existing building [) Replacement [ �p /d �p�,� �� _ - �� Code derived daily flow y� ov gpd Recommended design loading rate � bed, gpdNt gpd/(t Absorption area required _NA bed, ft trench, ft Maximum design loading rate bed, gpd/ft2 • F trench, MM Recommended infiltration surface elevation(s) SEA .3 ft (as referred to site plan benchmark) Additional design / site cons rations Parent material 9CS 11 13iVRk' l A - R P T Flood plain elevation, if applicable ft S = Suitable l e system coNyyENNTIO U Evs MOUN ❑ U IN �goHlvD U ESSURE AT_G9d DE U sYS_ T�AI�IN FILL HOLD ING TAN!( U = Unsuitable for system S O U [�S Ly'S Lam} $ t8• '$ 11 SOIL DESCRIPTION REPORT 'V//e::: Na% ,PEccH/��Nf�Ef� Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boun ty Roots GPD /f{ In. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed ITIench /o YR zi z — 51 17' .►M fo cs L F S y 4� -17 /o yR 313 .51 2 FSbk fie 475 /v1 . s c, Ground 3 171 7.5 yR S . �, S �� 7 8 elev. /03� ft. Depth to limiting factor Remarks: Boring # Z....... y 38 to /R y' /S / yie ,►.� � e4o _ _7 1 . 61 Ground 3 ��' 7 S y� 5 3 l2 /Co $� ��S`Je y elev. ev &rT 1 ft. Depth to limiting facto if Remarks: ARt A— of 13 2- S//$ 7 • T Name: — Please Print R n 6 e R T V L Q R 716S i k 'r phone. 7i F Address: 1/9 Signature_ Ulbricht & ASSOCIates Date: CST Number: Detusto Qnwaea Consultants Lot M3 ) 13M. 1` ' 7 or- 5 vRvFYo,e z-,o /0 O.,0 � 339 -- � �.p G j 2 2. y3 , L 51 -7 0 9a. f �5 � 3 0 /p0 . 2S 8 W ' A'REA- o t c (3 i 'f3 3 - g) ,5 i 10 3 . 3 y J fit► f3,)- 10 Io7.75 v S �/S • �.l E V h t-to4 � �J3 10-3. 95 , (3 y l os• y o T12EAj Ct �s I o s4 s Ia IReAjq,., X5. 550 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer YO Mailing Address Property Address ���; cV1, (Verification required from Planning Department for new construction) City /State t't� ` C.1 arcel Identification Number d 3 6 ' / 171 o LEGAL DESCRIPTION 1 Prope rty Location &� /4, ` '/4, Sec. N -RjjW, Town of Subdivision _� FO Q /e , Lot # Certified Survey Map # Plee�' , Volume , Page # Warranty Deed # -�— 7 -2 °2 ` Volume l J Pa e # ✓ > g Spec house ❑ yes 1� no Lot lines identifiable ) ❑ 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. SI NATURE OF APPtICANT 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 described above, by virtue of a warranty deed recorded in Register of Deeds Office. 1 / � / CI iff g idNATURE OF APPL WANT 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 RIVER BEND FIJT ADDITION iE SW114, PART OF THE SWI/4 OF T}-'E SWI14, PAR r OF THE SE! /4 OF THE SWI14, PART OF THE THE NWV4 OF THE SEV4 ALL IN SECTION 15, T31N, R18W, TOWN OF STAR PRAIRIE, an ;.(Ctl :3 !101 31P !PtAtl :1 to $tvq, cju�ty 164 %stiall m. w•9 ;. fqu:Atl It e.. wt"e;, 2"1 lot "t, ir:tss to petrel, itcA, atfite pit*tGAI tf 16WRIOPICI &AT pifttl Mfitt ttt it 00 0 1t -t.,1 aid spi.pt:l't :111 tetra tat Utict, — 7TZ7- V L —tr Ac 0- t -06 *.L -AC ullow T• E 20A0 MG 9 -01 ta il wjSr ij4 upC J 64- 0,1 2646 v ')S4 a I ;y t I � �. LOT! 27 LOT 26 I.W11 &c. 14 SQ. rf. &C i,'S, 231 so v r. aI AC lt�%L. fS.r ,-. ma; so." 1p &C p i-;"r P0811 doll. me VT L.0 "r A b - 14� T, LOT 28 I is YAC 2.0? ac• , 93, far go, FT. -5 90.042 20. FT. 1 7z Lz- 2.06 &C. Ex-- CS-T A H. rfig so. OT. "as' V WE LOT 24 p I a, LOT 2'9, 7 r 8 r r 7 tn� + 9�0 ,(� � ` a p �� 0 ft 44 ut L OT 2 /f OT 2 1 4c. 74.401 $0 FT 1.311 AC EIC ES-dr A LOT 30 ( g•f <,> % / �� °e