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HomeMy WebLinkAbout038-1179-80-000 a o ! } § o_ § k o 0 \ ; � § � ¢ � � 2 � % } 2 { � a � . \ � . � z k 2 Cl) 7 a ■ ! q � ) § + C \ U) / k k ] ) E N M \ ƒ { � k 2 : E $ \ \ # k / le $ ) 2 5 I ® m E � k �$ • _ ■ CL ° o k IL a) /m 0 k IL� \ " 0 a a n ) 2 ' k 0 B ) § § m Q o c m p (c�' j ƒ 0 0 6 'm o o « ° § 2 n \ _ / \ ƒ 6 § _ i $ ) cl ( S / \ § o n / \ \ \ 0 _ ) 0 CL C a \ § § ■ — I ° g / 2 & § a) ® » - k \\ \) \ 0 a f i 2 2 2 •• � © ® � L ( C _— \ E )) k a § c oIL 2 2 ST. CROIX COUNTY ZONING DEPARTi�ii t'I'.' '', AS BUILT SANITARY REPORT' Owner IOAQEL - Tklytr 1`fALL Address 0 /y8 42 City /State AEv✓ 1cqx 5 0i7 Legal Description: c Lot 29 Block Subdivision/CSM # A ifLE ie wE2 �E,vD ✓o ��, Al t k � /. Ste Sec. /S , T 31 N_R /8 W� Town of 57mP E PIN # 038-1179 � SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer WEEKS Size ST/PC / 260 / -- Setback from: House 2E' Well l WW /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: )AzWc -1 Width E ' Length 80 Number of Trenches 2 Setback from: House icy ' Well — PAL 30' Vent to fresh air intake - 100 ELEVATIONS Description of benchmark Elevation ioo Description of alternate benchmark I i d 5 ;,/}T T-� / Elevation 98.96 1 763 q g8.Y9 Tr Building Sewer 3, 30 ST/H'T Inle ' ST OutlpC Inlet PC Bottom Header/Manifold 75 � t p of ST/PC Manhole Cover Distribution Lines () (o, �4S `3 S• 3 y ( ) ( ) Bottom of System Final Grade Date of installation lit number 3/Sg State plan number Plumber's signature License number Date Inspector ' ' Complete plot plan a aisin Department Commerce Safety PRIVATE SEWAGE SYSTEM Count Safety and Buildings Division y: INSPECTION REPORT ST. CROIX GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar Permit No.: Personal information you provice may be used for secondary purposes [Privacy La s.15.04 (1)(m)). 315834 Permit Holder's Name: ❑ Cit �7 villa e Town of: State Plan ID No.: HALL, DAREL & TRISH STAR PR IE CST BM Elev... Insp. BM Elev.: BM Description: Parcel Tax No.: 038 - 1179 -80 -000 TANK INFORMATION ELEVATION DATA A9800223 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic ��n Benchmark h �. Dosi ng D Qtin� a 3" i Aeration Bldg. Sewer Holdi St /Inlet TANK SETBACK INFORMATION St/ Outlet TANK TO P/ L WELL BLDG. vent to ROAD Dt Inlet Air Intake Septic NA Dt Bottom Dosing NA Header_ Aeration NA Dist. Pipe s Holdin Bot. System -� 7 PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH I Lift Friction System TDH Ft H Forcemain Length Dia. Dist. To well SOIL ABSORPTION SYSTEM BED / TRENCH Width ) Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS �S N I N SYSTEM TO P/L BLDG WELL LAKE /STREAM Manufact u. SETBACK INFORMATION Type O r) u, M C R Model u System: 4 re ' � -�— OR UNIT ►� DISTRIBUTION SYSTEM Header Distribution Pi s i/ on P e l) /i x Hole Size x Hole Spacin ent To Air Intake Length Dia. Length Dia. � Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Gra ystems 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.) LOCATION: ST PRAIR 15.31.18,NW,SW 114 212TH AVENUE l_! p,�; 4 ^�„[.�.'Y►1A�- ������� r..<_ CU`"� C�� .S, C.sr), � �� -e� / - j / !�' / •�-- `r.���� ^� •- � rte, �-►-� ?^�� " Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. SANITARY PERMIT APPLICATION 20 Safety and 1 E. Washingto Division 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. - ST • See reverse side for instructions for completing this application State Sanitary Permit Num er 1516, 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 - PLEASE PRINT ALL INF RMATION Property Owner Name Pr perty Location D ,�. V/4 V 1/4, S T& , N, R 1 0 E (or)(D Property Owner's Mailing Mai ing Address Lot N inter Block Number gff City, State Zip Code Phone Number Subdiv Na or CSM Number ILL 1n W 1 5 5 ( > PP1F I V ✓ E OF BUILDING: (check one) ❑ State Owned E] ity Nearest Road Public 1 or 2 Family Dwelling - No_ of bedrooms ° V own o R All HZIE lip a–ri.. 111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) d 3� 1 ❑ Apartment/ Condo // 7p -s0 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. XNew 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 eepage Trench 22 E] In-Ground Pressure , 42 E] Pit Privy 13 Seepage Pit a" 5 x75 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate S. Perc. Rate Syystem Elev. 7. Final Grade // ,,� Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) T, q pp Elevation 6 0 '7Sp �^— J I Feet Feet VII. TANK Capacity in gallons Total # of Prefab. Site Fiber- Ex er. INFORMATION Gallons Tanks Manufacturers Name Concrete Con Steel Plastic p New Existin structed glass App. Tanks Tanks Xs 11 El 0 1:1 El Lift Pump Tank /Siphon Chamber 1 ❑ 1 ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's S (No S amps) MP/ Business Phone Number: P mber's Address (Street, City, State, Zip Code): 9 ,D E E2 IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater =; Issu g A ent Sig ature (No Stamps) Approved ❑ Owner Given Initial ( Surcharge Fee) Adverse Determination ! vU X. CONDITIONS OF APPROVAL / REASONS FOR ISAPPROVAL: S8D-6398 (8.11/96) DISTRIBUTION: original to County, One copy To: Safety i Buildings Division, Owner, Muosber c �' W 4 LA I N DD � a v fi W 0 0 b c N �\ CA 0 w b Cfl IN _;O -d • Wisconsin Department of Industry of pa SOIL AND SITE EVALUATION l r , ge / 3 Labor and Human Relations i , l � ` Division of safety A Buildings in accord with ILHR 83.05, Wis. e Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan ltncludeS,t not limited to vertical and horizontal reference point (SM), direction and % of s i cale or PARCE r dimensioned, north arrow, and location and distance to nearest road. ~ i ` 1 + APPLICANT INFORMATION PLEASE PRINT ALL INFORMATION R IE DAT PROPERTY OWNER: n,r• `� ` PRO W ;r - FIc�: �i G ti A RD STOUT GOV 114 S - ;8 r 3/ ,N,R �� E (o Wi� PROPERTY OWNER':S MAILING ADDRESS lOT B OR CSM it 135'3 1 4 w,4 7 TAP. CITY, STATE ZIP CODE �� � •'"� � �� U�ii? /,�E�j'?„ �S PHONE NUMBER OCITY []VILLAGE W NEAREST ROAD if Sow 5 yar� (�i5) s�f4 731 5T'.4 PRht�1E .` /yw CC (ptfew Construction Use [ residential / Number of b6drooms 3 + [ ] Addition b existing building (] Replacement [) Public or commercial describe Code derived daily Bow 'to 00 gpd Recommended design loading rate � � bed, gpd/ft � trench, gpd/ t Absorption area required K k bed, 112 7✓ trench, 112 Maximum design loading rate 7 bed, gpolft trench, gpdht Recommended infiltration surface elevation(s) SEA } . 3 it (as referred to site plan benchmark) Additional design / site cons ons Parent material $CS I 1 rati C,4,e f-K pv ,,, / Flood plain elevation, if applicable It IN - c t�'S l] U L S = Suitable for system MOUt� ❑ U G R D 1 PRESSURE I DE U SYS_ TEW IN FILL O S ING TAW U = Unsuitable for system [a-� F 9 .� SOIL DESCRIPTION REPORT 111 1lec = N RCe0Af11E vV&L> Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Roots GPD /ft in. M tench /... u sell Qu. Sz. Cont Color Gr. Sz. Sh. Bed n Y /o V/e 3/3 A / V-Fe cs z f .7 • z io y y 9�A �„ S o, s Ale c s _ Ground 0 /0 �C2 S . 6 � — . elev. y 9-Y� ft. Depth to limiting fac tor ff 7 Remarks: Boring # ... 1 0-1/ 100 313 -k-v'YC.e s Zt .� • f3 /0 Yle 36 Ground " O 7.5 fl& elev. Y �,_ It. Depth to limiting factor q Remarks: T — Name:—Please Print P C Q E R T V L Q R i'C T phone. 71s 38� Address: -,57-f( Signature: _ r c ht ik AU fates Date: CST Number: w a � _ � 1 y ti 0 c h� o T s • O � n zz .;> r w m n °u fr w ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer VA Re I 4 %2 i s k /7A 1 Mailing Address j09 E'/ ;zA Property Address ((Verification required from Planning Department for new construction) C City /State AEW PleAftWn ��,JJ Parcel Identification Number 65$ -1177- 20 -000 LEGAL DESCRI Property Location AI tom! ' /4, 5&J '/,, Sec. 14 T - 11 N -R_ j W, Town of 5�`AR Pita It Rip, Subdivision �n /p �; �pQ �e��J , Lot # Certified Survey Map # , Volume , Page # Warranty Deed # , Volume , Page # Spec house ❑ yes 9 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 masterplumber, 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. SIGNATURE 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 property described above, by virtue of a warranty deed recorded in Register of Deeds Office. SIGNATURE 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 � 0,, %98 15 :40 FAX 1 715 247 3622 RENAXTEAMIREALTY cool JA ju •11 ^ :�,: '= :` -�'�y ::1:..: : -: i ' T - °• - . � .. '• .. : �r�. ,1, " ! , :! r:a •. - .'`.*`a'�`�"` "'' -'' '�':r,, • .. .y t.• ,•� // 'i . � � t f1 ; :,',:: .f;: : .�� { " �' {: �; � J� '.�ir:'r 1'! /.~.•'.'•.' r. -:�'• - ::11 i - i {.• - .� J .. r . "1.�•� �"1•:r- } %.!w" • +.Y .. , . - •., • ' _ • ... X89' =��'u � ` 161 S- '- :'••_' ti. 294 Utz .LOT 2 7 ' �.f 1 + r9 AC' r AC c_At• E 76,�e6 SO. FY. r f, LOT -•T 39 -E S iT. Ill) . .11)z .11)z Z 28 •; • C. ESwT .f: LOT � • FT ►� Z.Ot � 3 90. 042 `o- FT- 1 n 0 2.06 AC. En =. £Sn►T � SO. f'f. j OT L 411.46 r• .n` N �g'y'3ZE . 1 ''" r g AC L O T � yl • 'y 1 � . 1 `, � 3�9.s , j . 2 • 1 gy2 "� fl Soo •1 LOT 3 f 67 &C. LOT 30 It IS A*