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HomeMy WebLinkAbout038-1179-90-000 S '1'. CROIX COUN 'I - Y ZONING DI 1'AlU'MEN'i' AS BUILT SANITARY REPORT ✓ p r ,� Owner RAE l Address r' City /State - 1998 _y ZON •. Legal Description: FlC6 OCT Lot �_ Block Subdivision/CSM II ! -� '�� ,[�. '�• sJ ,Sec. ,, TAN- R,/LW, Town of PIN It - SEPTIC TANK — DOSE CHAMBER — FOLDING TANK INFORMATION: Tank manufacturer Size ST/PC / 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: ,o zcA Wid ,L Length _ /.sue Number of Trenches Setback from: House Well P/L Z Vent to fresh air intake ELEVATIONS Description of benchmark = Elevation Description of alternate benchmark Elevation , Building Sewer Z,24 ST/HT Inlet ST Outlet-- L� Z2S­_ PC Inlet PC Bottom Header/Manifold 1,o4, 77 Top of SUPC Manhole Cover Distribution Lines Bottom of System Final Grade ( ) /�R s - Z/ ( ) ( ) Date of installation / / P mit nun cr y!/ State plan number Plumber's signature License number : ,2,2 �1 4 1 , "' Date Inspector ( omplcic plot plan •� NOTICE: Please provide the following: • A plan view sketch showing everything within 100 feet of the system. • Two horizontal reference points to center of septic tank manhole cover. • Show alternate benchmark, if applicable. PLAN VIEW 33 f��yprc e N ��-so �s �KS � INDICATE NORTH ARROW Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM y: Safety and Buildings Division Count INSPECTION REPORT ST. CROIX GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No: Personal information you provice may be used for secondary purposes [Privacy La i s.15.04 (1)(m)]. 320241 Permit Holder's Name: ❑ Cit n Villa Town of: State Plan ID No.: M & G INC. STAR PR IRIE CST BM Elev.: Insp. BM Elev.: BM Description: Parcel T x Ng-: / Iv �3�- 1179 -90 -000 TANK INFORMATION U G ELEVATION DATA A9800431 T E MANUFACTURER CAPACITY STATION BS HI FS ELEV. ptic Ben m rk Dosi ng - �.� 117 � Aeration —Bldg. Sewer IZ<`s 10t- Holding Inlet TANK SETBACK INFORMATION Outlet 1 L 4 lOVf TANK TO P/ L WELL BLDG. A ir ir I ntake ROAD A Septic,,, NA Dosing NA Header / Man. ? Ci6', A Ion A Dist. Pipe 0& •5 Hol I t. System 13.5 / 0 5 . & PUMP/ SIPHON INFORMATION Final Grade 10- 08 S Manufacturer D mand jO•?L Mod Number GPM TDH Lift Friction System Ft Forcemain th D' Ii Dist. To Well SOIL ABSORPTION SYSTEM tpd ' BENCH Width Lengt No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS Z I DIMENSION SYSTEM TO P/L I BLDG WELL LAKE /STREAM LEA ING Manufac SETBACK INFORMATION Type O tuber: CRAM Syst 1 OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length ��� Dia. Spacing Se— A 57 Z � Z � � 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 El 11 No E] Yes E] No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: STAR PRAIRIE 15.31.18,NE,SW 1146 212TH AVENUE 1.u-F 3e `' C vnS--Zn c noe- K S 4(4-9M—_FvFc% bI bol,c �a�v►d a , (ZD 25 fA - O� Plan on 4rrrJdl ❑ Yes ❑ No Use other side for additional information. 1 /7 SBD -6710 (R.3/97) Date Inspector's Wna6re Cert. No s % &Coniin Safety and Buildings Division SANITARY PERMIT APPLICATION 2 1 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm Code a Box 9 _ I 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 Num ber 3 20 2-L1 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 Property Location N, R ,�(or� 1/4 1/4, S T� , Property wner's Mailing Addr Lot Number Block Number 0 Cit ate , t Zip Code Phone Number Subdivi 'on N7ime oj.,f SM Num er ' ( . TYPE OF BUILDING: (check one) ❑ State Owned It Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms ° Tow OF III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo © `/� 79 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. M New 2. ❑ Replacement 3_ ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an ,______System ________ System____ ______ ___TankOnly Existing System Existing System B) El Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 ffl 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. nch) Elevation Feet Feet Capacit VII TANK in Ca g Total # Of Prefab. Site Fiber- Plastic Exper INFORMATION Gallons Tanks Manufacturers Name concrete Con Steel pl lass A New Existin structed g pp T nks Tank Septic Tank or Holding Tank A a j - ,® 1:1 El 1:1 El El Lift Pump Tank /Siphon Chamber ❑ 1 ❑ ❑ 1 ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for ins Ilation of the onsite sewage system shown on the attached plans. Plumber Na e: rirt) Plumb s Si r o5 s MP/MPRSW No.: Business Phone Number: mber s Address (Street, City, State, Zip Cod ): ,f1 IX. COUNTY/ EPARTMENTUSE ONLY (Includes Groundwater ate Is sued Disapproved Sanitary Permit Fee Issuing Age s Approved ❑ Owner Given Initial �) Surcharge Fee) na Adverse Determition U �eo l0 9 X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD -63M (R,11/96) otSrntaunoN: original to county. one cwy s.: Safety All aui46ngs Division. Owner. rtumber o2��a,�d€ 1 � .� /,�� � a� /Y,r'�ts�,F- � /Gf?;o • s,��.le,�� ,b?�Q.s�� 3 I � I 1 1 Labor Human Rela Department Industry, SOIL AND SITE EVALUATION REPORT Page / of -3 Lebo'; a Division or safety a 9uildings In accord with ILHR 133.05, Wis. Adm. 1 Attach complete site plan on paper not less than a 1/2 x 11 inches in size. Plan mu e, but* o 1 K not limited to vertical and horizontal reference point (84, direction and % of slop or F��1�9r PARC f dimensioned, north arrow, and location and distance to nearest road. car ���� APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION 3 '! , $ WE DATE PROPERTY OWNER: PRO LOCATI k'i'G h.4 RD 5 7-o V 7— GOVT. 3/ ,N,R /V E PROPERTY OWN R':S MAILING ADDRESS 10T ! 1 ' . 53 - 3 w ,4 7'0 )e'E�' rR. CITY, STATE � ZIP CODE PHONE NUMBER IL NEAREST ROAD If Sort syorco (; (v7 //WV CC (Aew Construction Use (4 1 Number or bbdrooms 3 to 4 [ ( Addition b existing building ( ( Replacement S ( ( Public or commerdal describe Code derived daily flow heel gpd Recommerded design loading rate : ✓ r" bed gpo1ft trench, gptilft 2 Absorption area required 12- bed, g2 /� trench, ft Maximum design loading rate , S bed, gpolft � Irerj , gpolft Recommended Infiltration surface elevations) SEA It (as referred to site plan benchmark) Additional design I site consjktafions Parent material 5CS (11) 13v PI-4 _ t-,AD T — O,/Jq /,9— Flood plain elevation, if applicable ft 0 S = Suitable for system CONVENTIONAL D N-GROUND PRESSURE AT -GRADE SYSTEM N FILL HOLDNO TANK U= Unsuitable for stem 11 S 11 U T75 I7 S O U ❑ S O S CI U ❑ S O U SOIL DESCRIPTION REPORT N��C = Nei iPE�oHp�,vfl Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bwxlory Roots GPD /ft In. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Tbxh Z - 2 /oYi2 313 5/ 17CS!✓,4!�_ ,t„-rP Ground 3 e YX O, s elev. 105.2 It. Depth to Smiling 18[clor Remarks: Boring # l/ ... © - 2_ /O YA 2- Z -i /1 N ^ Aj Ground elev. /OG , 75 ft. Depth to Smiting factor Z/ Remarks: ST Name: — Please Print R n 8 t R r V L 13 R t'C I-, l' Phone. Address: V C7 r Signature: / r c Date: CST Number: Private sewaae Consultants �t -0TZg� Ulbrlcht & Associates Private Sewage Consultants 665 O'Neil Rd. Hudson, Wis. 64016 L-0 T- AT Al , C'. Lo T Gp I � R 06 r /00.0 r i 2 T" r s 13y � c �3 i C3y � p�, g M T�S IoB .Z5 • _ /3 AC4'4-o-e P -r ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERT FORM Owner/Buyer Mailing Address �„r �� � ,,., till � � z Property Address (Verification required from Planning Department for new construction) City /State Zz Parcel Identification Number LE GAL DESCRIPTION Property Location �.� ' /4, s rJ '/4, Sec. /� , T -R W, Town of Subdivision a t �� , Lot # _ . Certified Survey Map # Volume , Page # Warranty Deed # lR /„� ,Volume Page # Spec house ® yes ❑ no Lot lines identifiable ® yes ❑ no SYST MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consuls 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. 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 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 OWN CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) ant (are) the owner(s) of the property described above, by virtue of a -warranty deed recorded in Register of Deeds Office. SIG A 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 A PP L E Rl VL., ? END LOCATED IN PART OF THE NWI 14 OF If IE SWI /'I, I'ARI Of If E SWI /4 OF I, !. 1 -'x 1 / 1 ' 1,1 I ';rt I I/t I tit_ _)t 1/', Ur IfJC JVVI /- r r1 I Err NEI /4 OF THE SWI 14 AN[) IN PART OF THE NWI /4 OF THE SE 1!4 ALL. 1r: `FCHON 1 °r, TSIN, R18W, TOWN OF STAR PRAIRIE, ST CROIX COUNTY, WISCONSIN. OWNEai .. - .. - : .... :.r... F LOT 27 ! r LOT 26 LOT 39 �x:YEaa Ei•.r i� ! C (' :]].2]i 50 fr 25 v aw.06] 50 GT A ry � v O LOT 28 / 90,02 50 f• 4 O ` c, LOT 38 2 D5 K ESri p y�lra:Ai B9. 'BB 50. IT O e .a�' rT g Od1 BB.JDS 50 IT. / 8 �\ CJI E f_ ` J �✓ LOT 29. g x ^ .]) `. ]2.94] VE/ 3 1 / 2 fT / ' / y ti ],2 LOT 23 4 m0 f QT 14 I ' W. m 4 or. ►� LOT 37 2 ti l I ', o m 91. e. .c •a wE E 5J f ! /I " / ' Ej I ]U9 i0 iT. � 8 Sq•• ]B. r4� � o O � / LOT 30 �tl <3 5oti 16,781 5G. f � r -- ` 19 i LOT 22 E' f LEGEND co. is LOT 36 NBSI{ - 1 194 y q r♦ z" :xo» .:oE • .r:D r1 ' . cE f uw0 9]9 B4 fT LOT 31 15I IT \ \ O = I :2 ».(E �,a: ♦ Ea.En'Cwi s. nT 5 LOT 35 (tl I , N v J , _. 20 X11 ax ian_E U ..,� < -o: ]!D .wr Dx�.E ?tl E• z ,91 I LOTJ LOT rv' 32/' EEBpEw _.E .. _ --- ___ -_' ,}• ]B9]6J 1]i 59 33 .T Wr O f LOT 34 t 7 ' NO rE ST. CROIX COUNTY WISCONSIN ZONING OFFICE ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016 -7710 (715) 386 -4680 October 15, 1998 REMAX Realty Attn: Mike Germain 103 Main Somerset, WI 54025 RE: Septic Inspection for M & G Inc. located at 1146 212th Avenue, Lot 30 of Apple River Bend, Town of Star Prairie, St. Croix County, Wisconsin Dear Mike: A septic inspection of the above referenced property was conducted on September 29, 1998. This property is located in the NEA of the SWA of Section 15, T31 N -R18W Lot 30 of Apple River Bend, Town of Star Prairie, St. Croix County, Wisconsin. At the time of the inspection, this septic system was found to be code compliant for a four (4) bedroom home. If you have any questions regarding this, please contact our office at (715) 3864680. Si rely, Rod Eslinger Assistant Zoning Administrator /sm