HomeMy WebLinkAbout038-1180-60-000 • ST. CROIX COUNTY ZONING DEPARTMENT
AS GUILT SANITARY REPORT
Owner
Address
City /State -�' n
Legal Description:
Lot /
_� Block Xr/ Subdivision/CSM # -
%, A�L 'V+_, Sec. , T LN -RAW, Town of
PIN #
SEPTIC CH
TANK — DOSE AMBER — HOLDING TANK INFORMATION:
Tank manufacturer - Size ST/PC / Setback from: House
Pump manufacturer Model 1, / Well y p/L
Alarm location
(HOLDING TANKS ONLY)
Setbacks: Service road Vent to fresh air intake
Meter location Water Line
Alarm location
SOIL ABSORPTION SYSTEM:
Type of system: � Width .Z_ Length Number of Trenches
Setback from: House _ Well ,-. 5-3 P/L -
�e Vent to flesh air intake
ELEVATIONS
Description of benchmark
Description of alternate benchmark _ /',� �, Elevation 2 ,
'��� Elevation �� /- R
Building Sewer 2 ST/HT Inlet 9, - ST Outlet PC Inlet
PC Bottom Header/Manifold Top of ST/PC Manhole Cover
Distribution Lines ( ) () ( )
Bottom of System () q /L7 () ( )
Final Grade () () ( )
Date of installation 5 / P rmit number
�7� State plan number
Plumber's signature License number
Date / /W
Inspector
Complete plot plan R
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County CROIX
Safety and Buildings Division INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary "Ybi -:
Personal information you provice may be used for secondary purposes [Privacy L , s.15.04 (1)(m)].
Permit Holder's Name: ��ityJ71 Y pI T�Rwn of: State Plan ID No.:
GERMAIN, MIKE TTA Ytcrj
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel T05%Q-;1180 -60 -000
TANK INFORMATION ELEVATION DATA A9800098
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic � s wir r' . t iJ ��� Benchmark /S �, c o �
Do
Aeration Bldg. Sewer
Holding - - St /)it Inlet
TA14K SETBACK INFORMATION St /kyk Outlet / 9 , 1 Y-23
TANK TO P/ L WELL BLDG. Ai, i to ROAD Dt Inlet
Air Intake
Septic 3 a- I + 2S' J NA Dt Bottom r ^
r
Dosing NA Headed
r
Aeration NA Dist. Pipe
Holding r Bot. System /,? 9� 5 7, 7 r S
PUMP/ SIPHON INFORMATION F t Mcle �, SD ld3, 6S�
oyJ d /
Manufacturer Demand t �' w. y0 99
!Forc er GPM
em Lift L riction H Ft
' Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width / Length / No. Of Trenches PFF No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS /Z DIMEN I N
LEACHING nuf Mumber-:
SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREAM INFORMATION TypeO kii,&}- ` r CHAM Mo el
System: Gn LP, �' d - d& Ac 1 X }� '� " O NIT
DISTRIBUTION SYSTEM
Header Maa4&fd Distribution Pipe(s)
Length _� r� x Hole Size x Hole Spacing Vent To Air Intake
r d
Dia. Length =_11 Dia. Spacing
Only
- --
SOIL COVER x Pressure Systems Only xx Mound O r At -Grad ems y'�
Depth Over Depth Over xx Depth Of xx Seeded / Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil
E] Yes E] No E] Yes El No 1
COMMENTS: (Include code discrepancies, persons present, etc.) 3 _
M M.�
LOCATION: STAR PRAIRIE 15.31.18,NE,SW ilia 212TH AVENUE
e,3
Plan revision required ?(b �eso No
Use other side for additional information. Jr -�e ff Wl,/ 121
SBD -6710 (R.3/97) Date Inspector's Signature Cert No.
Safety and Buildings Division
N)Lconsin SANITARY PERMIT APPLICATION 201E ox796 ngtonAve.
In accord with ILHR 83.05, Wis. Adm. Code P.O. Box I 53707-7969
Department of Commerce Madison, W W
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8112 x 11 inches in size.
• See reverse side for instructions for completing this application State Sanitary Permit Number
'5o7?lro
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)I. State Plan I.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION '��� —•
Prop rt y caner fjl�IJle Property Location
( /�' 1/4 1/4, S T , N, R J�(or
roperty Owner's Mailing dYs Lot Number _ Block Number
Cify ate ` Zip Code Phone Number Subdivis on ame o SM Num
b r c )
11. TYP B ILDING: (check one) E] State Owned ❑ 't
❑ Village
Public 0 1 or 2 Family Dwelling - No. of bedrooms cr Town OF
111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
O .3y -11 go r
1 ❑ Apartment/ Condo / �7- 3 $ 0
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. tz 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 1A Seepage Bed 21 ❑ Mound 30 Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 E] In- Ground Pressure 11 �,[ 1 42 E] Pit Privy
13 E] Seepage Pit 2 7 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./' ch) Elevations oe Feet /6 Feet
VII. TANK Capacity Site
INFORMATION in gallons Gallons Tanks Manufacturer's Name Conc ete con- Steel glass Plastic Appr
New l Existing structed
Tanks Tanks
eptic Tank g Tank _ S 2 El 10 El 1 11
Lift Pump Tank /Siphon Chamber o I n I M I El El El
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for insta ation of the onsite sewage system shown on the attached plans.
k umbe ' Na i t Plumb 's Sig u S MP /MPRSW No.: Business Phone Number:
7_3 �5
umber s Ac dress (Stet, Ci , State, Code):
3�
IX. COUNTY/ DEPARTMENT USE ONLY
E] Disapproved Sanitary Permit Fee ( i n cl udes S rchar Groudwater ate Issued Issui fff111���DDDyyy A ent Si ature (No Stamps)
Surcharge Feee) _
5ffApproved E] Owner Given Initial t IVA 00
Adverse De i
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD -6398 (R.11/96) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
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Labor, a H u man Rel an Sel ations dflndustry, SOIL AND SITE EVALUATION REPORT Page / of
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Labor
Division of Safety & Buildings in accord with ILHR 83.05, WIS. Adm. Co
11
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must' 1 t y2 r. c R o 1 ' K
not limited to vertical and horizontal reference point (BM), direction and % of slope or + PARC
dimensioned, north arrow, and location and distance to nearest road. T�
APPLICANT INrORMATION PLEASE PRINT ALL INFORMATION «D DA
PROPERTY OWNER: P LOCATION, ;;n r 7
�i'G !I A /?D STO V T-- GOVT. T ,N,R E
PROP E 0 N R':S MAILING ADDRESS
�f
W )e,�5Z= 7-,e N �1
CITY, STATE `
�S ZIP CODE PHONE NUMBER []CITY 4 .
It So .J S yo f � (�i,) 541 - (o7 31, r []VIL P R 1 I E REST ROAD
y, c c
10ew Construction Use J &+'Oesidential I Number of b6drooms 3 +o 4
J J Replacement J J public or commercial describe (J Addition lo existing bulkfiltg
Code derived daily flow T o& gpd Recommended design loading rate '7 bed, gpd/ft trench, gpolFt
Absorption area required W bed, R 75L9 trench, R Maximum design loading rate ' 7 bed, gpd/R trench, gpolR
Recommended Infiltration surface elevations) SEA Iq . 3 R (as referred to site plan benchmark)
Additional design / site oons rations
Parent material $CS 11 Flood plain elevation, if applicable R
S = Suitable lor system CONVENTIONAL MOUND / a Rpt��p U ESSURE AT-DE
S S SYSTEM IN f1LL HOLDING TAW
U Unsuitable for stem O S [I U O S L� [} us O U [IS ❑ U
SOIL bESCRIPTION REPORT 'I/M' = I VOTI
Boring # Horizon Depth Dominant Color Mottles Structure GPD /ft
In. Munsell tau. Sz. Cont Color Texture Gr. Sz. Sh. Consistence Bo rt by Roots
Bed
Z za? % .
Ground 3 2� �(0
etev.
/o2 -sL- ft.
Depth to
limiting
factor
Remarks:
Boring #
l o ye 3/3 0S , , y '
Ground -9 7. S Yj2 % /C� $ . D 7 . 8
elev.
/o V, 3 0 ft.
Depth to
limiting
fact
Remarks:
ST Name: - Please Print R n 8 t_ R r 2A L n R i L% T 7� a `
' J Phone: S 3L3 - f3 1 S 5
Address: `
Signature: L r c CSTA J. I/ P. —
r1% 0 _ �1 1/ / Private Sewage Consultants Date: CST Number:
-- �IEVAT� O►,S �
_ Ulbrlcht & Associates
r Private Sewage Consultants
B 7 . 30 $55 O'Neil Rd.
Hudson, Wis. 54016
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1 0 3 -30
SuU�EST�o 112 , Ja 5YS7
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46ev t T rp.vs C EO 13- Q s C
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
OwnerBuyer 0" � � h)
Mailing Address 4 f J�A";
Property Address �h
(Verification required from Planning Department for new construction) "/6 C p
City /State ty Parcel Identification Number "-
LE GAL DESCRIPTION
Property Location _ ' /,, soJ '/4, Sec. / f " ,T -R� W, Town of
Subdivision �p�,�na , Lot # .
Certified Survey Map # , Volume , Page #
Warranty Deed # Volume , Page #
Spec house � yes ❑ no Lot lines identifiable �ik 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
master plumber, journeyman plumber, restricted plumber or 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.
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 a piration date.
_ 3 Ic30/
ST NA F APPLICANT' DATH
OWNER CERTIFICATION
I (we) certify that all statements rni this form are true to the best of my (our) knowledge. I (we) ant (are) the owners) of
the property described above, by virtue of a \%arranty deed recorded in Register of Deeds Office.
0
S GNATI& 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
♦ 3
LOT 36 '
i N851
95 AC. v ~ I
85,084 90 FT P LOT 31
- -� ° ,
1.73 4C 1
I g I
75,367 90. FT.
I N 1 989 ° 50'06' • E 386.56'
I �
L UJ 1
- - J �, M 1 Nh9 ° 41'84 "[ 335.06 \,
- - LOT 35 245 06'
tt I ?I o <
10 1 I 1.91 AC.
ICI j I B3,J46 90. FT. '� \
LOT, °
1 N
616 1 1 LOT 32� 1
�.
I 1 13! 989 °56'04 "E 351.59' Q % w 2.04 AC.
Z 1 T 99,727 SO, FT
33;
8 D
!aJ I 1 < 1.74 AC. 1
LOT 34
�I 75,617 90. FT. > T.1 1,1 1 O
QL
I 1 2.27 AC.
1 ' 98,972 Sli. FT. �
L t 7
\ Od 10
� 246.50 0
\zz.ou' 576.5e aE
LOT 8 LOT 15
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a 0T OT �i s
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MY " - -
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UTILITY 9ac2MBNTc e j4k c�;
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No pole or buried cables are to be placed such that the installation vould disturb any survey state, or obstruct visio5 along
any lot line or street line.
The disturbance of a survey state by anyone is a violation of Section 276.12 of risconsin Statutes. utility usesents as
herein set forth are for the use of public bodies and private public utilities having the rigbt t3 serve the area.
DI1 D-�3
AIMS
SHEET I OF
Wisconsin Department of Commerce SOIL AND SITE EVALUATION
Division of Safety and Buildings Page of
Bureau of Integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must , County
include, but not limited to: vertical and horizontal reference point (BM), direction and
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
APPLICANT INFORMATION - Please print all information Reviewed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner Property Location
zeo� Govt. Lot 1/4 G 1/4,S S �� ,N,R ,r�(or) W
Property Owner's Mailing Addles Lot # Block # Subd. Name or CSM#
1
City State Zip Code Phone Number El city ❑ Village " M � Town Nearest Road IA - 617
New Construction Use: ZI Residential / Number of bedrooms - 3 ' Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow gpd Recommended design loading rate �� bed, gpd/ft trench, gpd /ft
Absorption area required _ bed, ft .S trench, ft2 Maximum design loading rate bed, gpd /ft gpd /ft
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design /site considerations
Parent material a4 l Flood plain elevation, if applicable ft
S = Suitable for system Conventional Mound In- Ground Pressure 7AT-7 System in Fill Holding Tank
U = Unsuitable for system El ❑ U ❑ S ❑ U ❑ S [] U S ❑ U ❑ S ❑ U ❑ S ❑ U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Structure GPD /ft2
in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots
Bed , Trench
6 e
Ground
elev. - -
��/ft.
Depth to
limiting
factor.
?1 in.
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
CST Nam (Pease n Signature Telephone No.
Address Date CST Number
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ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
n a all If a a an ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
r Hudson, WI 54016 -7710
(715) 386 -4680
June 30, 1998
Re /Max Team 1 Realty
Attn: Mike Germain
103 Main
Somerset, WI 54025
RE: Septic Inspection for Mike Germain located at 1118 212th Avenue, Lot 35 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 May 20, 1998. This
property i located in the NEY4 of the SWY4 of Section 15, T31 N -R1 8W, Lot 35 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 three (3) bedroom
home.
If you have any questions regarding this, please contact our office at (715) 386 -4680.
;I y,
mes K. Thompson
Zoning Specialist
/sm