HomeMy WebLinkAbout038-1181-50-000 ST. CROIX COUNTY ZONING DEPARTME *,� ,'.,.'
AS BUILT SANITARY REPORT
Owner G ( T 9 1.998
Address ST C RUX
COUNTY
City /State ,i' ZONINGOFFICE
Legal Description:
Lot Block Subdivision/CSM #
'/. '/, _U�_, Sec. ,L, -, TV N- R,/LW, Town of PIN # ?gl.- & Z
IS. 31.18,10
SEPTIC TANK — DOSE CHAMBER — HOLDING TANK INFORMATION:
Tank manufacturer 1A Size ST/Pgn / Setback from: House 1/ - Well P/L -3
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: Width _ Length Number of Trenches
Setback from: House ,,2,9_ Well g P/L .7cl._ Vent to fresh air intake
ELEVATIONS
Description of benchmark 1 i 3 � Elevation 0-e
Description of alternate benchmark Elevation /&s-
Building Sewer e; ST/HT Inlet /,93 ST Outlet PC Inlet
PC Bottom Header/Manifold / 7 Top of ST/PC Manhole Cover /o.s- iR
Distribution Lines
Bottom of System
Final Grade
Date of installation 2A9 P mit number - is /3 State plan number
Plumber's signature License number h' Date //
Inspector
Complete plot plan a
Wisconsin Department Commerce PRIVATE SEWAGE SYSTEM Count
Safety and Buildings Division y:
' INSPECTION REPORT ST CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Personal information you provice may be used for secondary purposes [Privacy La k s.15.04 (1)(m)]. 315913
Wit tldi jf*&me: ❑Sit�c Ll Villacie Ipwn of: State Plan ID No.:
CST BM Elev.: Insp. BM Elev.: IM Description: lAfZ Yl2A Parcel Tax No.:
038 - 1181 -50 -000
TANK INFORMATION ELEVATION DATA A9800302
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Se Bench N " _Vee
Dosing
,
Aeration Bldg. Sewer `0,�2--
Holding St Inlet
.7 103.8'
TANK SETBACK INFORMATION !y 00 outlet
TANK TO P / L WELL BLDG. Air Intake ROAD Dt Inlet
1
eptic vl ( } `] NA Dt Bottom
Dosin NA Header / Man.
A ation NA Dist. Pipe O
Holding Bot. System �j - �/ /UI.(.C'
PUMP/ SIPHON INFORMATION Final Grade lase
Manufacturer De an 1, rn� 3•
M um er
TD Lift Friction S st TDH Ft
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
IMENS EN M N S Width , Length 6 , No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSION
SETBACK
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Ma
INFORMATION Type , CHAMBE Mod
cyst Lek 2rj �( OR UNIT
DISTRIBUTION SYSTEM 3
Header/Manifold Distribution Pip s) , I x Hole Size x Hole Spacing Vent To Air Intake
Length � Dia. Length / Dia. M Spacing A( OA 77 Z
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
xx Mulched
Depth Over 3 S Depth Over xx Depth Of xx Seeded/ Sodded
Bed /Trench Center a Bed /Trench Edges Topsoil ❑ Yes E] No ❑ Yes ❑ No
COMMENTS. Includ de discrepancies, persons present, etc.)
:•QQATIQN(: STAR PRAIRIE 15.31.18,NW,SW 1100 212TH AVENUE --
KM 1� rv� -�y �
Plan revision required? ❑ Yes /tj No
Use other side for additional information. I P 7
SBD -6710 (R.3/97) Date Inspector's ignature Cert. No
Safety and Buildings Division
Vi sconsin SANITARY PERMIT APPLICATION 2 01 W. Washington Avenue
In accord with ILHR 83.05, Wis. Adm. Code P O Box 7
Department of Commerce Madison, WI 53707 -7302
• 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
Personal information you provide may be used for secondary purposes ❑ Check it revision to previo s ap ication
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N
Propert�wner Namel Property Location
1/4 j 1 /4, S T , N, R f4or&
Property Owner's M & dre Lot Number Block Numb i
Cit , tate Zip Code Phone Number Subdivisi n Na a or M Number
AM
r ( )
II. TYP IL 1 : (check one) ❑ State Owned " It� Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms 0 IX Town OF V
III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo
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. 5d New 2. ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an
------ System ________System ______ Tank Only stem stem
_______ ______________ Existing System Existing Sy
B) [ Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non- Pressurized Distribution Pressurized Distribution Experimental Other
11 (ZSeepage Bed 21 []Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In- Ground Pressure '1 r 42 ❑ Pit Privy
13 ❑ Seepage Pit ��` ��!'d 43 ❑ Vault Privy
14 ❑ System-In-Fi I I
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.) Prop q /ft.) (Gals/day /sq. ft.) (Min. /' ch) Elevation
S� _ 9 Feet Feet
VI. TANK Capacity
in gallons Total # of Prefab. Site Fiber-
INFORMATION Gallons Tanks Manufacturers Name concrete Con- Steel Plastic Ex er.
p
New Existin structed glass App.
Tanks Tanks
Septic Tank ® ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ I ❑ ❑ I ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for inji4lIation of the onsite sewage system shown on the attached plans.
7 Plu s Na : (Pr t)I Plumb rs Si ur No S ps) MP /MPRSW No.: Business Phone Number:
Plumber dre
dss (Street City, State, Zip Cod ):
�n d e
;,I
IX. COUNTY/ DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater °' a n te Issued Issuing Age ign ure (No S
Xlj Approved / 1 C0 � Su rge Fee)
r / / - 7/ g� � �l f./ � r✓ �
pP ❑ Owner Given Initial
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD- 6398 (8,11/97) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
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Wisconsin Department Commerce SOIL AND SITE EVALUATION
Division of Safety and Buildings
Bureau of Integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code Page of
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. 2 "/ - �
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). 'wed by Date
Property Owner l 7 7/5
Property Location
a Govt. Lot 1/4 G 1/4,S T N,R ore
Property OWner'9 Mailing Address Lot # B oc Subd. Name or C # ZI
City Sta Zip Code Phone Number J '
, 7 ( ) City ❑ illage [Y Town Nearest Road
IRI New Construction Use: Residential / Number of bedrooms Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow gpd Recommended design loading rate _ bed, gpd /ft , trench, gpd/11
Absorption area required _ bed, ft ft2 Maximum design loading rate
9 9 .7 bed, gpd /ft gpd /ft
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design /site considerations
Parent material o w .4t; j Flood plain elevation, if applicable A17 ft
S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
U = Unsuitable for system 2S ❑ u ®S ❑ U S ❑ U ®S ❑ U I ❑ S ®U ❑ S .® U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Structure
in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots GPD /ft2
Bed , Trench
Ground �S- `'
elev. - S
�t• — —
Depth to
limiting /
factor
in. �--C -Y
Remarks:
Boring #
Ll
Ground 7�
elev.
Depth to
limiting
factor
in. Remarks:
CST Name (P ase P nt) Signature ' Telephone No.
Address
�,p :) Date CST Number
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=yo s
Ale 1"'ex
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Wisconsin Department of Industry SOIL AND SITE EVALUATION RE Page of -
Labor and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis. A
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan lude PARCE
not limited to vertical and horizontal reference point (BM), direction and % of slo ale or
dimensioned, north arrow, and location and distance to nearest road. J L
APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION. IE DATE
7 C';C
PROPERTY OWNER: PROPq LOC
k h pD 5 7 U T GOVT. �4� 1f� '. T �� ,N.R IP E (00
PROPERTY OWNER':S MAILING ADDRESS LOT # K l
35 1 4 w14 r_0 lej�5c
CITY, STATE ZIP CODE PHONE NUMBER CITY QVILLAGE 00 . WN NEAREST ROAD
5yof(a (71'5)s4q-(o731 1 6T7AR PRAIRIE- //WY- cc
1,0ew Construction Use ( e.- iesidential /Number of b6drooms 3 to 4 (] Addition to existing building
] Replacement [ ] Public or commercial describe
Code derived daily flow y °o[� gpd Recommended design loading rate bed, gpd4t trench, gpd/ft
Absorption area required PS Q bed, 11: �S d trench, 11 Maximum design loading rate ' 7 bed, gpd/ft trench, gpd/ft
Recommended infiltration surface elevation(s) SEA } • 3 It (as referred to site plan benchmark)
Additional design / site cons rations
Parent material 5CS 11 0 N^ - M1/4- BsFM Flood plain elevation, if applicable ft
S = Suitable for system 217 0 U L K ❑ U IN GRtJND U ESSURE AT S O U SYS TEM SS IN � 11 S pd
U = Unsuitable for system L�� Cs� [�'$ O
SOIL DESCRIPTION REPORT 4 02 = Nei ,PEcoHp�,v�Ef)
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bound3y Roots GPD /ft
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed tendi
.w -Fp- Cs
Sn C y '
Ground /y- 7o /O /e yG6 s. Q S �,� 1 8
elev.
/o,, . yo ft.
Depth to
limiting
f
Remarks:
Boring #
l D /o ye 311,1 �o L AAA R G s 3 -f
2 Z 31(, 24 5 M /vvt R CS 2 . , G
Ground e
e lev.
/pS • � ft. /D S • 0 S �� • Q
Depth to
limiting
factor
Remarks:
CST Name: — Please Print R t R T D L Q R I 1 T Phone. 71s 38& _ S 1 5
Address: I -J 7 - Si ' CSTA 1
Signature: Ulbricht & Associates Date: CST Number:
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERS141P CERTIFICATION FORM
Owner/Buyer
Mailing Address
Property Address �
(Verification required from Planning Department for new construction)
City/State ` Parcel Identification Number
LEGAL DESCRIPTION
Property Locations ' /,, ' / <, Sec. � , T ,2/N -R -/,? _W, Town of S
Subdivision _a�� , Lot #.
Certified Survey Map # , Volume , Page #
Warranty Deed # !M S1 7 - ,Volume 4?- ?S` , Page # / i5
Spec house 0 yes ❑ no Lot lines identifiable 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 4TURY
hree ear expiration date.
SI OF APPL ICANT 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 describ d above, by virtue of a �� arranty deed recorded in Register of Deeds Office.
G /a r / gg
SIG AMRE F 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
06/x5/98 TSU 11:26 FAX 715 386 4687 REGISTER OF DEEDS 01001
5$1$17 "L 1335, PACE 1 3 U3 &
STATE BAR OF WISCONSIN FORM Z - 1982 j
I' WARRANTY DEED k
DOCUMENT NQ,
CROIX I l i
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r 71 � 2 3 i9sa
conveys and warrants to i 9:45
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!f t1 T""S $P AC£ Re3ERVEt7 POR REGORbiNa DATA
i I I NAME Aut1 RG'1VRN A00RES5
t the following described real estate in c;t
State of Wisconsin: M'# (-> ' .
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li Lot 44 , Plat of Apple River Bend First I1 �� q� - �� - , �►'
Addition, Town o Star P rairie, St. Croix j�
?i County, Wisconsin.
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o�NTIFICATIbN NUMBER i
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?� This in no
homestead property.
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i I� Euvpdmzowanmaes- .Easements, xestrietiona, rights -cf -way and covenants
f of record, if any. t�
li Dated this f
i day of , A. D,,
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(SEAL) (SEAL)
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�? AU TFIENTICATIDN .ACKNOWLEDGMENT �f
Signatun(s) �` State of Wisconsin, J �
j� S t Croix
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autrnticated this � �,{ County. II
f — y 19 Personally came before me this _ 12th d of
the abcKv named
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ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
r r r r N rrr■
ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
Hudson, WI 5401 6-7710
(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 1100 212th Avenue, Lot 44 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 NWA of the SWA of Section 15, T31 N -R1 8W, Lot
44 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) 3864680.
Sin rely,
(
Rod Eslinger
Assistant Zoning Administrator
Am