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. a ST. CROIX COUNTY ZONING DEPART
AS BUILT SANITARY REPORT
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Owner l /
Address , ) �' /
City /State St , 999
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Legal Description:
Lot Block Subdiv' ' �e,...
><ston/CSM # T7_
'' /., V <a�, Sec., "N -RAW, Town of PIN #
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION:' 18 3 ! $ c"
Tank manufacturer Size ST/PC / Setback from: Housed Well _zz 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: _ .f�,� Width /V ,, Length 9! , Number of Trenches
Setback from: House Well PAL Vent to fresh air intake
ELEVATIONS
Description of benchmark Elevation /tea e
Description of alternate benchmark ��, j / G Elevation zay, -/,
Building Sewer / 7V ST/HT Inlet �/, SX ST O utlet i Q /, , 7 — PC Inlet
PC Bottom Header/Manifold 2Z-1 Top of ST/PC Manhole Cover i a , /
Distribution Lines
Bottom of System
Final Grade O a4. 1< 9
Date of installation / / rmit number 1 State plan number
Plumber's signature License number _ Date
Inspector
Complete plot plan Or
Wiscpnsin Department of Commerce PRIVATE SEWAGE SYSTEM Count
' Safetjrand Buildings Division INSPECTION REPORT y ST. CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) SanitarulOel[r)itlup.:
Personal information you provice may be used for secondary purposes [Privacy L s.15.04 (1)(m)). 5 U �� b6 6611
i nit Holdec.'s,.N.ame: Cll?X_P ,!,(i NI _�wn of: State Plan ID No.:
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Ta�f�lo_:1077- 60-000
D, 0 /00- 61. Pa U LS
TANK INFORMATION ELEVATION DATA A9800049
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic p ec,�,a� �� .�� Benchmark
Dosing,
Aeration Bldg. Sewer
Holding St /,* Inlet ,
� /o /. 8 �
TANK SETBACK INFORMATION St /-10 Outlet . 7
TANK TO P/ L WELL BLDG. Airl to ntake ROAD Dt Inlet
Air I
Septic NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade r
Manufacturer d eman '
rn 1 6-, 12Z /0
Model Number GPM
TDH I Lift Lricti System TDH Ft
Forcemain gth Dia. H ead Dist. To well
SOIL ABSORPTION SYSTEM
BED/TRENCH width Len No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
D IMENSIONS �a- `7� DIMENSION
SETBACK
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING manuf acturer:
INFORMATION TypeO - vzt,,,� CHAMBER Mod Number:
System: 17� 3 , SU Y �o° �/p OR UNIT
DISTRIBUTION SYSTEM
Header /Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length Dia. Spacing
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 3 Q" Bed /Trench Edges �b Topsoil ❑ Yes
❑ No ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: STAR PRARIE 18.31.18.318C,NW,SW 2137 80TH STREET
Cw
Plan revision required? ❑ Yes ❑ No
Use other side for additional information. ? 6 1
SBD -6710 (R.3/97) Date In a is Signature Cert. No
Vi sconsin Safety and Buildings Division
SANITARY PERMIT APPLICATION 2 01 E. Washington Ave.
P.O. Box 7969
Department of Commerce accord with ILHR 83.05, Wis. Adm. Code
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
- 307661
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 m Property Location
I 1/4 1/4, S Ig T , N, RZf AorkO
Property Owner's Mai dd ess of Number Block Nu ber
_213 7 G y, late Zip Code Phon Number Subdivision Name or CS Number
(7I )di17 -3 2
II. TYPE OF BUILDING: (check one) ❑ State Owned it Nearest Road
Public 1 or 2 Family Dwelling - No_ of bedrooms C ro
111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment /Condo d`'8— /C ? - ""'o erd
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..0 New 2. E] Replacement 3_ E] Replacement of 4. E] Reconnection of 5. E] 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 E] Pit Privy
13 E] Seepage Pit I Z X 9`� 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/d /sq. ft.) (Min. inch) Elevation
-� Feet Feet
Capacity
VII. TANK in Ca ga llo ns Total # Of Prefab. Site Fiber- Exper.
INFORMATION Manufacturer's Name Con- Steel Plastic
New Existin Gallons Tanks concrete strutted glass App.
Tanks Tanks
Septic Tank — - ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ 1 ❑ I ❑ 1 ❑ 1 ❑ ❑
VI11. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for ins lation of the onsite sewage system shown on the attached plans.
7 Plumer' Na e: rrt) Ptumbe s Si a o` MP /MPRSW No.: Business Phone Number.
Plumbers Ac dress (St o t, y, State -Zip Code):
IX. COUNTY/ DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater D ate Issued Issuing Agent Signature (No Stamps)
A roved Surcharge Fee)
pp ❑Owner Given Initial �' �� oil �i
Adverse Determination o
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: _
cyst :1, Cc�n ✓iot b� ivlSftt / /r. c/ d, �o>°;✓ ff%ICCC -1 `�8 --7 ( c�v� '� "rw �' iK
�65 ;�1 E�a✓rn9 3 X43
SBD -6398 (R.11/96) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, plumber
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Wvi in Department of Commerce SOIL AND SITE EVALUATION
Division''of Safety and Buildings SOIL of
Bureau of Integrated Services in acxorda F h s 83.09, Wis. Adm. Code
Attach complete site plan on paper not less than 8 1/2 x 1 in z..4
ean must County
include, but not limited to: vertical and horizontal referen BM
( f t
percent slope, scale or dimensions, north arrow, and I and distance to nearest road. Parcel I.D. #
APPLICANT INFORMATION - Please print s format MIX Re
by Date
Personal information you provide may be used for secondary pu rivacy La�i►C�.0M3b�1(1! (m)).
Property Owner Property Lactation V /
A . 1. Govt. Lot 1/ r 1/4,S TT ,N,R �(or
Z� ►ty Owner's Mailing Add Lot # BI # Subd. Name or CSM#
City Stat Zip Code Phone Number ❑ City v ge Town Nearest Road
W New Construction Use: Residential / Number of bedrooms Addition to existing building
❑ Replacement /c El Public or commercial - Describe:
Code derived daily flow gpd Recommended design loading rate bed, gp� gpd*
Absorption area required �� bed, ft '� trench, f1 Maximum design loading rate ` bed, gpd/fF gpd/ft
Recommended infiltration surface elevation(s) �� - 7 ft (as referred to site plan benchmark)
Additional design/site siderations
Parent material �� Flood plain elevation, if applicable ft
S = Suitable for system Conventional Mound In -Ground Pressure AT -Grade System in Fill Holding Tank
U= Unsuitable for system S❑ u � s El W S ❑ u i m s ❑ u [- 0 U ❑ S A U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
13, in. Munsell Qu. Sz. Copt. Color Gr. Sz. Sh. Bed , Trench
r-
Ground T-
elev. !
Depth to
limiting
factor
Remarks:
Boring #
Ll
Ground
elev.
1�ft.
Depth to
limiting
factor
in. Remarks:
CST Name (P ase nt Signatu a Telephone No.
Address Date CST Number
-
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I
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
W:71 RTIFICATION FORM
Owner/Buyer
Mailing Address
Property Address
(Veri ication required from Planning Department for new construction)
p
City /State Vi Parcel Identification Number
LE GAL DESCRIPTION
Property Location '/4,. t '/4, Sec. T -R_2y_W, Town of
Subdivision 7 , Lot #
- 4 , z 4 ,
Certified Survey Map # , Volume , Page #
Warranty Deed # `rf S�'gr` , Volume K7 , Page # S�5
Spec house ❑ yes 4 no Lot lines identifiable P' 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 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 se tic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
days of a thre ear expirat' e.
SIG14ATURE 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 pro d cribed a , by virtue of a warranty deed recorded in Register of Deeds Office.
y , z - 7 e
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