HomeMy WebLinkAbout038-1084-90-200 ST. CROIX COUNTY ZONING DEPART
AS BUILT SANITARY REPORT
..Owner r
Address - S7 E — Q —
City/State JO P7&F,,?J,6 . - > / o
Legal Deverlptlous
Lot _� Blook A(h Subdivision/CSM #
'/4 &E 1 /4 , Sec. 2V T 1 N -RAW, Town of 5 7A /��/2E PIN - O- zoo
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION
Tank manufacturer (, �� fi's Size ST/PC IM21 A Setback from: House Well P/L /QDv
Pump manufacturer AA Model kA
Alarm' location IVd
— Omu TANKS ONLY)
Setbacks: Service ro fresh air intake Water Line
Meter location
Alarm3location
i
SOW ABSORPTION SYSTEM
Type of system: - rife) ej.1 Width _ Length 3— Number of Trenches
Setback from: House YA . Well 1 0-5 - P/L 1 0 Vent to fresh air intake /oo '
ELEVATIONS
Description of benchmark T a Sw Lo T S ,' xic Elevation oo 0
Description of alternate benchmark Elevation
Building Sewer ST/HT Inlet 2-9, Y 2 ST Outlet PC Inlet IM
PC Bottom A /h Header/Manifold . L Top of ST/PC Manhole Cover ,� 7 3
Distribution Lines (j s y ( )
Bottom of System { 1) �`, / (Z) 2L ( )
4
Final Grade (f) f d G ( /D -P G ( )
Date of installation ?0 Permit numbers State .plan number
Plumber's signature - _ License number :72/ 7y/ Date b /
Inspector
Complete plot plan Or
'Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County- CROIX
Safety and Buildings Division INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary3P�it1�.:
Personal information you provice may be used for secondary purposes [Privacy N, s.15.04 (1)(m)].
P�,rpniiFiQlder'sNaulP,�, �y� lLi11ao5�.Gl_TAwn of: State Plan ID No.:
CST BIM 131;1{ Insp. BM Elev.: BM Description`: Eitc YrttCcE�'1lfCl C; Parcel T�x�f_:1084-90 -200
I /OVi Lo 0
TANK INFORMATION ELEVATION DATA A9800179
TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV.
Septic L � � BenchmgZ -7 -S - �07, �oc�
Dosing
Aeration Bldg. Sewer y l cam, S
Holding t i Inlet
TANK SETBACK INFORMATION St W Outlet
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic j 17 1 NA Dt Bottom
Dosing NA Header/ Man.
Aeration NA Dist. Pipe pD G l tS
Holding Bot. System i ! /o_q2 77. (
PUMP/ SIPHON INFORMATION Final Grade Ca /60. 8'8'
Manufacturer and '7 o G / K , .; �r -7 9, °` �
Model Number GPM Y1'lw►f S 7� ��'
TDH Lift &g!k S st TDH Ft
Forcemain Dist. To well
SOIL ABSORPTION SYSTEM
BED E Width 3 / Length 3 No. Of�renches PIT No. Of Pits Inside
I Dia Liqui pth
DIME ION v` DIMEN N
G f ct
SETBACK SYSTEM TO P / L BLDG LEAC Manufacturer
WELL LAKE /STREAM CHAM R
INFORMATION Type Mode Num
Syst m03� ''�`+� y 7 10 / OR UNIT
DISTRIBUTION SYSTEM
Header / Mani old Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length i"_ Dia. Length 3� Dia. 3 Spacing (� G�t4w b� S r - ✓Q
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 E] Yes E] No E] Yes E] No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: STAR PRAIRIE 20.31.18,NE,SE 2046 CTY RD C
( e(c - _,r "n ....-
9S
Plan revision required? [:]Yes R No - l it
Use other side for additional information.
Date Inspect 's Signature Cert. No.
SBD -6710 (R.3197)
SANITARY PERMIT APPLICATION Saf E w n De Si on
Visconsin 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 �� x
than 8 1/2 x 11 inches in size.
• See reverse side for instructions for completing this application State Sanitary Permit Nuum�mberr
The information you provide may be used by other government agency programs ❑ Check it revision previobs application
[Privacy Law, s. 15.04 (1) (m)]_ State Plan I.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATI N
Property Owner Name Property Location
.._ IS 1/4 1/4, 5 g T , N, R /8 E (oq ok
Property Owner's Mailing Address Lot tuber Block Number
s4 0 7P
C , State Zip Code Phone Number Sub e or CSM er
II. TYPE F BUILDING: (check one) ❑ State Owned ❑ LO eares oa ❑ e Ej Public 1 or 2 Famil Dwellin - No. of bedrooms OF "' C
111 BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
1 E] Apartment/ Condo g'3 A
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 QRSeepage TrenchJ;+f�� �'' 22 ❑ In- Ground Pressure f 42 ❑ Pit Privy
13 E] Seepage Pit -Tr7ii�At 5 C � X 3 B 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
3d Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation
Feet Feet
VII. TANK. in g s Total # of Prefab. Site Fiber- Exper.
INFORMATION g Gallons Tanks Manufacturers Name Concrete Con Steel glass Plastic App
New Existing structed
Tanks Tanks
eptic Tank i� ❑ ❑ El 1:1 11
Lift Pump Tank /Siphon Chamber I I ❑ I ❑ I ❑ I ❑ 1 ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sews e s stem shown on the attached plans.
Plumber's Name: (Print) Plumb 's ignature: (No Sta MPRSW Business Phone Number:
-s -6
Plumber's Address (Street, City, State, Zip Cod( ):
F i ✓^
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee. (Includes Groundwater ate Issued Issu' Agent Signature (No Stamps)
A roved Surcharge fee) Q
pp E] Owner Given Initial %rb w /oa 5/ L 1 { o
Adverse Determination 117
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBO-6= (FI 11/96) DISTRIBUTION: Original to County. One copy To: Safety 6 Buildings Division. Owner, Plumber
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Wi #cansia Department of Industry SOIL AND SITE EVALUATION
Labor and Human Relations Page —L— of --
Division of Safety and Buildings 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 I
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
7'� (AIL/ - 9a -boa
APPLICANT INFORMATION - Ple print all infor'nito Revie ed by Date
Personal information you provide may be used fc secondary ptm r _ s qacy I. aw s;;; .04 (1) (m)).
Property Owner Property Location (�
I SO V-\ ,c),. ovt. Lot 1/4 s6 1/4,S )D T3 N, R I i E (ore
Property Owner's Mailing Address, of # Block# Subd. Name or CSM#
SW 3 - �r, a '* T7 a 1 Q
City State Zip Code PffW4 rKber oa
❑City ❑ Villag � Town Nearest Rd ea
�f`Il
® New Construction Use: ® Residential / Number of bedrooms 3 Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow q - 5 0 gpd ^ Recommended design loading rate bed, gpd/ft trench, gpd/ft
Absorption area required p �I 3 bed, ft J (Od.5 trench, ft 2 Maximum design loading rate bed, gpd/fl m trench, gpd/ft
Recommended infiltration surface elevation(s) SGC a- +cy �n Qejr - - ke-s4 ft (as referred to site plan benchmark)
Additional design/site considerations
Parent material OL Flood plain elevation, if applicable ft
Eu =Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
= Unsuitable for system ® S ❑ U ®. S ❑ U ®S ❑ U I ® S ❑ u [Is ® U EIS iKl U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Structure GPD /ft
in. Munsell Ou. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots
Bed , Trench
-5 In 4R Q/a =---- 5 L If (o R a r-
Ground t2 L
elev.
Depth to L 2,41 7,S -1e'q d ►a� L C 5 IJ f . 7 ; . 9
limiting
factor
Of in.
Remarks: 3 '' h d r'. 2 o r v P a e- \
Boring #
e n
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
CST Name (Please Print) Signature Telephone No.
1 A J , 5- � �� k '7 - � q1 - 3 5 9
Address Date CST Number
a a
9 -13- 99 alp
SY a b
I OF REPORT ON SOIL BORINGS AND SAFETY &BUILDINGS
INDUS, DIVISION
LABOR HUMAN RE ONS PERCOLATION TESTS (115) MADISON W 53707
(ILHR 83.090) & Chapter 145)
LOCATION: SECTION: WNSHI MUNICIPALITY: LOT N"1.:BLK. NO.: SUBDIVISION NAME:
--- G�
COUNTY: IMAILING ADDRESS:
J
USE DATES OBSERVATIONS MADE G
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
�esidence �Vew ❑Replace
RATING: S= Site suitable for system U= Site unsuitable for system
rfAs ONVENTIONAL: MOUND: IN- GROUND - PRESSURE: SYSTEM- IN- FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
❑U �$ ❑U �$ ❑U ❑$ NU ❑$ ®U
If Percolation Tests are NOT re uired DESIG2712
4 If any portion of the tested area is in the
under s. ILHR 83.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: o
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER - INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- —lei 0/5 fZ� — " 1 4 5P
B a o oo- ,l/ 7 yd s awl _36 0„
B- 3
B-
B- 5 Q �o � ��
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES
NUM riG3ES AFTER SWELLING INTERVAL -MIN. PERIOD 1 PERIOD 2 P RI D PER INCH
P-
-,3
P- p`t
P-
P-
P-
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION
3
uogonjlsuoo Aug to Uels ayl of joud pelsod pue peurelgo aq Isnw llwjed
Aiepues ayl llwiad a ulelgo of iapio ul Aluoylne leool aleudoidde ayl of pallucIns eq Isnw uotleoildde llwied a pug
walsAs a6emas aleAud ayl jol sueld to las eleldwoo V aouenssl liwied of joud play ayl ul isel loos S1141 ;0 u011e31lueA
Isenbai Aew luawliedaO ayl jo Alunoo ayl llwjad Ajellues a 6uunoas ul dais lsnl Bull Si uodej lsal loos si41
:U3NMO 3Hl 01
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer yrT ®n
1,' r f S
Mailing Address �� j 90 rr? e , f p 1 Tr 5 0Pn e ,, 1 , 5 . e1 *7— �_7
Property Address 0 t./ C y 2 � S ftst-; -T &) 1§ 5
(Verification required from Planning Department for new construction)-- z
City/State E - .l1/
Parcel Identification Number
'L EGAL DESCRIPTION
Purrs SF 07CIV ,'k Q r d ��1` � 1 c /2',E -k" a S� .L•
Property Location r /., % <, Sec. ,�, T r
.�N -Rff W Town of
Subdivision Lot #_. .
Certified Survey Map # l�_ Volume . Page #
Warranty Deed # Volume 1 page #
Spec house ❑ yes Ano Lot lines identifiable 0 y es y IBC no
SYSTEM- LANCE
I vroperus emdmaiboanoeofy�msq) dcsystuacouldtesultmitspncmatlti Maraca+ etobaadlewastes.Propexmambeaanm
eondsts of pnmpiag oat flue septic task evexy d=e years or roone4 if neo&d by a licensed pumper. What you put into fire system
can affect dw fumction of the septic twk a trcatarent stage in die waste disposal_system,
T� ProPertY Owner agrees to submit to St. tic Zoning De pwtment a certification foam, signed by die owner and by a
u 7 o, w myOanplumbeT. d lu mba
resWetopo a IieensedpwnpervecifYmg that (1) true wastewaterdisposal system
P Ming condition and/or (2) after inspection and pomzping.(rf'necessary), the septic-tank-is less than 113 full of sludge.
Vwt, tC und6zzigned have read dare above requires and agree to ma tamia true ovate
set form, heroin, as set by the Department of Commerce and the t sewage system with the standards
stating � year septic system has been maintained must be of Natural R,esour�ces State of Wisconsin.. Cextificafion
completed and returned to the St. Croix Co Zo ' Office within 30
days of three year expiration date. Y ro
F
APPLI DATE
O R. RTIFICATION
I (we) catify 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.
SI F APPLICANT / >
� DATE
oanation that is mis
-representod 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
03/30/1998 14:50 7152467079 REMAXTEAMIREALTY:NR PAGE 04
40002
• 03 /13114 FRI 10:50 FAX 715 080 1687 RBCISTER OF DEEDS _ -_
l
472816
GIRTtAIBD 9URVNY�lA
Located in Dart of the 354 of the ME% end iri Dart of the NSA of
the SO al .l in section 20, Township 31 NWisCOnain9e.3B Neat.
Town of S.Car prairie, St. Croix County, NE Cotner of
seotton 20
LE_ GEND OWN
G 1 • Iron pipe list, urban WWA
e wlObinp 4.00!0$ /I1n, ft. r•N. „ +
wi $10
S 0 1i from pipe fou•o
� OouM'7 4•et � on piemum•nt 7
0 I
Alumin GOP 'ounE }T ant
ii � 5��4dt7 ` � PuG�� ' 'vim 4 —•� �"'�
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i W aroai24tio7� �� ,e►, I -.
SCAGB 114 LIPET
56 a 0 5.80,
ANtROVED 0 / rte .~ LOT 2 p �r
Me L 2 1991 83,222 54- it-
ST. C=3 GOUWA, 1.96 Acres
r'L'14 1 +4i."KS PL•1+2Y:Vty `—
An4?2aiWNGC.•CNa►'ifIFF
�1R00.. E{ n•r of
LOT 1 •
\' N 55,231 lip. R ,,, 1 ° ' ,,.�• g
ri 2.00 Acre• • �'b. - � icl eo s� 11
4 01 , r
�'�� ` f _ /'fir ,�•�'� 8
•
Y +'' /
/gyp S.
/ 5E Corner of
section 20
Thle Instrument 081M4 by are" eeoror pro]. No- pi -
VOLUME 8 PAGE 2393