HomeMy WebLinkAbout038-1183-50-000 s �
ST. CROIX COUNTY ZONING DEPARTMENT
AS BUILT SANITARY REPORT
Owner P( - 60/41"0- 4 « /,! e r .s
Property Address -Pd f 3'
City /State So r= r_ _ i e Y - I-)
Legal Description: K - N6 o
Lot Z Block Subdivision/CSM # VC,
'/4 : 6] '/4, Sec. ,Tom/ N -I - W, Town of fii s� ,�YU ,` �' P C� t , SD -ate a
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION
Tank manufacturer jn ,d ii es fea- y Size ST/PC (6WI Setback from: House -L Well A6L 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: �ve. c% Width 3_ Length - 7 5` Number of Trenches 2_
Setback from: House yD ' Well i P/L /D , Vent to fresh air intake
ELEVATIONS
Description of benchmark �'�J <. v Z` .d ` �-e Elevation /e°J
Description of alternate benchmark Elevation (do . �
Building Sewer / r ST/HT Inlet Z-6 ST Outlet 94, .5 PC Inlet
PC Bottom Header/Manifold 22 Top of ST/PC Manhole Cover 1 0/- fie"
Distribution Lines 7 () ( )
Bottom of System
Final Grade O `� O C )
Date of installation 7 /3 / /5/r Termit number /5���� State plan number
Plumber's signature �— e / cense number o?�l ��y'6 Date 1-71
Inspector -2 2 . /
Complete plot plan
fe sin Department Commerce
Sa and Buildings Di PRIVATE SEWAGE SYSTEM Coun ty:
Y:
INSPECTION REPORT ST. CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)j. 315883
Permit Holder's Name: City ❑ V I Ewn o State Plan ID No.:
HEINTZ JOHN AR RA
CST BM Elev.: Insp. BM Elev : BM Description: Parcel Tax No.:
/Uv�� IU�.Cl�
TANK INFORMATION ELEVATION DATA A9800275 7/30
TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV.
Septic t- Benchmark
Aeration Bldg. Sewer
Holding St/Pf Inlet
TANK SETBACK INFORMATION St /off Outlet
TANK TO P/ L WELL BLDG. AirI to ntake ROAD Dt Inlet
irl
Septic 3 �G / �� NA Dt Bottom
Dosi NA Header / Man. x.47 f
Aeration NA Dist. Pipe /7�
- - -may
Hstaing Bot. System ��r' .
PUMP/ SIPHON INFORMATION Final Grade
cturer Deman ° 01
4 /D
Model Number GPM
"
LH Lift L ctiI System TDH Ft ead
cem n Length Dia. H Dist. To well
SOIL ABSORPTION SYSTEM
`h r BED /TRENCH Width / Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIO S a E I N
SETBACK
SYSTEM TO P/ L BLDG WELL LAKE / ST nu acturer:
INFORMATION TypeO AMBER Model Number:
System: a��� 3a 3 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 Bed/ Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
i
COMMENTS: (Include code discrepancies, persons present, etc.) `r'
LOCATION: STAR PRAIRIE 21.31.18,SE,NW 2095 CO;K DRIVE
0��� � -�.�✓J �' �yl -r �,c ca -5 �c� .� ���= 1 �- Z� �:n�?� .{ , , ^f - c <� . �,2� -U1,E � l -� , ; �r �,� ,
l39''c C
? / _(L
Plan revision required? ❑ Yes ❑ ��
Use other side for additional information.
SBD -6710 (R.3/97) Date Inspector's Signatu a Cert No
Safety and Buildings Division
VisConsin 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 81/2 x 11 inches in size. -ST (r * - r x
• See reverse side for instructions for completing this application State Sanitary Permit N um b er
Personal information you provide may be used for secondary purposes ❑ Check it revision t o previous a p ication
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Property Owner Name Property Location
d N E 1 /4y�f Zia, S 21 T �� , N, R/ E (o r62
Property Owner's Mailing Address Lot Number
�� Block Number
96� c o �� �'
City, State Zip Code Phone Number Subdivision Name or CSM Number
Cid R I C ( ) Cir'C ,4 C_
II. PE F BUILDING: (check one) ❑ State Owned � ity Nearest Road
Public 1 or 2 Family Dwelling - No_ of bedrooms _ E] Town OF Q>r / . r C4 d lr it /Yr ry e
III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 63$ - 1 !B _ 5'366a
1 ❑ Apartment/ Condo v x r • 4 7
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. g 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 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 RSeepage Trench 22 ❑ In- Ground Pressure l 42 ❑ Pit Privy
13 ❑ Seepage Pit X 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
OO Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min-/inch) Elevation
7"7 F Feet I JAJ Feet
VII. TANK Capacity
in gallons Total # Of , Prefab. Site Fiber- Ex per
INFORMATION New Existin Gallons Tanks Manufacturers Name concrete Con Steel glass Plastic A p p
structed
Tanks Tanks
Septic Tank Q( s A ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber I I I ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite se age system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signa re: (No Stamps) /MPRSW No.: Business Phone Number:
79 9 D *71 3 2
Plumber's Address (Street, City, State, Zip Code):
a u a[ o..r✓
IX" COUNTY / DEPARTMENT USE ONLY
[:]Disapproved Sanitary Permit Fee (Includes Groundwater ate sue d I suing A t Si ce (No Stamps)
>" roved Surcharge Fee)
pp ❑Owner Given Initial �]
Adverse Determination �O 1
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD- 6398 (R.11/97) DISTRIBUTION: original to County, One copy To: Safety & Buildings Division, Owner, Plumber
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'Wisconsfri Department of Commerce SOIL AND SITE EVALUATION
Division of Safety and Buildings Page _ of
Bureau of Integrated Services in acc a (t ' . HR 83.09, Wis. Adm. Code
Attach complete site plan on paper not less than 8 1/ 1 21�y rch s in*e. Plan m� t Coun
include, but not limited to: vertical and horizontal r r points on anC,, /
percent slope, scale or dimensions, north arrow, a d location and ista o neareEro d. Parcel I.D. #
¢1y' 7
APPLICANT INFORMATION - Please in ,all infcgfrt 9. _ I F rev_iew V b Date
Personal information you provide may be used for seconda *ses (Prime. 15.04 ( ? f
Property Owner Location
Lot 1/4 1/4,S / TS) ,N,R E
Property Owner's Mailing Address Lot # Block Subd. Name or CSM#
City State Zip Code Phone Number ❑ City ❑ Vill e [9 Town Nearest Road
( ) + L
® New Construction Use: Residential / Number of bedrooms - 2 Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow —� and Recommended design loading rate bed, gpde — trench, gPd/ft
Absorption area required ly3 bed, ft .5��. - trench, ft 2 Maximum design loading rate /7 bed, gpd/ft gpd/ft
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design /site considerations
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 14 S ❑ U 50 S ❑ U MIS ❑ U EN S ❑ U EIS O U EIS 4 U
SOIL DESCRIPTION REPORT
Boring Horizon Depth Dominant Color Mottles Structure GPD /ft
9 Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
® 7;
Ground 3 e1ja s-
elev.
Wi n• S / t
Depth to
limiting
factor
Remarks:
Boring #
r
s
Ground M c J
elev. / _
/-e ft.
Depth to
limiting
factor
C � in. Remarks:
CST Name lease rin ign e Telephone No.
Address Date CST Number
z)t 1211
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer John N. Heintz / P. C. Collova Builders, Inc.
Mailing Address 905 County Road H, New Richmond, WI 54017
Property Address 2095 Cook Drive, Somerset, WI 54025
(Verification required from Planning Department for new construction)
City/State star Prairie, W1 Parcel Identification Number
LEGAL DESCRIPTION
Property Location SE %,, NW j 4 , Sec, 21 , ' 31 N -R 18 W, Town of Star Prairie
Subdivision Circle C Lot # 5
Certified Survey Map # Volume . Page #
Warranty Deed # 550521 Volume 12 0 2 , Page # 234
Spec house 13 yes O no Lot lines identifiable 1J yes O no
SYSTEM MAIdVT'ENANCE
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
masterplumber, 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.
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.
NATURE OF APPLIC CO 3V / l op
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 owners) of
the property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
NATURE OF APPLIC
DATE
sssass Any information that is mis- represented may result in the sanitary permit being revoked b the Zoning De artment
Y g . p ssssss
•• Include with tills 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
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ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
ST. CROIX COUNTY GOVERNMENT CENTER
""■�� 1101 Carmichael Road
Hudson, WI 54016 -7710
(715) 386 -4680
October 23, 1998
REMAX Realty
Attn: Mike Germain
103 Main
Somerset, WI 54025
RE: Septic Inspection for John Heintz located at 2095 Cook Drive, Lot 5 of Circle "C"
Addition, Town of Star Prairie, St. Croix County, Wisconsin
Dear Mike:
A septic inspection of the above referenced property was conducted on July 31, 1998. This
property is located in the SE of the NW of Section 21, T31 N -R1 8W, Lot 5 of Circle "C"
Addition, 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) 386 -4680.
Sinc ely,
mes K. Thompson
Zoning Specialist
/sm