HomeMy WebLinkAbout038-1183-70-000 CROIX COUN'T'Y ZONING DET'ART'MENT
AS RUIL'I' SANI'T'ARY REPOR"I'
Owner
Address Ca' IeX
City /State �c�sc,r/
Legal Description: lt�Nryk f
Lot _Y Block ��G�F
Subdivision/CSM it �' '
Sec. a, TAN -R,�E W, Town of
PIN # -�-
S
rd
EPTIC TANK — DOSE CLAMBER — HOLDING TANK INFO RMATIO1Vl�� 13or
Tank manufacturer ` �s�� Size ST/PC Setback from: House I f Well P-
Pump manufacturer Model P /L4
Alarm location
(HOLDING TANKS ONLY)
Setbacks: Service road Vent to fresh air intake
Meter location Water Line
Alarm location
SOIL ABSORPTION SYSTEM:
Type of �?
yp system: `tr ,� e Width � Length _-`-'- Number of Trenches
Setback from: douse SD Well . p/L
mg Vent to fresh air intake •�-
ELEVATIONS:
Description of benchmark
Description of alternate benchmark Elevation T�,�� � �"' �� e � �
Elevation
Building Sewer 1 ST/HT Inlet 7,5 ST Outlet y7. 17' PC Inlet
PC Bottom Header/Manifold 5 Top of ST/PC Manhole Cover
Distribution Lines
Bottom of System
Final Grade
Date of installation 4 � / Permit number ��t� ®Zi
State plan number
Plumber's signature `-
� License number tea_ 2F?,a Date
Inspector
Complcic plot plan K
r
Safet Department Commerce
S • a a Buildings' Di PRIVATE SEWAGE SYSTEM Coun ty:
y ST . CROI X
' INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary- PgrSn6tN�.:
Personal information you provice may be used for secondary purposes [Privacy L s.15.04 (1) (m)]. .S L4 U
ffil s�t /P . C COLLOVA el i -n of: State Plan ID No.:
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel T
M' L 1183 -70 -000
TANK INFORMATION ELEVATION DATA A9800491
TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV.
Septic JOCO Benc m 4b ?7.3 l0i •3 1 It
Dosing
Aeration _�-- �. Bldg. Sewer `F
Holding r St /Inlet - 2- 7
TANK SETBACK INFORMATION St/ I�Outlet
TANKTO P/L WELL BLDG. AAiirIntake ROAD Dt Inlet --,
Septic 5 I 1,8 NA Dt Bottom
Dosing — — — --- NA Header / Man. �,'75 S4.
Aeration _ NA Dist. Pipe
Holding — Bot. System 77
PUMP/ SIPHON INFORMATION Final Grade 3,7;�
Manufacturer Demand 51 AA�J q6
Model Number — GPM
TDH Lif Friction, M ead— stem TDH - Ft oss
Forcemain Length Dia. _ Dist. To Wel*—
SOIL ON SYSTEM
DIMENI N Width / Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSION
SETBACK
SYSTEM TO P/L I BLDG I WELL LAKE /STREAM LEACHING Manufacturer:
INFORMATION Type Of CHAMBER Moe Number:
sys s y�rtw►� sa �1� OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold , Distribution Pipe(s) x Hole Size x Hole Spacing I Vent To Air Intake
��
Length W_ Dia. Length Dia. � Spacing DEL/ p 4- t vt/
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 C] No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: STAR PRAIRIE 21.31.18,SE,NW 2105 COOK DR - CIRLCE "C" LOT 7
r� ,� Y �e� . � c '�S`� w� dto;r�� • 3 7
pz tCU 6 " 1 d
W &j— NoT 'D ¢ZwQ A-T 1 N=ib (cc�l
�1�ae s r uired? ❑ Yes KL No
Use other side for additional information.
SBD -6710 (R.3/97) Date Inspector's Sigrffture
*6 Ons in Safety and Buildings Division
S ANITARY PERMIT APPLICATION 201 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 8 112 x 11 inches in size. S r'Q r
• See reverse side for instructions for completing this application State Sanitary Permit Number
Personal information you provide may be used for secondary purposes _ 3`2-4002— ❑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 RMATI N
Property Owner Name Property Location
C �o 4/,1 r 2 It 1 /a 1/4, Sag l T 3 / r N, R J8 E (orlo
Prope Owner's Mailing Address Lot Number Block Number
City, State I Zip Code Phone Number Subdivision Name or CSM Number
II. TYPE OF BUILDING: (check one) ❑ State Owned 0 c ity Nearest Road
Public a 1 or 2 Family Dwelling -No. of bedrooms 3 Y . Town g OF
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. 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 Seepage Trench 22 ❑ In- Ground Pressure , 42 ❑ Pit Privy
13 ❑ Seepage Pit Z' S X 57 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
ys� Required (sq. ft.) Proposed (sq. ft.) (Gals/da /sq. ft.) (Min. /inch) Elevation
1: t_6 y Feet 'Ft?, S Feet
VII. TANK Capacity
in gallons Total # of r Prefab. Site Fiber- Ex er.
INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel Plastic p
New Existing structed glass App.
T nks Tanks
Septic T k �- ��Q 1 � sTeY,v ® ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamberj ❑ ❑ ❑ I ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite se ge system shown on the attached plans.
Plumber's Name: (Print) Plumb / er's Si ature: Stamp P PRSW No.: Business Phone Number:
�> /l. - 7 1 �-_T pa 3 /mil
Plumber's Address (Street, City State, Zip Code):
G ' a
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued Issuing A ent Signature (No Stamps)
A roved surchar Fee)
Adverse Determination DD ((// // OD o
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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Wisconsin Department of Commerce SOIL AND SITE EVALUATION
Division of.Safety and Buildings Page of
Bureau of Integrated Services in accordanciR 83.09, Wis. Adm. Code
Attach complete site plan on paper not less than 8 1/2 x 1 F es'in size. Ian rust ' County
include, but not limited to: vertical and horizontal referen (BM�1 ' nd percent slope, scale or dimensions, north arrow, and I too d dis est rods parcel
I.D. #
�ip'. � 4,n
APPLICANT INFORMATION - Please prin 1f "nformation. °7 /:337 Reviewed by Date
Personal information you provide maybe used for secondary pu ,(Privacy �o (1) (m)).
Property ner 0� F t perty ` ation
Govt. Lb 5 1/4 1/4,S T ,N,R or)
Property Owner's Mailing Address �` L k# Bloc Subd. Name or CSM#
c
City State Zip Code Phone Number ❑ City r Villa E25, Town Nearest Road
G r t/
(� New Construction Use: Residential / Number of bedrooms Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow :1 'c gpd Recommended design loading rate _ bed, gpd/ft gpd/ft
Absorption area required Gy3 bed, ft .S/ trench, ft2 Maximum design loading rate 7 bed, gpd/ft _ trench, gpd/ft
Recommended infiltration surface elevation(s) Zl el 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 ® S El IRS [I U � S El 0 S El 1:1 S 2� U ❑ s ® u
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft2
Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
W
Ground
elev. ,s ' s 71
Depth to
limiting
factor
Remarks:
Boring #
L4 /14
a
t r
T
Ground
el le� ev �.
9 ' r
Depth to
limiting
factor
>9 in. Remarks:
CST Name (P ea Print) Sig ture Telephone No.
Z A7
Address Date CST Number
,G
945
lea
17?
AN
36' 3 � Q r
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ST CROIX COUNTY
SEPTIC 'TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buycr John N. Heintz / P. C. Collova Builders, Inc.
Mailing Address 905 County Road II, New Richmond, WI 54017
.S"
Property Address '2 /0
've Somerset, WI 54025
(Verification required from Planning Department for new construction)
City/State Star Prairie, W I Parcel Identification Number
LEGAL DESCRIPTION
Property Location SW V., NW %., Sec. _21 - 1' — 31 N -k - 18 1 8 W, Town o f S t a r Prairie
Subdivision Circ C
Lot 7
Certfed Survey Map #
Volume Page It
Warranty Deed # 550521 Volume 1202 234
Page #
Spec house ® yes Q no Lot lines identifiable ® yes O no
SYSTEM MAIL EMNANCE
Improper use and maintenance of your septic system could result in its pncmature.failure to handle wastes. Proper maintenance
eoasists of pumping out the septic taxi; every three years or sooner, if needed by a licensed P um
can affect the function of the septic tank as a treatment stage in the waste disposal system. per. What you put into the system
The property owner agrees to submit to St.
u Croix Zoning Department a certification fo rm,
is in n proper r mber, operatin atin eymanplumber, restricted plumber or a Ucenscdpumper verifying that (1) the on sitc ystem
u tg 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
set forth, herein, as set by the De parent of Co the the private sewage disposal system with the standards
tmrtcrce 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.
/G�NARI OF APPLI r l_z
DATE
OWNER CER'TMCATION
I (we) certify that all statements on this form am true to the best of my (our) knowledge. I (we) am (arc) die owne s of
the property described ve, by virtue of a warranty deed recorded in Register of Deeds Office. )
IGNATURE O APPLIC q - 2 -y - r l f
DATE
••••" Any info n that is mis- represented may result in the sanitary permit being revoked b the Zoning Department.
•• Include with this apPllcation: a stamped warranty decd from the Register of Deeds office
a copy of the certified survey map if reference is made in Ute warranty deed
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ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
1 r r N
In ST. CROIX COUNTY GOVERNMENT CENTER
_ ' " ■�, 1101 Carmichael Road
Hudson, WI 54016 -7710
z (715) 386 -4680
January 25, 1999
P.C. Collova Builders
Attn: Lori
705 County Trunk E
Hudson, WI 54016
RE: Septic Inspection for P.C. CollovMohn Heintz located at 2105 Cook Drive,
Lot 7 of Circle "C" Addition, Town of Star Prairie, St. Croix County, Wisconsin
Dear Lori:
A septic inspection of the above referenced property was conducted on November 19,1998.
This property is located in the SE of the NWA of Section 21, T31 N -R1 8W, Lot 7 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 three (3) bedroom
home.
If you have any questions regarding this, please contact our office at (715) 3864680.
Si rely,
C Rod Eslinger /
Assistant Zoning Administrator
AM
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