HomeMy WebLinkAbout038-1184-10-000 ST. CROIX COUNTY ZONING DEPARTMEN
AS BUILT SANITARY REPORT
Owner _ aG'c �_:, 11t j•�. 1
Address / - ` Tai ►�, u > 2� ,
City /State
Legal Description: " ° " "' r '`'`
Lot Block Subdivision/CSM # r��G
%, --!2� % .J2LL Sec. a L , T N -R - _ s- ---- -_
�L 1�, Town of s-a��,� u - � , � � PIN #
SEPTIC TANK -- DOSE CHAMBER - TANK INFORMATION:
Tank manufacturer _ JV , `�lw s t��, Size ST/PC lilted / Setback from: House Well
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: 'Tv e.a -,�/t Width ,5_ Length 7S Number of Trenches 2
Setback from: House Well .(w 4'e-« P /L Vent to fresh air intake /r "1=&
ELEVATIONS
Description of benchmark i Elevation D_ l e , , a
Description of alternate benchmark Elevation ro r <3
Building Sewer ST/HT Inlet 2 ST Outlet PC Inlet
PC Bottom Header/Manifold Top of ST/PC Manhole Cover M5, Zg
Distribution Lines
Bottom of System O
Final Grade ( ) / d' S.:21 () ( )
Date of installation lz ��/ 9 ermit number jr->7<e 1 State plan number
Plumber's signature License number 2�;7 »fie Date /
Inspector /4,1� G d
Complete plot plan Or
WiscoPrsin Department of Commerce PRIVATE SEWAGE SYSTEM Count
• Safety and Buildings Division I NSPECTION REPORT y ST. CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) SanitarxP(8urljt�lp.:
Personal information you provice may be used for secondary purposes (Privacy L s.15.04 (1)(m)]. 33 1 �� bb tt3311
� .T . H BUILDERS (HEINTZ) ' hhR PNej T�gwn of: State Plan ID N o.:
CST BM El L VA Insp. BM Elev.: BM Descriptio : Parcel Tax No.:
t oo loo v a "V X- r 63I? - 118'q _10
TANK INFORMATION ELEVATION DATA A9800070
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
S ptI W ��PC 1 D� Benchm 7 y �2 1OSs. 51 fob
Dosing
Aeration. Bldg. Sewer �] /0
Holding Inlet 444/7 jp el, p?j
TANK SETBACK INFORMATION utlet Cl �l 103.7/
TANK TO P/ L WELL BLDG. Air Ia e ROAD Dt Inlet
Septic i �' 1J! �) r NA Dt Bottom
Dosing NA Header/ Man.
7,rz�L�a.y
Aera 'on Dist. Pipe
7• lo/ a
Holding Bot. System _��z, `6
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand IAu t4 C to . 7 C /OS - )L
Model N ber GPM
TDH Li Frictio ystem TDH Ft
Forcemain Length Dia. Fi Dist. To well
SOIL RPTION SYSTEM
BE RE idth Length / No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSION
SETBACK
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING manufacture
INFORMATION Type O CHA Mode u
Systemepn �? y" G� OR UNIT
DISTRIBUTION SYSTEM
Header / Mani old Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
•
Length I c { Dia. Length �I Dia. 4 e_(4,".j,7,X Spacing _�•� f O
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over � �� Depth Over xx Seeded/ Sodded xx Mulched
Bed /Trench Center �/ Bed
I /Trench Edges Topsoil ❑Yes E] No I No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: STAR PRAIRIE 21.31.18,SE,NW 2050 CTY RD C
A0 w� I ( u -1 0 C s�
AA (91
Plan revision r quired? ❑ Yes No
Use other side for additional information. H
SBD -6710 (R.3/97) Date Inspector's Signature e
t
S
Vi icons i n Safety and Buildings Division
SANITARY PERMIT APPLICATION 201 E. Washington Ave.
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
than 8112 x 11 inches in size. re
• See reverse side for instructions for completing this application State Sanit Permit Num er
y be used b y g agency programs The information you provide may other government a enc ro rams
Jk ❑ if revisio 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 Name Property Location
va I) va, 5 ' a/ T 3l r N, R F E (or�
Property Owner's Mailing Add ess Lot Number Block Number
S eGJ .0 /l
City, State Zip Code Phone Number Subdivision Name or CSM Number
? , !7r [ (— ) — CiN C
II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ ity � Nearest Road
Public 1 or 2 Family Dwelling - No_ of bedrooms � - Town OF S7`a Y � ? H C
III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) o'Lf 3 j 1'9 . g 29'
1 ❑ Apartment/ Condo J ( - 60
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 E] 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. & New 2. ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5_ ❑ Repair of an
______System System
_____________________ Tank Only______________ Existing System ________ Exist' Syrstem
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 ❑ Seepage Pit W 5X 43 ❑ Vault Privy
14 []
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
SD Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation
5_0 7 SO 0 �� /06 Feet / 9 Feet
VII. TANK Capacity
INFORMATION in gallons Total # of Manuf Name Prefab. Site Fiber Ex per-
anu
New ExiStin Gallons Tanks Concrete Steel glass Plastic A p p
strutted
rokif Tank Tanks
an A v or 7"evAl ❑ 1 ❑ ❑ T ❑ ❑
Lift Pump Tank /Siphon Chamber[ ❑ ❑ 1 ❑ ❑ 1 ❑ I ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: (No S amps) P/ PRSW No.: Business Phone Number:
h, ��1 -r �✓ 12 ?g Q a �� - ��� - -,31z�
Plumber's Address (Street, City, State, Zip Code):
, I 7el S ev J Ac. _ mot°'
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanit 0 Permit Fee (Includes Groundwater ate ssu fssui Agent Signature (No Stamps)
A roved Surcharge Fee) pp ❑Owner Given Initial r�
Adverse Determination
X. CONDITIONS OF APPROVAL /REASONS FOR DISAPPROVAL:
� ggf DISTRIBUTION: original to county, one copy To: Safety & Bud ings Division, owner, Nuunber
s.'fe
a A
d
� � 3
Wisconsin Department of Commerce * 3OILA SITE EVALUATION
Division of Safety and Buildings r3 Page of
Baeau of Integrated Services cordance wife �: LHR 83.09, Wis. Adm. Code
Attach complete site plan on paper not less 1/2 x 1 � �� ze. Plan st County
include, but not limited to: vertical and horiz reference point (BM), direction a `
i
percent slope, scale or dimensions, north ar o nd h n di to near t road. Parcel I.D. #
. � n d l
r •�.
5T CROIX
APPLICANT INFORMATION - Plea' 'ntK19tAfation., :, ~ ev wed Dat
IN O FFICE
Personal information you provide may be used for seco ary�xUpposes (�nvacy Lm<s> 1 (1) (m)).
Prope Owner ", Property Location 1 � 7 2 � d .: - - -�'" Govt. Lot �� 1/4 w' 1 /4,S T� N,R E (or& 1 V Z 72
Property Owners Mailing Address Lot # Block# I Subd.jlame or CSM#
City State Zip Code // Phone Number ❑ City Vill ® Town Nearest Road
y l —
❑ 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 --/--= gpd/ft gpd/ft
Absorption area required 2nn bed, ft ft Maximum design loading rate bed, gpd/fi G trench, gpd/ft
Recommended infiltration surface elevation(s) ,/ms ft (as referred to site plan benchmark)
Additional design /site considerations
Parent material i r�� , 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 91 S El [3 S❑ U 1A S El ❑ S O u ❑ s 19 u
SOIL DESCRIPTION REPORT
Boren # Horizon Depth Dominant Color Mottles Structure GPD /ft
9 Texture Consistence Boundary Roots
r in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Ground S 1
elev.
Depth to
limiting
factor
Remarks:
Boring #
La c✓
3 d y,
Ground
elev.
JA S%
Depth to
limiting
factor
; �in. Remarks:
CST Name (Pease Print) I Si at re / _ Telephone No.
Address Date CST Number
llz / 7
3s i
ya /
v
l
t
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
OwnerMuyer To- /N z 4
Mailing Address q0 H /1) Fw R ctc�n��u p , W z 5 7
20 5 4 0 ca,
c
Property Address 90� Pe
(Verification required from Planning Department for new construction)
City/State _S R P lAl2 r E Parcel Identification Number
LEGAL DESCRIPTION
Property Location %., %., Sec. , T N -R �f W, Town of �A� � ,PA �A i .e"
Subdivision e 4 (1 4 c &, Lot # ! l
Certified Survey Map # , Volume , Page #
Warranty Deed # 55 0 S Z , Volume l a . Page # c7l 3
Spec house ❑ yes )(no Lot lines identifiable )2dyes ❑ 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
masterplumber, journeyman plumber, restrictedplumber 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 yeaZexp ' o n date.
u 3 / a2
NATURE OF APPLIC 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 rty described :bo by virtue of a warranty deed recorded in Register of Deeds Office.
,i
r ***A TUR E OF APPL 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
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ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
Kno ST. CROIX COUNTY GOVERNMENT CENTER
■oun
1101 Carmichael Road
Hudson, WI 54016 -7710
(715) 386 -4680
June 25, 1998
River Valley Abstract & Title
206 2nd Street
Hudson, WI 54016
RE: Septic Inspection for P.C. Collova Builders /John Heintz located at 2050 County Road C,
Lot 11 of Circle "C" Addition, Town of Star Prairie, St. Croix County, Wisconsin
To Whom It May Concern:
A septic inspection of the above referenced property was conducted on April 27, 1998. This
property is located in the SE Y4 of the NW of Section 21, T31 N -R18W, Lot 11 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) 386 -4680.
Sincerely,
P f � 4ve
Rod Eslinger
Assistant Zoning Administrator
/sm
l
FAX
ST. CROIX COUNTY ZONING OFFICE
1101 Carmichael Road
Hudson, VVI 54016
(715) 386 -4680
DATE: _ q�
TO: Fax Number.
Name: ��� dLg-' /�
FROM: Fax Number. 386 -4686
� �'
Name: ke 1
Number of Pages Including Cover Sheep
IF COMPLETE AND LEGIBLE INFORMATION IS NOT RECEIVED, PLEASE
CONTACT:
NAME:
TELEPHONE NUMBER: -- , fG� - .. E7 C/ 9