HomeMy WebLinkAbout038-1113-30-000 y
ST. CROIX COUNTY ZONING DEPARTMEN
AS BUILT SANITARY REPORT
Owner e . �er `
Address
U-) 411
City /State'
Legal Description:
Lot Block C k
—� Subdwis�on/CSM #
''+lOiZ '!4 Sec. , TV'N -R�W, Town of 0 , PIN #
SEPTIC TANK -- DOSE CHAMBER — HOLDING TANK INFORMAT OIN: Y8 A
Tank manufacturer Xwow�,S
Size ST/PC // Setback from: House We
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 stem: � /11 Number of TrenOes
Setback from:
YP system:. Got Length ?'S"
House Well 67D P� dd' Vent to fresh air intake 6d
ELEVATIONS:
Description of benchmark ✓� Elevations
Description of alternate benchmark Elevation 2()
Building SewenGA, 22 ST/HT Inlet :$k ST Outlet. PC Inlet T
PC Bottom Header/Manifold 45� Top of ST/PC Manhole Cover -
Distribution Lines
Bottom of System
Final Grade
Date of install $ /f ermit number l oZ State plan number
Plumber's signature License number 11 Date 17 /S ?l`�'
Inspector
Complete plot plan
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County:
Safety and Buildings Divi sion 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)]. 315952
Permit Holder's Name: ❑City ❑ Village Town of: State Plan ID No.:
JELLBERG, JAMES STAR PRAIRIE
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
OD I I Jp IS.-,5e $2l n,, 11�6w� 1 038 - 1113 -30 -000
TANK INFORMATION ELEVATION DATA A9800339
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic � �; u 0ctia Benchna i f 1,/-7 ) 61.t7 I v b
Elm
Dosing
Aeration Bldg. Sewer
Holding St to Inlet
TANK SETBACK INFORMATION St Io Outlet aryl, 1 7 6-2Z `7 5-- 8
TANK TO P/ L WELL Air BLDG. Air I to ntake ROAD Dt Inlet Tr Septic X( i NA Dt Bottom
Dosing NA Header/ Man. c'fSZL I I .sj 939. E SL
Aerati n NA Dist. Pipe 1-I S Sq. 5 • i✓(– ,�
Holding — Bot. System rP 95.2 cl. 3 139.2
PUMP/ SIPHON INFORMATION Final Grade 1 ni•17 io •i � /
Manufacturer De nd
�. WA l01l47 2.2v q8 9
Model Number
umbe GPM
TDH Lift Friction Syestem TDH Ft
oss Forcemai n Leng _ Fii I Dist. To well
SOIL ABSORPTION SYSTEM
E ENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSION IZ �9'(� --� DIMENSION
SETBACK
SYSTEM TO P/L BLDG WELL LAKE /STREA TC anufacturer:
INFORMATION Type O r AM R Mode ber:
Syst an,,Gnftana )'j �S
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) '' LI x Hole Size x Hole Spacing I Vent To Air Intake
Length - tp Dia Length Dia. 7 • Spacing (✓ �T lit- �jC 2? Zel
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded Tx� Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes F] No Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: STAR PRARIE 28.31.18.480A,NW,SE 1076 192ND AVENUE
Plan revision required? ❑ Yes g- No
Use other side for additional information.
SBD -6710 (R.3/97) Date Inspector's Anature ert. No
* 6ons in SANITARY PERMIT APPLICATION 2 01 E. Washnlgton ve.slon
P.O. Box 7969
Department of Commerce In 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. S4, C Ir i )L
• See reverse side for instructions for completing this application State San it ary Permit Number
The information ou p rovide may be used b other g overnment ag ency p rograms y p y y g 9 y p g ❑Chet; k 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 Name Property Location
►"�-� / ", /4 SE 1/4, S 'd $ T .3) , N, R E (or
Property Owner's Mail in Address Lot Number Block Number
City, State Zip Code Phone Numb r Subdivision Name or M Number
/ G Oti l�J ( S) C-5 U � l 3 /
II. TYPE OF BUILDING: (check one) ❑ State Owned o it ge B
Public or 2 Family Dwelling - No. of bed p Villa rooms Town oF,a./' P 9 C
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. ❑ New 2 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
1eepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 []Holding Tank
12 E] Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 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 y /sq. ft.) (Min. /inch) � Elevation
s
14 o / O o Feet I Feet
Ca acct
VII. TANK in allo s Total # of r Prefab. Site Fiber- xper.
E
INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con- Steel glaze Plastic App
New
Existin structed
Tanks Tanks
Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ 1 ❑ 1 ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumb 's ignatur�: ( Stamps) MP /MPRSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Zip Code). )
IX. COUNTY / DEPARTMENT tKE ONLff J
❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued Issuing Agent Signature (No Stamps)
Approved []Owner Given Initial Surcharge Fee)
Adverse Determination q9 f
X. OF APPROVAL/ REASONS FOR DISAPPROVAL:
1 u- " 2� (&_.�& (2�� .93
SBD-6398 (R 11/96) DISTRIBUTION: Original to county. One copy To: Safety & Buildings Division, Owner, Plumber
PLOT PLAN
PROJECT James Kiellbera ADDRESS 1076 192nd Ave New Richmond Wi 54017
NW 1/4 SE 1/4S 28 /T 31 /R 18 TOWN Star Prairie COUNTY ST. CROIX
MPRS Shaun Bird 226900 —DATE 7 /29/98 BEDROOM 3
CONVENTIONAL XXX IN -G UND PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 Gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .4 ABSORPTION AREA 1 134 BED SIZE 12'X94'
IL BENCHMARK V.R.P. Base of Siding ASSUME ELEVATION 100'
❑ BOREHOLE O WELL - H.R.P. Same as Benchmark
Alt. BM SYSTEM ELEVATION 88 .2
Grade at House @ 98.9 300'
Property Line
30' Driveway
5 '
Existing 3 •well
Bedroom 0 ,
House VENT
x` 12" GRADE
A Cleanout is to 10 B.M. 5' 30 Alt. TWAR COVEJUNG
be installed M' M.
the effluent line T 12" 6' 0 3'
" SEWER ROCK
12'
40'
120'
Failing System
Vent 35' B -1 20,
7% 5'
Slope
B -2
r 12' X 94' Bed
Vent r
B -3
Wisconsin'Department of Commerce SOIL AND SITE EVALUATION
Division of Safety and Buildings Page of
Bureau of Integrated Services 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 1 5} Q i ,
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
30- 060
APPLICANT INFORMATION - Please print all information Reviewed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner Property Location
/XX e Govt. Lot Lj 1 /45fr 1/4,S T ,N,R ! E( r) W
Property Owner's Mailing Address Lot # Block# ubd. Name or CSM#
G� S
City State , Zip Code Phone Number p City ❑ Village 9 Town Nearest Road
New Construction Use: Residential / Number of bedrooms _ Addition to existing building
Replacement S Public or commercial - Describe: 1/
Code derived daily flow d Recommended design loading rate / bed, gpd /f? rench, gpd /ft
Absorption area required bed, ft 106 trench, ft2 Maximum design loading rate bed, gpd /ft trench, 9pd/ft
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design /site considerations ,, /
Parent material Flood plain elevation, if applicable /y )A ft
S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Holding Tank
= Lunsuitable for system X S ❑ U J'S ❑ U 191 S El '�S ❑ U ❑ S U ❑ S
U U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
e s y
Ground `
fI�
ft.
Depth to
limiting
fa�jr� ,
7 " .n.
�' Remarks:
Boring #
Ground
el� ;
l ft.
tepthOo
limiting
facto
Z 5 A 1 in. Remarks:
CST Name (Please Print) Signature Telephone No.
Address Date CST Numb
c
Soil Test Plot Plan
Project Name James Kjellberg Shaun
Address 1076 192nd Ave ✓�G�
New Richmond Wi 54017 _ C TM #3922
Lot 1 Subdivision Date 7/29/98
N W 1 /4SE 1/45 T 3 N/R 1 8 W Township Star Prairie
n Boring ()Well PL Property Line County ST. CROIX
IL BM or VRP Assume Elevation 100 ft. Base of Siding
System Elevation 88.2 * H R P Same as B
Alt. BM Grade at House @ 98.9
300'
Property Line
0' Driveway
5'
Existing 3 • Well
Bedroom 0 ,
House
10' j & M.
5 30' Alt.
T .M. N
a .
120'
Failing System
Vent B -1
35' 0'
7% 5 ,
Slope
-2
5 '
-3
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
This is to certify that I have inspected the septic tank presently
serving the ,,,�,�1t ) b ,ru— residence located at:
N W 1/4, S 1/4, Sec. T E _L_N, R_L2 W, Town of
Upon inspection, I certify that I have found the
tank and baffles to be in good condition, and it appears to be
functioning properly.
Last time serviced ? — a %— ° f,
Did flow back occur from absorption system? Yes No (if no, skip
next line)
Approximate volume or length of time: gallons minutes
Capacity: �
Construction: Prefab Concrete x Steel Other
Manufacurer (if known) : �f�`_u'
Age o known) :
( lgnature) (Name) Please Print
(Title) (License Number)
2- q 9y
(Date)
Form to be completed by licensed plumber (s.145.06, Wisconsin Statutes)
or Licensed Disposer (NR 113 Wisconsin Administrative Code)
Plumber (applying for sanitary permit) Certification:
In accepting the above statement regarding existing septic tank
condition, I certify that the tank to the best of my knowledge will
conform to the requirements of ILHR -83, W Adm. Code (except for
inspection opening over outlet baffle).
Name �� �1 �%' Signature MP /MPRS
5/88
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
/ OWNERSHIP CERTIFICATION FORM
--
� i��-tl.;•ril3t:yer a rvt � ���d��
Mailing Address m
Property Address ,/NrGll le C_14� Ap",gel A —If S o/ :2
(Verification required from Planning Department for new construction)
City /State ��1/17. , �' Parcel Identification Number
LE GAL DESCRIPTION
Property Location '` /a, , ' /a, Sec. , T_,TZN -R_,z��W, Town of
Subdivision , Lot # � .
Ssa
Certified Survey Map # L/ ,Volume ,Page #
Warranty Deed # , Volume d , Page # 4 � l
SI)CC house ❑ yes _f� no Lot lines identifiable Ek 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
raster pluniber, 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 bill 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 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.
GNATURE OF AP CANT 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 property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
fl
/IGNTATiOF APP NT 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
53249
CERTIFIED SURVEY MAP
Located in Part of the Northwest Quarter of the Southeast Quarter and Part of the Southwest Quarter of
the Northeast Quarter of Section 28, Township 31 North, Range 18 West, Town of Star Prairie, St. Croix
County, Wisconsin
Prepared for and at the request of:
OWNER:
James and Janice M. Kjeliberg NOTE: The parcel shown on this map is subject to State, County and Township
1076 192nd Avenue laws, rules and regulations ( i.e, wetlands, minimum lot size, access to parcel,
New Richmond, WI 54017 etc.). Before purchasing or developing any parcel, contact the St. Croix County
Drafted by. Kristi A. E Zoning Office and the appropriate Town Board for advice.
NORTH LINE OF THE S 112 U_N_PL_ATT_E_D_L_A_N_D_S I 300 0 300
OF SW 114 OF NE 114 R = EAST
OF SECT /ON 28 -S 88'37'08" E 636.94' --� I GRAPHIC SCALE
TOTAL AREA LOT 1 : — X X SCALE IN FEET: 1 inch = 300 feet
323, 887 50. FT. FENCE \�
7.44 ACRES j� I
AREA EXCLUDING R.O. 1O C14 317,974 SO. FT o i Z t6
H p N ni
7.30 ACRES Z I = �
S
O
H I tl
I LOT 2 Z ,.
W W ° 0
I
I
TOTAL AREA LOT 2 .• 0 3: � I 4 F W /S
926,656 50. FT w ; z o ; ��O c0,
k I ° =� '� " ° w Z ,/DOUGLAS J. `�
21.27 ACRES i Q'
AREA EXCLUD /NG R.O.W. a i o SHED � � o fr g ; a�
921,529 SO. FT ; o (] Z I _
21.16 ACRES Z °
-- 684.00' -- i� x NORTH LINE OF THE
_ _ X— X
ZNW 114 OF SE 114 5 �
J � — X— i X —X —X—X— X �`� EA
ST LINE OF TH
FENCE ! NW 114 OF SE 114
I i
tl 0 a' i l l W rn i 1
I
WON q 3 S 8659'54" E
3 Z W:D 0 1 .- I I 338.43' - -„� I I NOTE LOT 1 IS
0 0 1 ` I BEING RE BY
J v Z o ;f OWNER. LOT 2 IS
- a to , ► i , , BEING DEEDED TO
° of f I l i AN ADJOINING OWNER.
o Z M I i l LOT 1 �' I I^ THESE PARCELS ARE
a_ 'n UJ U to
I i l M I M 00l EXEMPT FROM APPROVALS
w
6 o W '� o 0 ; i z i PER COUNTY LAND USE
a o_ i- o o f I° g i REGULATIONS: CHAPTER
0 I SHEDEJ SHED i i 18.05 (A)(3).
V) I o rn J 1 I N
ro W ° z i o i w n HOUSE I o ' N a;
CC L \ ^ O Z O ; N SEPTIC i i `o
Qj 'J W J t� ° L D
t o ONO
Z O m U 3 0 CENTERL /NE W d
z iii . i l o o z DRIVEWAY , , i i S\ NO V 2 2 1996
I rn, i Gi Q� , I i I W W KATHLEEN H WALS 8
0 3 W J I I I N; i t o Aeptster of pq H
h z ' i 1. i r, ^ I I o W W SL Cr oix Co, M
.... t t .. .......
R 9
/.O.W. �� 1 N89'2" ii�638--
684.00'_ 03'1 .41�
- 1= _ `� --299 -- -�
-Z — i�i__338.43�—
AI UE - —
��w 88'59'5" W 638.43' — —
CENTERLINE 192nd Ave.
SOT 1 I I OT I of UNPLATTED_LANDS
UNPLATTED_LANDS I ICSM JII M
VOLUME �9�_PAGE_2592 D,