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Home My WebLink About038-1166-80-000 ST. CROIX COUNTY ZONING DEPARTMENT, ' 9 AS BUILT SANITARY REPORT \` • tip L� Owner Property Address o 7` 9 9P P City/State Sr y CE Legal Description: Lot e_ Block Subdivision/CSM # S ' /4, ' /4, Sec. Q U , T 31 N-RIJ W, Town of S7 r �, a� �. r PIN # SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer a Size ST/PC J / Setback from: Housed Well / P/L Pump manufacturer Model Alarm location (HOLDING TANKS ONLY Setbacks. S road Ve Water Line Meter to 'ion Alarm loca ion SOIL ABSORPTION SYSTEM Type of system: _rd,d Oezt Width la Length 5 1/ Number of Trenches Setback from: House Well P/L Vent to fresh air intake ELEVATIONS Description of benchmark Elevation D d • ° Description of alternate benchmark T�s o ,c ,� �L ' ., Elevation 1 .67 , Building Sewer Z 47 F 7 ST/HT Inlet f60.9 d ST Outlet i Dd .,I / PC Inlet PC Bottom Header/Manifold Top of ST/PC Manhole Cover /d3- Vd' Distribution Lines ( ) ? � () ( ) Bottom of System( Final Grade Date of installation / / Permit number State plan number Plumber's signature .dLrLoo- number pyd Date Inspector If Complete plot plan Wisconsin Department of Industry SOIL AND SITE EVALUATION Labor and Human Relations Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Adm. Code Page of 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), direct* percent slope, scale or dimensions, north arrow, and location and distance t road Marcel I. D. # APPLICANT INFORMATION - Please print all inform ion. Revi ed by Date Personal information you provide may be used for secondary purposes (Privacy aw, 15.04 (1) Property Owner Propefy Location, c° c arr7 ( li Govt. Lot sr� 1/4 . W 1/4,S T N,R p E (or( roperty Owner's Mailing Address °� ''�� , a Lot�i Block# Su ame or CSM# L O City State Zip Code Phone Number El City :� a Town Nearest Road `:'�, �� i :� '\ _ a #^� o `r 4 7 (� New Construction Use: Reside ialI plumb � dr s`�' Addition to existing building ❑ Replacement El Publicmerci I ��(( Code derived daily flow 4(S'D N z Q jgggcom en ed design loading rate bed, gpd/te --z� trench, gpd/ft Absorption area required Gy3 bed, ft _3_ _ t,��rc�X �` i um design loading rate _ bed, gpd/ft _ trench, gpd/11 Recommended infiltration surface elevation(s) S' NTV J ft (as referred to site plan benchmark) Additional design /site considerations 1 D S•' f GO Parent material rS� iti%y.r .4 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 ❑ s ❑ u ❑ s ❑ u 1 ❑ S ❑ u I ❑ S ❑ U EIS ❑ U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles G in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz Sh Consistence Boundary Roots PD /ft 2 Bed ,Trench' - 04 d 4 S Ground �elev. 3 - 444P A — r'C 4s- �s S 7 7� =szft• Depth to - - -- — — — -- . — limiting actor in. t Remarks: Boring # Ground elev. - -- ft. ' D epth — — -- e th to limiting factor in. Remarks: CST Name (Please Print) Signature Telephone No. Address Date CST Number er Wiscort Department of Industry SOIL AND SITE EVALUATION REPORT Pa e of Labor and Human Relations 9 Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less te s i Ian must include, but not limited to vertical and horizontal referenction / opescale or PARCEL I.D. # dimensioned, north arrow, and location and r ad. APPLICANT INFORMATION PLEASE ATIO REVIEWED BY DATE PROPER OWNER: ti , RTY LOCATION �� ` _ 6W. LOTS 1 II / V 1, I 114 PROPERTY OWNE MAILING ADDRESS BLO K # I SUBD NAME OR CSM CI T E ZIP CODE R CITY PV1 LLA OWN NEAREST R? J 1 r l' New Construction Use Residential / Number of bedrooms 1- [ ] Addition to existing building j J Replacement [ ] Public or commercial describe Code derived daily flow gpd Recommended design loading rate � 7 ed, gpd /ft trench, gpd/ft Absorption area required tl_ bed, ft , S trench, ft Maximum design loading rate _ bed, gpd /ft ench, gpd/ft Recommended infiltration surface elevation(s) It (as referred to site plan benchmark) Additional design / site considerations Parent material Flood plain elevation, if applicable It S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE I AT -GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem ® S 1:1 U 13S O U ®S [It 19 S ❑ U ❑ S N U ❑ S IN U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench Ground elev. A"- ft. _ Depth to limiting factor Remarks: Boring # ki Ground ` S elev. ` Depth to limiting factor Remarks: CST Name:— Please Print Phone: Address: L L, r Signature: ��, / _ i/ Date: / _ / CST Number: 1 PROPERT'II OWNER _1 � SOIL DESCRIPTION REPORT Page,�of PARCEL I.D. Borin g # Horizon Depth Dominant Color Mottles Structure G /ft Texture Consistence Botxhdary Roots -- .. : : .............. in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ;Trench ................ Ground o elev. - ft. J f � Depth to — limiting factor , Remarks: Boring # 7 _ / Ground elev. Depth to limiting factor Remarks: Boring # Ground elev. 9 ft. - - - - - Depth to limiting factor y 2I(F Remarks: Boring # w Ground elev. ft. ! Depth to limiting factor Remarks: con 013"10 ncin'M 62 �,�o /oS � 0 6 17s�5,= 3s� O D � ` /00 _74o Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: Safety and Buildings Division INSPECTION REPORT ST. CROIX Sanitary Permit No GENERAL INFORMATION (ATTACH TO PERMIT) 315937 Personal inf6rmation you provice may be used for secondary purposes [Privacy L w, s.15.04 (1)(m)]. er it H City ❑ Village Town of: State Plan ID No.: �'. ��U'dU BUILDERS TAR P E Parcel Tax No.: CST BM Elev.; Insp. BM Elev.: BM Description: 038-1166-80-000 100 l UU / u TANK INFORMATION ELEVATION DATA A9800325 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Bench r �` t 3S /04'n oa eptic (�I�c�t�+ca -trn �rcr�e'� Ov6 o r ti Dosing Ifii (�"A "15 �D7' 3 Aeratio Bldg. Sewer I• 8 Holding , / Inlet /00.9 . �} TANK SETBACK INFORMATION � ti � Outlet - ss L l00 zy TANK TO P / L WELL BLDJrE[��E Dt Inlet e +100, w( L r NA Dt Bottom Dosing NA Header / Man. �•� ��9�' Aeration NA Dist. Pipe `► S`/� �I 9� tq Holding Bot. System /O•,`�Z� 3 PUMP/ SIPHON INFORMATION Final Grade y.? !Forcemain 4Length D mand .`za 9 s` X03• ead - -- GPM tem TDH Ft Dia. Dist. To Well fINFORMATION BSORPTION SYSTEM No. Of Pits Inside Dia. Liquid Depth TRENCH Width / �i Length No. Of Trenches p, I N D1 EN I N LEA RING Manufacturer: ACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LE A T P r /J o el Number: Sy e r�i I b0 "f ��-- O R UNIT DISTRIBUTION SYSTEM Distribution Pi e(s) x Hole Size x Hole Spacing Vent To Air Intake Header / Manifold P .� ,/ r / i 1 p0 Length _ Dia Length Dia. Spacing phS7 Z SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only xx De th Of xx Seeded / ffodd xx Mulched Depth Over Depth Over P Bed /Trench Ed es Topsoil ❑Yes ❑ Yes ❑ Bed /Trench Center No 9 COMMENTS (Include code discrepancies, persons present, etc.) LOCATION: STAR PRAIRIE 28.31.18.800,SE,NW 1959 104TH STREET D� C a Z O/OLI Sew" < f+ P16� P(, re v',s;P,j r-et CAL bar; foe�c� v r Plan revision required? [Yes ❑ No ` F- A - d '7 Use other side for additional information. Date Inspector's Sign ture SBD -6710 (R.3/97) Safety and Buildings Division N4.4consin SANITARY 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. , j G Ve f • See reverse side for instructions for completing this application State Sanitary Permit N r Personal information you provide may be used for secondary purposes �eck 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 C r y 114, 1/4, S,2 T Yf , N, R/7 E (or Pr perty Owner's Mailing A dress Lot Number 70 T � � Block Number 7 7 City State I Zip Code Phone Number Subdivision Name or CSM Number a nd f Ol G ( ) R e e-Q :U -e II. TYPE OF BUILDING: (check one) ❑ State Owned 0 C) Nearest Nearest Road Public 1 or 2 Family Dwelling- No. of bedrooms _y__ ❑ Town IF III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) c► 1 C] Apartment/ Condo a 9 . 31' l K. 506) d 3 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. A 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 elSeepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure Y , 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 yso Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation d 3 7 Z/ GL Feet , g Feet VII. TANK Capacity INFORMATION in gallons Total # of Manufacturer's Name Prefab. Site Fiber- Ex p er. New Existin Gallons Tanks Concrete Con- Steel glass Plastic A p p Tanks Tan structed Septic T o artk' .e' �''�Gf 25°� 1,�/ ❑ ❑ 1:1 1 0 Lift Pump Tank /Siphon Chamber 1 ❑ ❑ ❑ ❑ Vill. 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: o Stamps) IPRSW No.: Business Phone Number: Plumber's Address (Street, Cit , State, Zi Code): / ?� s �`Y s� G► r �/ IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued Issuing Agent Signature (Stamps) Cf1' A [� Surcharge Fee) . Pp roved ❑ Owner Given Initial Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.11/97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber Safety and Buildings Division 201 W. Washington Avenue �+ - SANITARY PERMIT APPLICATION NOsconsin P O Box 7302 Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code 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. • See reverse side for instructions for completing this application State Sanitary Permit Number 31593 Personal information you provide may be used for secondary purposes ❑ Check it revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Owner Name Property Location R. (f , > t l4� 1 14,5, ; 2f T _?/ , N, R /f E(or)60 Propert Owner's Mailing Address Lot Number Block Number FF Co 4 City, State r7ip Code Phone Number Subdivision Name or CSM Number s II. TYPE F BUILDING: (check one) ❑ State Owned its Nearest Road C] VII age Public M 1 or 2 Family Dwelling - No. of bedrooms - F bg Town OF r Q III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo a3 1/4 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. M New 2 ❑ Replacement 3_ ❑ Replacement of 4_ ❑ Reconnection of 5_ ❑ Repair of an ------ System -------- System Tank Only 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 [4 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/day /sq. ft_) (Min. /inch) Elevation Is 3 SAO �tJa 3 Feet 7 r Feet Cap acit y VII TANK in Ca gallo Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existing strutted Tanks Tanks Septic Tank or Holding Tank XC I Z ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamberl I I ❑ ❑ ❑ 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) Plumber's Signature: (No Stamps) PI PRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): 6 d S c IX. COUNTY/ DEPARTMEN US E ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Signature (No Stamps) Surcharge Fee) Approved ❑ Owner Given Initial Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.11/97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber C G o l� Q d r f Pic- _ . � G S i' • aa.cJ W "5 e 8� a k n �'G , Co /larJ� e�C �' /mil P r �s �5� �/u / .s2� �aur.�_v �' :.�_�TQ_��s. r' ✓�- - �- ��- L''".� /�%v -e_ 66 n a va "n � a 6 Wisconsin Department Industry Labor and Human Relations SOIL AND SITE EVALUATION REPORT Page of Division df Safety &Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less ttpo*, i i Ian must include, but not limited to vertical and horizontal referencrection / ope, scale or PARCEL I.D. # dimensioned, north arrow, and location and Wst r ad. APPLICANT INFORMATION PLEASE ATION REVIEWED BY DATE PROPER OW ER: 103JERTY LOCATION . LOTS - 1/4 1/4,S 8 T N,Ror)(g PROPERTY OWNE%S MAILING ADDRESS' # BLO K # SUB NAME OR CSM # �,cz+�' CI T E ZIP CODE R ! CITY VILLAGF &OWN NEAREST ROAD . �] New Construction Use Residential / Number of bedrooms [ ] Addition to existing building [ j Replacement [ ] Public or commercial describe Code derived daily flow cp gpd Recommended design loading rate f 7 bed, gpd /ft gpd/ft Absorption area required `sue bed, ft trench, ft Maximum design loading rate �;� bed, gpd /ft ,� trench, gpd /ft Recommended infiltration surface elevation(s) �� ft (as referred to site plan benchmark) Additional design / site considerations Parent material ' Z9 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 13S ❑U ®S El ®S ❑U ❑S U ❑S ®U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD /ft Boring # Horizon Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed JTitench / / J Ground elev. Depth to limiting factor Remarks: Boring # •:. 7 Ground ` elev. ` ft. Depth to / '42 limiting factor Remarks: CST Name:— Please Print Phone: Address: Signature: Date: CST Number: PROPERTY OWNER SOIL DESCRIPTION REPORT Page'�of Boring # Horizon Depth Dominant Color Mottles Structure GPD /ft in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Bax>dary Roots C Bed jTrench l-- I s ..2_. Ground 29 , G elev. �2 ft. Depth to limiting = -- — 7 ij fact Remarks: Boring # 4 _119 ZZ�2 Ground -� _ _ ZV el V elev. ft. Depth to limiting factor Remarks: Boring # Ground '' '�j elev. - Depth to limiting fact Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD- 8330(R.05/92) Aoc �OC9 �• o,� m1 S.�i� iZ+S�AWA, jo /oS � Q a 3s � e 0 0/ j /ao O �j X$" "O; J ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer 11� . , I II' vA 1 d F �A �o � Mailing Address - 7 0 Cc�- R-� F— �� u �.4U r Property Address _ C j �/ / �g� S - f - ,� /mac✓ /P �c �r�ur! (Verification required from Planning Department for new construction) 2 - a � City/State Parcel Identification Number LEGAL DESCRIPTION Property Location 5 E y., N W y,, Sec. 2 T 3 �N -R Town of Subdivision E5 -A- -- i5- f- K. Lot # . Certified Survey Map # Volume Page # Warranty Deed # _ -58 3-3 /s Volume 3 Page It �S 5 Spec hous!,�<yeS ❑ no 410 Lot lines identifiable 9 yes fg�io SYSTEM MAINTENANCE s o OVA c� A E 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 b a licensed can affect the fim ction of the septic tank as a treatment stage is the waste disposal system, pumper. What you put into the system The Property owner agrees to submit to St. Croix Zoning Department a certification fo masterplumber, journeyman plumber, restrictedplumber or a licensed �, signed to by the owner and by a is in proper operating condition and/or (2) after inspection and Pr verifyi that (1) the on-site waswaterdisposal system Pumper (if necessary), the septic tank is less than 1/3 full 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 OF APPLICANT da a year expiration date. SI NATURE 7 1 V / '?F 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 described above, bbyy�virtue of a warranty deed recorded in Register of Deeds Office. S GNA TURE OF APPL ICANT 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 Y W r r I , LL ID 3 N w ` OQ CY M— N CD ° D M co Z I G i J N QI J I 01 WI / CL I ' / iW i is ti_ 3 � � oM iU N fV W N� �' ® ~ Z : f� m O O m ;D I I \ m I I ' I I 1 I \ LL \ I W \ W I �I \ �y� fA U ° \ W Q I \ \ o v /l N y \ 0 w LAJ in \ \ z (D _ (DD o