HomeMy WebLinkAbout038-1120-20-075 03,?- /za - ao�6zs" c;�9, -T4 l; y
ST. CROIX COUNTY ZONING DEPARTMENT
AS BUILT SANITARY REPORT
An
Owner
Address :r r» (r
City /Stat g Y
Legal description:
Lot Block
Subdivision/CSM #
Sec. - .a, T3-R j�' W, Town ot PIN #
SEPTIC TANK -- DOSE CHAMBER -- H "G TANK INFORMATION:
Tank manufacturer -R °L r/UPeZ' q/PC Setback from: House t We11
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: Width 3 Length Number of Trenches C2
Setback from: House I ' / Well ;�'.Zo 7 P/L - /DU Vent to fresh air intake _�>Sd
ELEVATIONS
Description of benchmark Elevation
Description of alternate be nchmark 6,o rwc C OS Elevation
Building Sewer ST/HT Inlet ST Outlet PC Inlet
PC Bottom Header/Manifold Top of ST/PC Manhole Cover
Distribution Lines () () ( )
Bottom of System 05
Final Grade
Date of installatioqILPermit number '� State plan number
, �// Plumber's signature`'' License numbe>: / Date��/ /
Inspector �
Complete plot plan
Wisconsin Department of Commerce
Safety and Buildings Division PRIVATE SEWAGE SYSTEM County:
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. 320273
Permit Holder's Name: p Cit ❑ Villa e Town of: State Plan ID No.:
BROWN, JASON STAR PRA E
CST BM Elev.:- Insp. BM Elev.: BM Description: Parcel Tax No.:
�., j 038- 1120 -20 -000
TANK INFORMATION ELEVATION DATA A9800461
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic
/j'}"� '�.r, Benchmark �� Qt
Dosing
Aeration Bldg. Sewer
Holding St/ Ht Inlet
1
TANK SETBACK INFORMATION St/ Ht outlet
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
E t take
Septic NA Dt Bottom
Dosing NA Header / Man.'
Aeration NA Dist. Pipe
Holding Bot. System
7,3 u'
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand`' ` t `n
Model Number GPM
TDH Lift Friction System TDH Ft
Forcemain Length Dia. Ff Dist. To well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Lengt�!, , No. Of Trenches pIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 41 ,� DIMEN I N
SETBACK
SYSTEM TO P/ L BLDG I WELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION Type O ✓�,) CHAMBER Model Number:
System:.�, /' ��. 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
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: STAR PRARIE 29.31.18.497A,SW,SE 969 192ND AVENUE
Plan revision required? ❑ Yes ❑ No
Use other side for additional information. Llb ) , 1 ,
SBD -6710 (R.3/97) Date Inspector's Signature Cert. No
Safety and Buildings Division
� SANITARY PERMIT APPLICATION 201 W. Washington Avenue
`.►500115%11 P O Box 73
I
In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 -7302
Department of Commerce
• Attach complete plans (to the county copy only) for the system, on paper not less County G? Cr f
than 8 1/2 x 11 inches in size.
e See reverse side for instructions for completing this application State Sanitary Permit Number
3202
Personal information you provide may be used for secondary purposes ❑ Check if revision to previous application
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION y9 71� "
Proapcbv Owner Nam H ro cation / 1/4� 1/4, 5 ?� T , N, R /6' E (or
Property Own M fling dre s Lot Number / Bloc Number
Ali to f Zip C �t/ P Nu b Subdivision Na CSM
( )
II. YP B ILDING: (check one) ❑ State Owned !t� f r q crest R�ad� U
VII age d a J
Lj Public 1 or 2 Family Dwelling - No. of bedrooms Town OF /^
III BUILDIN USE: (If building type is public, check all that apply) I Pakircel Tax Number(s) 7�
1 ❑ Apartment/ Condo
2 ❑ Assembly Hall 6 [] Medical Facility/ Nursing Home 10 ❑Outdoor Recreational Facility
3 E] Campground 7 E] 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. E] Replacement of 4_ E] Reconnection of 5. E] Repair of an
�S stem System _____________ Tank Only_ ____________ Existing System _- Exlstlnq System
_
Y
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 r 22 E] In- Ground Pressur 42 [] Pit Privy
13�❑ Seepage Pit,, -3ti �61 ��� ,�l e ,(�� C►� 43 C] Vault Privy
14 E] System- In -Fill c � ��
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate ed 5. Perc. Rate 6. Sys em Elev. 7. Final Grade
l Requir (s . ft.) Prop? (sq. ft.) ( als/da /sq. ft.) (Min. /inch) / 4 5 /�5 P�iq, Elevation
S r � Feet 140 Feet
VII. TANK Capacity Site
INFORMATION in gallons Total # of Manufacturer's Name Prefab Plastic
. Con- Steel Fiber- asc Exper-
New Existin Gallons Tanks Concrete strutted glass App-
Tanks Tanks ,n,�
i Ta olding Tank DV � cues d (I El El ❑
Lift Pump Tank /Siphon Chamber o El I
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sews shown on the attached plans.
Plumb 's Name: (Print) Plu b 's Signature: (N Stamps) / Business P��um��
k
Plumb i ; A d !street .� Stale 'p Code / e2�
L ', ��✓✓ v
IX. COUNTY / DEPARTMENT USE ONLY
[] Disapproved Sanitary Permit Fee (includes Groundwater ate ssue Issuing Agent Signature (No Stamps)
Surcharge Fee) /1
�] Approved p Owner Given Initial ��0.0
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
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W isconsin Department of Commerce SOIL AND SITE EVALUATION
Dision 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 Pfau must County
include, but not limited to: vertical and horizontal reference point (BM� ec 6 and �-
percent slope, scale or dimensions, north arrow, and location and di b9 to n ares&ad.
Pareel LD. #
APPLICANT INFORMATION - Please print all info ion�t F00 Reviewed by Date
Personal information you provide may be used for secondary purposes (Pri4 yow, s 15 b4 (1) {m)).
Property Owner Prep r �Location t�
51�a*./ r ✓ +tlf�„Nl f_af:: f �� F14,S C 2 I TS N,R ! � E (or W
Property Owner's Mailing Addr L # .B(6pkff • Subd. Name or C
VC
City State Zip � j Code Phone Number ❑ City Village ,� Town Near st Road
J n, Q l �/ ^ CJ� - ✓ �y r ^ Jim ,
;K-Vew Construction Use: AResidential / Number of bedrooms Addition to existing building
❑ Replacement [I Public or commercial - Describe:
Code derived daily flow / gpd Recommended design loading rate bed, gpd /fi trench, gpd /ft
Absorption area required qa bed, ft2 d trennnch, ft 2 Maximum design loading rate bed, gpd/ft ' trench, gpd /ft
Recommended infiltration surface elevation (s) r, T✓ 7J�i y�I ,/ ft (as referred to site plan benchmark)
Additional design /site considerations
Parent material Flood plain elevation, if applicable ^/ v r7 ft
F u Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank = Unsuitable for system S❑ U �S ❑ U �S ❑
U c El U ❑ S U ❑ S U
SOIL DESCRIPTION REPORT
Boris # Horizon Depth Dominant Color Mottles Structure GPD /ft
9 Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
Ground
ele /
r��ft. '
Depth to
limiting
Min. )
Z/• Remarks:
Boring #
601 -1 3 1 ,i
oa
OF
Ground
A e v
Depth to
limiting
/ � fa �✓
in. Remarks:
CST Name Please Print) Siqpato Telephone No.
Address / , � f` �� Date 17 CST Number
4
Soil Test Plot Plan
'Project Name Jason Brown Shaun B'
Address 439 Park Lane
Hudson Wi 54016 CSTM #3922
Lot 6 Subdivision Vol 11 pg 3203 Date 7/15/98
SW 1 /4SE 1/4S T 31 N /R W TownshipStar Prairie
❑ Boring ()Well PL Property Line County ST. CROIX
IL BM or VRP Assume Elevation 100 ft. Top of Nail in Tree with Orange Ribbon
System Elevation 9 5.5/94.5 * H R p SE Corner of Property
Alt, BM Top of Fence Post with Orange Ribbon @ 104.8
192nd Ave
66'
700'
Property Line
Pro 3
Bedroom
House Pro Driveway
0'
130, 1 75' B -2
Pri A B -3 35' 15'
60' Rep A 15'
25
12' B -5 75 ' B -4
B.M. 6%
Slope 10'
Alt.
1320' Property Line 420'
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer U& SO O A
Mailing Addres / Ark 1
Property Address �� / 1 a "
A1 (Verification required from Planning Department for new construction)
City /State b- I Parcel Identification Number d Oi!)
LEGAL DESCRIPTION
r
�G- /q r
Property Location ' /q, ' , Sec. �, T ( N -R� , Town of
Subdivision , Lot #
Certified Survey Map # , Volume , Page it 3 �g
Warranty Deed # �O "��(O , Volume ?5 , Page #
Spec house ❑ yes 0 no Lot lines identifiable R 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
master plumber, 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.
- b " 8 W 711
S NATURE OF APPLICANT 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. C�
4 f) ANA / I� R
SNATURE OF APPLICANT 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
4
FILEp
8 A UG 0 5 1996 ► 2
584464 KADIo uWAIS H 3
L ca, wi
CERTIF RVEY MAP
Located in part of the Southwest Quarter o ast Quarter of Section 29, Township 31 North, Range 18
West, Town of Star Prairie, St. Croix County, Wisconsin, being part of Lot 4 of Certified Survey Map as described
and recorded in Volume 11 page 3203, Document No. 554710 at the St. Croix County Register of Deeds Office.
Prepared for and at the request of: LINE DIRECTION DISTANCE
OWNER: �►�,,R L1 NOO'00 43 E 24.17
Ralph Mondor .i+'� GQ� +y� R— N00'17'41 "E
1854 100th Street'
New Richmond, WI 54017 ✓��� �'�, '� L NOO'00 11 21.21
Drafted by. Krtsti A. Eylandt 6�z 9� $� R =S00' 17'41 "W R= 21.36'
KONAI,D F. L3 R.O.W. LOT 5 S89'47 07 E 241.12
THIS MAP SUPERCEDES C.S.M. JOHNSON � L4 R.O.W. LOT 6 S89 66.00'
1 VOL 12 PG. 3471 DOC. NO. 5 L5 TOTAL R.O.W. S89 07 E 307.12'
581239 AMIFIRY•A it
: ELEVATIONS BASED ON ASSUMED DATUM.
� , ORTY < ir'P •,.• A` BENCH MARKS:
I 114 CORNER <t SUR` E ,��, BM X11: TOP IRON PIPE. ELEV= 100.00 N
/ 1
SECT /ON 29 ,31 - 18 * ���r,�,,, BM #2: TOP IRON PIPE. ELEV= 120.40' o 0) N
I 1 (ALUM. CO. MON. - v
1 CAPPED BERNTSEN) o t
JOINT DRIVEWAY c .J ai
i UNPLATTED LANDS o •�
I LOT 5& 6 N 0 o
1 NORTH LINE OF 7HE SW 114 OF THE S£ 114 SEE DETAIL
I
ni .. c
I 192nd Ave 19 2 N _D_ AVENUE R= N89 '42'19"W °°
j -1 - 1 - — — — — — — — — — — SBW59 - E 307.12' N E
-- 241.12' -_� �i 6�0' - o o o
` - rT/ - - " c a m
M 1 WA O I V I MI v ° iM 1 \ -' O / \ /I 1 �` J Vi O O
nl I �i . /I I N iM my
I I 01 d nI I t01 I � O� � J i d I M N 2 -
�r L_ CA
i gi al I �i I i I C4 �M O I N� � N O
I I I C7 ri 1
I i k ' 00i I ofsl I-4 c 00 r, a In l 0v-m° a
1 I I N I H I b O m -j O OI ° • d
ro 5
a. ^I �Icil�l _ ���� I -I ob I I N I s pl E N o°
ZI .i I -jI S89 E�� \mil I >I 11 zo 1 1 r` M d I W C °,
I . -CC W / 1 -C � c + r +
139.78'
In �I of I �� �1 ���� BM 2 1\ / o � 3 rn � aj t ° a,
I M o Inl io of c c
Zj •yin I I 3 N89'S5'23 "E / n _ ° n 1 1-� "I ° a�i
V °
g l i I I w/ co 209.95' I ' �-" P I _ � 3 7 m
I O I '� i. ' Iri R =N89'42'19 "W I I Oo I d o °° a°
° w l a I -0- - -- r� sD ° ►k 210.00' 3 i I O N I g LO >I N o L' o
- - - - -- 0 P If) ; m of 1 1 I ,ri'r rn w o+
Q-1 I :l TO ADJOINING LAND OWNER O I m °� m •C
NON \ 006 I 1 1 I M �- C
z i I S89 57'38"E 657.34' Z �' nlr. oM / —1 1\ N Lq o W W 0 ^ ry
�1
i
LL r` ° O 1 /N89'59'33 "W \ \ °fM V U 9 i d >,
1 ELEV =91.1 �'•� c) z ! N o ,
,II \ 240.82' �I c 1° Q Q y -° ° c
1 ��
\ u I o 0 00 a (U
TOTAL AREA: I o : M N o v
vl 3 C x
ti 979,445 SO. FT. \ 1 N lii \ \ o o n 5
(d LU 22.48 ACRES SETBACK = o~ z ~
AREA EXCLUD. R.O.W LOT fi �'� J ��
W 977,979 SO. FT. i W V) J in 2 1 1 W
.' �' 22.45 ACRES in o i o
w^'
b 0 05 1
N Q0 tiN�W�
I z 4i 1 c
1\ SOUTH 114 CORNER FND /RQN /PE L §F j j Q V J a
1 SEC77ON 29- ,J1 -18 S18'42 46� 0.55 I I
\\ (ALUM. CO. MON.- FROU COMPUTED POS /AON I I
CAPPED BERNTS'EN) 1 16'
SOUTN LINE OF THE I /
SW 114 SE 114 / — 1314.32'
— x —x —x —x Jt
` -- -- --- N89'47'01'W 1314.32 ------
- - -- v
LEGEND: N89'47'01'W 2628.64'---- -
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