HomeMy WebLinkAbout038-1172-50-000 • 'Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count :
Safety and Buildings Division INSPECTION REPORT
T • CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary jgr� �o.:
Personal information you provice may be used for secondary purposes [Privacy w, s.15.04 (1)(m)]. 3l1 t3 LL
Permit Holder's Name: ❑Slty f ft92 own of: State Plan ID No.:
K ING, CORY & JENNIFER gfj& YKAl
CST BM Elev.: / Insp. BM Elev.: BM Description: / Parceldaj921172 -50 -000
TANK INFORMATION ELEVATION DATA A9800209
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
!� Benchmark 4) /(L>
Septic Q� S �._ �� a. � 9 Z — o,
Dosing , , 15. � 95 2.2
Aeration Bldg. Sewer
Holdin St / Inlet
TANK SETBACK INFORMATION St/ Outlet
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Ax
Septic NA Dt Bottom
Dosing NA Heade - 7, '
11 Aeration A Dist. Pipe 76 /,
Holding
oldin Bot. System ;( e,5z
PUMP/ SIPHON INFORMATION Final Grade % S� , S
Manuf turer Demand S7 /� r
�, ! ✓� f
Model Number GPM
TDH Lift L ction tem TDH t
Forcemarnj Length Dia. Dist. To well
SOIL ABSORPTION SYSTEM
BED / width i Length No. Of Trenches No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS �� DIMEN
Manufact - ' — ' - �
SYSTEM TO P/L BLDG WELL LAKE /STREAM L
SETBACK
Type O CHAMBER— Mod Number:
INFORMATION T
Y /l�.v -Ccnd; � OR . IT
System: %C�
DISTRIBUTION SYSTEM
Header / Manifold e /A Distribution Pipe(s) �, x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. T 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 El No
COMMENTS: (Include code discrepancies, persons present, etc.)
CATION: STAR PRAIRIE 29.31.19,NW,NE 1975N HAWK DRIVE 4
/� . "? y �� � C� -n-� ' 1 cl �-"�. '�[ „-•-\ P / � - cam.- ..C� -
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD -6710 (R.3/97) Date Inspector's Signature Cert. No
Safety and Buildings Division
Vi sconsin SANITARY PERMIT APPLICATION 2 01 W. Washington Avenue
In accord with ILHR 83.05 Wis. Adm. Code P O Box 7302
Department of Commerce Madison, Wl 53707 -7302
• Attach complete plans (to the county copy only) for the system, on paper not less County �!
than 81/2 x 11 inches in size. , C r1> A
• See reverse side for instructions for completing this application State sanitary Permit Number
Personal information ou p rovide may be used for seconds
y p y second 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 INF RMATION r�
Property Owner me (�, ]/ Property Location
erDr + J 2 v1 V\ 1 "I `1 f ed W LAY IV 1 9 1/4, 5,9 1 T N, R , E (or
Propert wner's Mai Ing Add ss Lot Number BIoSjNumber
ci State Zi_2 Code Phone Number S Name or cfi Number
i 1
I wbd� 115Y761 > la, ,v
11. YPE F BUILDING: (check one) ❑ State Owned !t� Nearest Road
VII age
Public 1 or 2 Family Dwelling No. of bedrooms Town OF y N' /-
III BUILDING USE (If building type is public, check all that apply) Parcel TaxNumber(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. F] Replacement 3. E3 Replacement of 4 E] Reconnection of 5. E] Repair of an
- ___ - -------- System _______ ____ __Tank Only_ ____ _______ Existing ___ _____ExistingS -fstem
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
11g.Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ 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
h � R?uire�d (sq. ft.) Proppo ed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation
V 9 � r Feet 9y. 6 Feet
Capacity
VII. TANK in Ca allo Total # of Prefab. Site Fiber- Exper.
INFORMATION g Gallons an Manufacturers Name Concrete Con- Steel glass Plastic App
New Existing strutted
Tanks Tanks
Septic Tank or Holding Tank ) 106 9 ❑ I ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ 1 0101010 ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
3 26Y
Plumber' me: (P )- J r Plumb Signature Stamps MP /MPRSW No.: Business Phone Number:
e
Plumber's Address (Street, City, State Zip Cod
8 ,I ] 5
IX. COUNTY/ DEPARTMENT USE ONLY
E] Disapproved Sanitary Permit Fee (I ^dudes Groundwater ate slue Issuin nt Signature (No Stamps)
CKApproved E] Owner Given Initial f O a Q G / A SS harge Fee) 6131
O K/ qa
Adverse Determination U
X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL:
SBD- 6398 (R.11/97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
PLOT PLAN
PROJECT Cory and Jennifer Kina ADDRESS 2119 4th Ave N ADt #2 Menomonie Wi 54751
NW 1/4 NE 1 /4S 29 /T 31 N/R 19 W TOWN Star Prairie COUNTY ST. CROIX
MPRS BYRON BIRD JR. 3318 L DATE 5/29/98 BEDROOM 4
CONVENTIONAL XXX IN -GA6O ND PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1200 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 864 BED SIZE 12'X 72'
BENCHMARK V.R.P. Top of White Stake ASSUME ELEVATION 100'
❑ BOREHOLE O WELL *H. R. P. Same as Alt. Benchmark
SYSTEM ELEVATION 90.
Alternate Benchmark TOP OF CORNER POST Alt. B.M.
VENT
615' PL AL 354'
12" GRADE 70'
TYPAR COVERING
12 3' 6' (1) 3' *1
i SEWER R K
12' 30'
x B -1 80 -2
y 30' 10 ' — — — 12' X 72' Bed
-,� o� T 40' -3 Vent
20 ' REP. A
Li 80'
d B -4 - w
o
PROPOSED
DRIVEWAY
PL PL
PL 485'
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
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
APPLICANT INFORMATION - Please print all information. wed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
01
Property Owner Property Location
O y`� • w , Cr. ` Govt. Lot /� 114
411 T N,R E (r W
Property Owner's WAiling Address ® Lot # Block# Subd Name or C #
yr V . GI o?- 0 4,1'x/ r . cle -7-1
City State Zip Code Phone Number ❑ City Villa t + Town
ow Nearest Road
[ New Construction Use: Residential / Number of bedrooms Addition to existing building
❑ Replacement Public or commercial - Describe:
Code derived daily flow 6J 22 gpd Recommended design loading rate _! bed, gpd/ft gpd /ft
Absorption area required !V3 - 7 bed, ft 7S & trench, ft Maximum design loading rate o_bed, gpd /ft Z_ trench, gpd /ft
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design /site considerations X IOP I
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 C gs ❑ U I As ❑ U tiks ❑ U I Jas ❑ U I ❑ S F U ❑ S ,PrU
SOIL DESCRIPTION REPORT
Boring Horizon Depth Dominant Color Mottles Structure GPD /ft
g in. Munsell ou. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench
si-7 r -
Ground _ ��
ev. r
ft l .
Depth to
limiting
fa for
2,�in.
3 , Remarks:
Boring #
G
oC e,
p iF i� Sr
Ground
Depth
limiting "' A Id
factor s _ f,
in. Remarks: `'"j C Ra Y
CST N)(�Print) � Signature w `„ ZO1 / lephone No.
'4G OFFICE /
Addr ss _ - t datb : ` CST Number
e, g't� ,/'ice S v ��
` Soil Test Plot Plan
Project Name CORY & JENNIFER KING Byro ird Jr.
Address 2119 4TH AVE. N. APT 2 '
M ENO I E, WI 54751 CS #3479
Lot 9 Subdivision CNTRYL IVING Date 5 /6/98
NW 1 /4NE 1/4S T 31 N/R 19 W Township STAR PRAIRIE
Boring ()Well PL Property Line County S T. CROIX
BM or VRP Assume Elevation 100 ft.TOP OF WHITE STAKE
System Elevation 90.7 * H R P Same as Alt. Benchmark
Alternate Benchmark TOP OF CORNER POST I o0
615' PL 354' Alt.
70'
*B.M.
z 30'
B -1 80' -2
x 20 PRI. A
b 30' -3
40'
x 20' REP. A
N
o d ¢
Li B -4 80 - w
x �
o °°
PROPOSED
DRIVEWAY M
PL PL
PL 485'
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner /Buyer
Mailing Address al Iq tt , A,,p nAA9 J�
Property Address no
(Verificatio required from Planning Department for new construction)
City /State pr Parcel Identification Number 3 Y
LE GAL DESCRIPTION
Property Location & LJ '/4, _ ' /,, Sec. ��, T_ 3 t N -R�W, Town of Jj-otir Pr6l r t' e. .
Subdivision L )CA4AJ 1 7 /OLV , Lot #
Certified Survey Map # C , Volume "'" , Page #
Warranty Deed # 5 �,S , Volum Page #
Spec house ❑ yes>LJW Lot lines identifiable $ 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 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 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
days of the thfe year exp _� )J] ion date.
5 ,l `''
SIGNA E F APPLICAN 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 prol erty d's,cribed above, y virtue of a warranty deed recorded in Register of Deeds Office. Q
SIGN iJRE F APPLIC N 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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463.56'
72 � 44.4
ro 419.13'
N87 11 ' 50 ° W -
1318.19'
(S88 ° 57'53 "E, 1318.53')
LOT
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5.88 ACRES ° �-�R I Ii IrG
ACRES Ln E: —
256,183 SQ. FT. m
SQ. FT. W 0
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. 74' 262.82 ' 0 EASEMENT
81
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W N87 3912211W -� 64.06'
SOUTH LINE OF THE NWI /4 OF TH
1
ND I OA I" IRON PIPE FOUND .N01 ° 57'3
-- — COMPUTED POSITION.
® i" IRON PIPE FOUND N51 ° 23'
COMPUTED POSITION.
Wisconsin, Department of Industry SOIL AND SIT I E PORT Page _ of
Laborer "! Relations
�+is0n of Safety & Buildings
in accord v4ith`XL Code
COUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in gaze but
C o
d %
not limited to vertical and horizontal reference point (BM), direction anr PARCEL I. . #
dimensioned, north arrow, and location and distance to nearest road. }
APPLICANT INFORMATION- PLE ASE PRINT �L INFORMATION . REVIEWED BY DATE
PROPERTY OWNER �� ... PROPtiR OCATION
r . Ae U) 1/4 N /4,5� T3J N,R E (oi
PROPERTY OWNER':S MAILING AD ESS 1 t BLOCK# SUBD. NAME OR CSM #
ou..r, r "
CITY, STATE ZIP CODE PHONE NUMBER [ ❑VIL E OWN NEAREST ROAD
, So C /S C'T G 'ui '5 ` OCO ( - 71 5147
[New Construction Us J Residential / Number of bedrooms ( J Addition to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow � gpd Recommended design loading rate - .7 bed, gpd /ft gpd /ft
Absorption area required ) bed, ft trench, ft Maximum design loading rate bed, gpd /ft gpd/ft
Recommended infiltration surface elevation(s) 1 / ft (as referred to site plan benchmark)
Additional design / site considerations S— 2
Parent material Flood plain elevation, if applicable — ft
S = Suitable for system C II VENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM FILL HOLDING TANK
U= Unsuitable fors stem ,®S El U 3S El U [XS E3 U S❑ U ❑ S U ❑ S 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
...........- S 33 A4
Ground
elev.
Depth to
limiting
factor AM
y�
Remarks:
Boring #
Ground
eI v.
f d
7f t.
Depth to
n
limiting V
factor�
s
O.¢ Lb _
JJ Remarks:
CST Name:—Please Print Phone:
Address: e
Signature: Date T Number:
I
y Soil Test Plot Plan
Project Name Cha Borgstrom Byron Bird Jr.
Address 2033 Co. Rd. C / �. 4
Somerset Wi 54025 G TM #3479
Lot 9 Subdivision Country Livin Date 8/31/94
NW 1/4 NE 1/4S29 T 3 N /1319 W Township Sta Prairie
F1 Boring ()Well PL Property Line County ST. CROIX
IL BM or VRP Assume Elevation 100 ft Top of Prope Lin Rod
System Elevation 102.1 * H R P Same as Benchmark
398' Property Line
i
.p
0
o
A Pro 3
Bedroom
o House
B -1 40 , B -2
r
Pri A 0'
40' 20' 25'
B -3
Rep A
0'
B -5 40 ' B -4
% o
lope
0
c�
r
398' Property Line
Night Hawk Drive
ST. CROIX COUNTY ZONING DEPARTMENT
/I AS BUILT SANITARY REPORT
Owner ' K . , N
Address t
City /State o,-,_
Legal Description:
Lot_ Block — Subdivision/CSM # w N:eY_
'V4A V4 kf , S ec.21, T-I N -RAW, Town of r PIN # - 7 D
SEPTIC TANK DOSE CHAMBER -- HOLDING TANK INFORMATION
Tank manufacturer LL2e Size ST/PC P2
,� Setback from: House Well
Pump manufacture_ r, Model
Alarm location
(HOLDING TANKS ONLY)
Setbacks: Service road Ven, fir intake Water Line
Meter location
Alarm location
SOIL ABSORPTION SYSTEM
Type of system: A 44 Width Length Number of Trencl ps
Setback from: House ' Well !� /L IdJ Vent to fresh air intake / DT
ELEVATIONS
Description of benchmark , 02 Elevations G-
Description of alternate benchmar �� n-� -Elevation
Building Sewer ST/HT Inlet � ST Outlet PC Inlet
PC Bottom Header/Manifold / b Top of ST/PC Manhole Cover
Distribution Lines ( ) r () ( )
Bottom of System
Final Grade O � O ( )
Date of installation i r - t number _�U� -.7- State plan number
Plumber's signature License number Date
Inspector
Complete plot plan