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N 2' 0 `m a d a • 'ca a a m :� `m I _1 A Ua�l'',ovic°� CROIX COUN'I'Y ZONING DEI'AR`I'MEN:3',,'< ` AS BUILT SANI'T'ARY REI'OIt'I' Owner I Address City /State sY CRUx ccwNn Legal D cription: Lot Block Subdivision/CSM It ��v� e� 7 � yT �' /,, Sec., TN -R,/W, Town of aH PIN �3l � SEPTIC TANK — DOSE CHAMBER — HOLDING TANK INFORMATION: $ - 7 s $ Tank manufacturer Size ST/PQI / Setback from: House Well V P L e_r, 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 Length Setback from: - House �— Well O p/L ��, ` t t—'?-0 fresh Number of Trenches 1;21 L_ air intake ELEVATIONS: Description of benchmark ������` ;� % Elevation G Description of alternate benchmark Elevation J03 Building Sewer �- SVHT Inlet 106- -- 1a/v• 1.5' ST Outlet PC Inlet PC Bottom Header/Manifold ? 31 Top of ST/PC Manhole Cover JC7- Y e Distribution Lines (�� � �_ 7? oZl ( ) Bottom of System( ) ��� () ��• ( ) Final Grade ( ) �p /. ( ) ( ) Date of installation Permit number � State plan number Plumber's signature f ''� License numbers Date/ Inspector Con1pictc,Plot plan Wiscorin Department of Commerce Count PRIVATE SEWAGE SYSTEM Safety and Buildings Division INSPECTION REPORT ST. CROIX GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Personal information you provice may be used for secondary purposes [Privacy L w, s.15.04 (1)(m)]. 320250 Permit Holder's Name: a Cit � Villa e Town of: State Plan ID No.: NELSON, CHRIS STAR PM IE CST BM Elev. - - Insp. BM Elev.: BM Descriptio Parcel Tax No.: 038 - 1165 -40 -000 TANK INFORMATION ELEVATION DATA A9800435 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Sept c ZED Benc Dosing Alf, 0) - Aeration Bldg. Sewer Holding St /Ht Inlet TANK SETBACK INFORMATION (� Q St /Ht Outlet 2.17 105 TANK TO P/ L WELL BLDG. Air Intake RIS)ADJ Dt Inlet eptic W ZTj 0 NA Dt Bottom Dosing NA Header / Man. �� �f.62 Up • FjKin NA Dist. Pipe Holding Bo. System q7 4 . I` PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand 5� a � 1 3 1p Model Number - GPM TDH i Lift Friction S ste TDH Ft Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BE R Width 3 f Length N0.Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DI SIONS DIMENSI N - SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREAM ACHING Manufacturer: INFORMATION Type / AMBER I N um er: Sys m h - /� (, OR DISTRIBUTION SYSTEM ���ewl Th ���{ru 64a. Header/Manifold Distribution Pipe(s) � 2 x Hole Site r x Hole Spacing Vent To Air Intake Length Dia. Length � Dia. l Spacing I Z�/Y�G✓!s �j• 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 30.31.18.788,NE,SE 1963 RIVERVIEW LANE 0�1 2,0 f-I . j b W.� /w tv� AA I Plan revision required? ❑ Yes (No Use other side for additional information. Z� 9.6 �' 7 SBD -6710 (R.3/97) Date Inspect s Signature CC =�No. lVi sconsin Safety and Buildings Division SANITARY PERMIT APPLICATION 201 E. Washington Ave. In r P.O. Box 7969 Department of Commerce acco d 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. d • See reverse side for instructions for completing this application State Sanitary Permit Number 320250 The information you provide may be used by other government agency programs ❑ 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 Property Owner Name Property Location d j / je /4 r 1/4, 5 a T _3, N, R E (or W Property Owner's Mailing Address Lot Number Block Number e. � Y City, state Zip Code Phone Number Subdi ision Name or CSM Number C�i- z.�.t' 11. PE OF BUILDING: (check one) ❑ State Owned ❑ �t ❑ VII � Nearest Road age Public &kl or 2 Family Dwelling - No. of bedrooms own of -5 I C, III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) A __- � 6 . yo 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. raBew 2 ❑ Replacement 3, ❑ Replacement of 4_ ❑ Reconnection Of S. ❑ Repair of an ,____ystem ________ 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 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 E5eepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit z 43 Vault Privy 14 ❑ System -In -Fill ;� - J� Q ' , }/ VI. ABSORP SYSTEM INFORMATION: 1 _ Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade 00 ji�jCO Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation - % r Feet , J Feet Cap acity VII. TANK in Ca gallo Total # Of Prefab. Site Fiber Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con Steel glass Plastic App New Existing structed Tanks Tanks eptic an lding*enk r ' a ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ 1 ❑ 1 ❑ 1 ❑ 1 ❑ ❑ VIII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plum r' ignature: (No Sta p MP /MPRSW No.: ) Business Phone Number: Plu b is Address (Street, City, ate, Ip Code): , 7 � 6 �� /nom � 15 IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued Issuing A entSignature (No Stamps) A roved (�. pp [ Given Initial ) QD I'� //C45 Surcharge Fee) Adverse Determination l o X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD -6398 (R.11/96) DISTRIBUTION: Original to County, One copy To: Safety 3 Buildings Division, Owner, lRrrimber PLOT PLAN PROJECT Chris Nelson ADDRESS 794 Wilfred Rd. Hudson Wi 54016 NE 1/4 SE 1/4S 30 /T 31 N/R 18 W TOWN Star Prairie COUNTY ST. CROIX MPRS Byron Bird Jr. 220527 DATE 9 /1 1/98 BEDROOM 4 CONVENTIONAL XXX IN- GROUND ESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1200 LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE <3 ABSORPTION AREA 763 # of chambers 24 BENCHMARK V.R.P. Base of White Post ASSUME ELEVATION 100' ❑ BOREHOLE (DWELL *H.R.P. Same as Benchmark SYSTEM ELEVATION 99.0 jL— idewinder High apacity Leaching hamber with 31.8 t ^2 per chamber 152' 34 Grade at System Elevation River View L ane 360' 15' 2Q:,!-2 30 , B -5 T 2- 34" X 76.5 Infiltrator Leaching Chambers -3 0 , Pro 4 70 , 6' Spacing Between Trenches Count Bedroom 5, Road C House N B -4 0 B -1 15' Vents r 100' 320' 30' B M 165' Property Line ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer C l r , WS Mailing Address �� S� 1 Co Property Address o s� (Verification required from Planning Department for new construction) oS�L City /State soI���i'L Parcel Identification Number LE GAL DESCRIPTION Property Locatior 11 /4 / Sec. T -R . &W, Town of Subdivision �✓���Z _ ,Lot # o� .ems Certified Survey Map # , Volume r , Page # Warranty Deed # _J c�C'� / �� , Volume — 415 , Page # Spec house ❑ yes fix° o Lot lines identifiable byes ❑ 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. 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 ex iration date. JU � 1 q SIGNATURE 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. SIGNATURE OF APPLICANT 1 / �1 C��s 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 INDUS TNZENT OF REPORT ON SOIL BORINGS AND SAFETY &BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS ( P.O. BOX 3707 HUMAN RELATIONS 1 / MADISON, WI 53707 j (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: OWNSH UNICIPALITY: LOT NO.: BLK- NO.: SUBDIVISION NAME: V / ���/ /T' N/R E (o ' s�� ,- < COU TY: MAILING ADDRESS: USE DATES OBSERVATIONS M DE V 7 NO. BEDRMS.: COMMERCIAL DESCRIPTION: R PERCOLATION TEST 9 01�esidence ANew ❑Replace _ RATING: S= Site suitable for system U= Site unsuitable for system ON ENTIO� NAL: S D: IN- GROUND URE: SY STEM -I ®ILL O EOMMEND LDING TANK: RCED SYSTEM:(optional) �& SS I MO U N ( �J I S U C U If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED HEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 2 4 4 , B- l9 - 1.2e,14'11.2- > - L � .- / B- IfId B- -- PERCOLATION TESTS �-e } TEST DEPTH . WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES f NUMBER IbiglillG6 AFTERSWELLING INTERVAL -MIN. PERIOD 1 PERIOD 2 P E R PER INCH P- P- P_ P- P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and t of land slope. SYSTEM ELEVATION x b l w e E 70 �A5f_sZ .. .� i E z �• I LO C A NW V SE I/ DATED REVISE[ q/°� LO s ?u 2 4 4 ' S '2 c i •� ry X C0 V \ 09 00 6 /0 2.502,E 05 33' \yp .M 33 N m S S/ I 24 0 �M M .NN 3.319 AC. to i °o'� , 01 o (O o g n. N tnN ton _i UJ r'I I i M 7. S3o15'56' E Di r 285.04 w 2 3 co Ml �� , ' w ap I ��� 2.988 AC . • I (V � ar4 N Z J �a Pp`�P Z o } I , �o � O I, a o S 3 15.5 E c M 2.596 AC. IM.O 010 i o N2-2459'5 Lu d to i 3 3 36} to 0 O r I CO ' C O O la! \N • N P GE yN� I N Z o o , �p� EPy�t� iM N 1.672 AC. 5 25 02 i Al 2p 1 3110 N ® ��• S M S3015 56"E m � 25 ,9 / 311. 0 20.6 ' © \I� Q O 2e 0 / DETENTION WATER ,�,�° 2 0�' w. _ DETENTION AREA /a C:) Lam I I-- -T