HomeMy WebLinkAbout040-1237-60-000 --.r! .
Safety and Buildings Division
Vi sconsin SANITARY PERMIT APPLICATION 201 E. Washington Ave.
In accord with ILHR 83.05, Wis. Adm. Code P.O. Box l 53707 -7969
Department of Commerce Madison, W WI
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 vi x 11 inches in size. 57" C ✓o
• See reverse side for instructions for completing this application State Sanitary Permit Number
3 0-775 - b
The information you provide may be used by other government agency programs ❑ Check it revision to previous application
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N
Property Owner Name Property Location
tj�,)x S�f/ 114, S _? T ;? , N, R If E (or W
Property Owner's Mailing Address Lot Number Block Number
13 5 - 3 Q& ,'7`U c-e
City, State Zip Code Phone Number Subdivision Name or CSM Number
4 et t/ tomj S (7is 5V - Cali - - ryr tjQoc�
II. TYPE OF BUILDING: (check one) ❑ State Owned C Nearest Road
villa ge
Public jo 1 or 2 Family Dwelling - No. of bedrooms_ Town OF a
III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Numbers)
O A! 0 --1237 - a G
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. j. 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 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In- Ground Pressure / 42 E] Pit Privy
13 E] Seepage Pit (6 x7 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
lly` d I 7 ,5_e 7--5 ,,u ,L- 9d 3 7 Feet 3 9 7 Feet
VII. TANK Capacity site
INFORMATION in gallons Total # of Manufacturer's Name Prefab. Con- Steel in plastic Exper.
New Existin Gallons Tanks Concrete strutted glass App
Tanks Tanks
e tic T orMeW"Tq'r1f9Tc OC �QO ,r ` r �GtJQ fd.�/� El
Lift Pump Tank CV 5a 64W" 0a El
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite se ge system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: (No Stamps) MPRSW No.: Business Phone Number: - N
Plumber's Address (Street, City, State, Zip Code):
v 7e S'c a - te - R � 4, 1 _ 2 1 ' �t'a
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Iss Tit Signature (No Stamps)
�� Surcharge Fee) 4/
Approved []Owner Given Initial j�j1 � /?�j od S1
Adverse Determination / V
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD -6398 (R.11/96) DISTRIBUTION: Original to County, One copy To: Safety 8 Buildings Division, Owner, Plumber
. "isconW Department of Commerce PRIVATE SEWAGE SYSTEM Count
Safety and Buildings Division SST . CROIX
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar3tr" jam.:
Personal information you provice may be used for secondary purposes [Privacy Lkvv, s.15.04 ( 1)(m)j.
Permit Holder's Name: Village E] Town of: State Plan ID No.:
STOUT, RICHARD 1+#
CST BM Elev.: Insp. BM Elev.: BM�Descrip n: - L Parcel j�>41far —
OD I
11 I `l Y 1 1
TANK INFORMATION ELEVATION DATA A9800
E MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic eCGt 60 Bench
Dosing-- 05 U sz ?,4- f 13 '7 2o.
Aeration Bldg. Sewer 3
Holding t/ Inlet 11.q(
TANK SETBACK INFORMATION St/ loft Outlet
TAN P/ L WELL t �Tj Air I to ntake ROAD Dt Inlet
Air
( , eptic '
)-� P`/ NA Dt Bottom BSI �0
Dosi �` NA He ader /Man. (" p�
Aeration A Dist. Pipe `O Holding Bot. System
PUMP/ SIPHON INFORMATION c Final Grade d'
Manufacturer (( 5 Demand cat 7 �
Model Number GPM
TDH Li Friction S FFii ystems TDH Ft
Forcemain Length 57�� Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED Width Length No. Of enches PIT No. Of Pits Inside Dia. Liqui epth
DIMENSIONS DIMENSION
SYSTEM TO P/ L BLDG WELL LAKE /STREAM STREAM LEACHIN anu ac u
SETBACK --
INFORMATION T e /^ CHAMB :
yp 69 1 7 Mo el N er:
Syste •L�61 �"'— OR UNIT
DISTRIBUTION SYSTEM
Header / Man) fold " Distribution Pipe(s) �� i x Hole Size x Hole Spacing Vent To Air Inta e
Length Dia. Length Dia. Spacing I STwI �(, - I
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 es Topsoil
COMMENTS (Include code discrepancies, persons present, etc.) °s
LOCATION: TROY 3.28.19,NW,SW 616 OAKLEY CIRCLE - COUNTRYWOOD L T 65
3.) W4d V44 �� l l j i w5
I u vA lnC� tin b ��✓ \( � t 5 � b ►�
'D - 7 N
FB �
Plan revision required? Yes El No
Use other side for additional Information. � U 443
SBD -6710 (R.3/97) Date Inspect is Signature rCe — rt -- N o.
-.
ST. CROIX COUNTY ZONING DEPARTMEN,!t "
AS BUILT SANUARY REPORT F, 'y PVE0
Owner �t �.� .ST6u 7`' I
out�TV
Property Address �,�.?w �k yip c T>�a sr c Ra,,
'�, ; .
City /State - 13�Lso� �,�- ,f� �d ZONfNGOFFFCE
Legal Description: .-
Lot �4 Block Subdivision/CSM # c�v�� L100
/4 t /4, Sec. , T N -R W, Town of �"Ya _ PIN # 6 fat 7 -ea ao®
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION
Tank manufacturer 14 00AWIV& �es7-& VV/ Size ST/PC/ /Gsd Setback from: House lS' Well e)w P/L
Pump manufacturer d �.- 4 5 Model
Alarm location zFa ez i -
(HOLDING TANKS ONLY)
Setbacks: Service road Vent to fresh air intake Water Line
Meter location
Alarm location
SOIL ABSORPTION SYSTEM
Type of system: CQ Width S Length 7.S Number of Trenches 2
Setback from: House Co ' Well P/L Vent to fresh air intake
ELEVATIONS
Description of benchmark Elevation
Description of alternate benchmark A- vT,;P-� Elevation
Building Sewer ST/HT Inlet ST Outlet PC Inlet
PC Bottom Header/Manifold 9l Flf Top of ST/PC Manhole Cover
Distribution Lines
Bottom of System(
Final Grade () () ( )
Date of installation fZPermit number State plan number
Plumber's signature License number Date - Z // )W-
Inspector O'cla Complete plot plan �
a 7
Q
F
jJ �T
adx 7 5
0
5 ��7
3 k+%c►.,
W e s
5'r
t
f
t +..
PU('1P CHAMBER CROSS SEC T IOIJ AU5 SPECIF ICA 1101_)l
VC UT CAP
`l "C.I. VIMT PIPE
WEATHERPROOF APPROVED LOCKIAIG
25� FROM DOOR,
JUUCTIOtJ BOX MAMHOLE COVET
WIMDOW OR FRESH 12 "MIU.
AIR IAITAKE
GRADE
18" /h11IJ. _
COQDUIT
18 "MIN. v - - - -- - -- _ _
� 11�
INLET PROVIDE
_T
AIRTIGHT SEAL
*� A
I I
I I I ALARM
e I II
I I
*APPROVED ( i ON
c JOINTS WITH I I
ELEV. FT APPROVED PIPE I
OFF
3' ONTO PUMP �
o SOLID SOIL
COAICRETE BLOCK - -
RISER EXIT PERMITTED OIJLy IF TAMK MAMUFACTURER HAS SUCH APPROVAL
SEPTIC f SPECIFICATIOAIS
DOSE
TAMKS MAIJUFACTURER: kIUMBER OF DOSES:L_.PER DAB
TAWK SIZE: GALLONS DOSE VOLUME
ALARM MAMUFACTURER: _� e Je , /a,�/Al INCLUDING 6ACKFLOW: �� 3 GALLON
MODEL NUMBER: - 49`U ) CAPACITIES: A_ U1CHE5 OR L GALLOU:
SWITCH TyPf: Y C B= INCHES OR GALLO►J`.
PUMP MANUFACTURER: rs'der1J,y C = �' �� INCHES OR 1.2 - 7 - GALL0Q
MODEL HUMBER: 4.LD �/l D= INCHES OR !3G GALLOM
SWITCH TYPE: hJ CXG MOTE: PUMP AND ALARM ARE TO BE
MINIMUM DISCHARGE RATE _ GPM INSTALLED OM SEPARATE CIRCUITS
VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE.. l_ FEET
+ MINIMUM NETWORK SUPPLY PRESSURE . , , , , _ , FEET
-} Ze_� FEET OF FORCE MAIM X 3: ,7? fT
/l00 FLFRICTIOU FACTOR.. FEET
TOTAL OyIUAMIC. HEAD = /� FEET
INTERNAL DIMEIJSIOMS OF TAIJK: LENGTH ;WIDTH ;LIQUID DEPTH
SIGNED:
LICEW NUMBER: ;Z- DATE: -: �
Goulds
—�-
SubmerSi 1e
Effluent -Pump
387 ,1 EPO4
EP05
APPLICATIONS • Fasteners: 300 series • =erged in high ■ Motor Housing: Cast iron
Specifically designed for the stainless steel. ne oil for for efficient heat transfer,
following uses: • Capable of running lubrication and efficient strength, and durability.
Effluent systems dry without damage to heat transfer. ■ Motor Cover: Thermoplas-
components. tic cover with integral handle
• Homes Motor: Available for automatic and and float switch attachment
•Farms manual operation. Automatic points.
• Heavy duty sump • EPO4 Single phase: 0.4 HP, models include Mechanical
• Water transfer 115 or 230 V, 60 Hz, 1550 Float Switch assembled and ■ Power Cable: Severe duty
RPM, built in overload with rated oil and water resistant.
• Dewatering preset at the factory.
automatic reset. ■Bearings: Upper and lower
SPECIFICATIONS • EP05 Single phase: 0.5 HP, FEATURES heavy duty ball bearing
115 V, 60 Hz, 1550 RPM, construction.
Pump: EPO4 built in overload with ■ EPO4 Impeller: Thermo-
- Solids handling capability: automatic reset. plastic Semi -open design
1 /4' maximum. • Power cord: 10 foot with pump out vanes for AGENCY LISTING
�- • Capacities: up to 55 GPM. standard length, 1613 SJTO mechanical seal protection. CO. Canadian Standards Asse tion
r 1 • Total heads: up to 24 feet. with three prong grounding
• Discharge size: l' /i ' NPT. plug. Optional 20 foot ■ EP05 Impeller: Thermo- (CSA listed model numbers
• Mechanical seal: carbon- length, 16/3 SJTW with plastic enclosed design for end in "F' or "AC.)
rotary/ceramic- stationary, three prong grounding plug improved performance.
BUNA -N elastomers. (standard on EP05). ■Casing and Base: Rugged
• Temperature: thermoplastic design provides
104 °F (40 °C) continuous superior strength and
140 °F (60 °C) intermittent. corrosion resistance.
• Fasteners: 300 series METERS FEET
stainless steel. 10
• Capable of running
dry without damage to 9 30 =► s�PM: r
components.
'isFr` i
Pump: EP05 8 j
• Solids handling capability: 0 7 25 j
% maximum. W - -- - - -- - --
• Capacities: up to 60 GPM. s 20 I
• Total heads: up to 31 feet.
• Discharge size: 1 NPT. Z 5 -- - -- --
• Mechanical seal: carbon- >_ 15
rotary/ceramic- stationary, a
BUNA -N elastomers. 4 —� — — - -- - - -� -- — EPQ5
I
Temperature: ° 3 10 Za.o
104 °F (40 °C) continuous
140 °F (60 °C) intermittent. 2 i
5
i
0 0 0 10 20 30 40 50 GPM
L ' L L
0 2 4 6 8 10 12 m
CAPACITY
®1995 Goulds Pumps, Inc. Effective May, 1995
83871
wiiscofis n Department of Industry SOIL AND SITE EVALUATION REPORT Page 1 of 3
.Labor and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Cod& - °g"
t'k a O
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must i 61 fiut � ` Croix
not limited to vertical and horizontal reference point (BM), direction and % of slope,
PARCEL D.
dimensioned, north arrow, and location and distance to nearest road. �'°� -'` Pendr
APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION REVIEWED3Y DATE
PROPERTY OWNER: PROP WWCATION
Richard Stout GOVT. L VV fl4 ISK. 1/4,S 3� T AR 19 ngor) W
PROPERTY OWNER':S MAILING ADDRESS LOT # 0 S 'D. #
1353 Awatukee Trl 65 ood
CITY, STATE ZIP CODE PHONE NUMBER [:]CITY ❑VIL • NEAREST ROAD
Hudson, WI. 54016 (715) 549 -6731 Troy _. Tower Rd.
[x] New Construction Use P ] Residential / Number of bedrooms 3 [ ] Addition to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow 450 gpd Recommended design loading rate .5 bed, gpd /ft .6 trench, gpd /ft
Absorption area required 900 bed, ft 750 trench, ft Maximum design loading rate • 5 bed, gpd /ft •6 trench, gpd /ft
Recommended infiltration surface elevation(s) 90.37 ft (as referred to site plan benchmark)
Additional design / site considerations alt. site system el. = 89.74
Parent material pitted outwash plain Flood plain elevation, if applicable na ft
S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable fors stem ®S ❑ U ®S ❑ U ®S ❑ U ®S ❑ U ®S ❑ U ❑ S CCU
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Structure GPD /ft
Boring # Horizon Texture Consistence BoLridaly Roots
.................
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
. . ..... _. . _ . _ .. .. ... .
.................
1? 1 0 -16 10 r2/2 none 1 2msbk mfr 9W if .5 .6
2 16 -34 10 r4/4 none sicl lfsbk mfr CfW if .2 .3
Ground 3 34 -84 7.5 r4 6 none fs osQ mvfr na na .5 .6
elev.
9 3.9 ft.
Depth to
limiting
factor
+84"
Remarks:
Boring #
1 0 -16 10 r2/2 none 1 2msbk mfr 9W if 2 5 .6
w- ,._,.. ,,.,; 2 16 -36 10 r4/4 none sicl lfsbk mfr if .2 .3
U
Ground 3 36 -84 7.5 r4 6 none fs Oscf mvfr na na .5 .6
elev.
94 ft.
Depth to
limiting
factor
+84"
Remarks:
CST Name:— Please Print Gary L. Steel Phone: 715- 246 -6200
A ddress:
1554 200tW Ave., New Richmond, WI. 54017 MO2298
Signature: Date: CST Number:
4 -19 -96
STEEL'S SOIL SERVICE
Gary L. Steel 1554 200th Ave.
CSTM2298 Richard Stout New Richmond WI 54017
MPRSW 3254 NW4SW4 T28N -R19W (715) 246 -6200
town of Troy
lot #65- Country Wood
N
1 " =40'
BM.= top of 1" steel pipe C el. 100' by NW lot corner
A
�-�w�� rte•
R2
0 7a
�r
Gary L. Steel
4 -19 -96
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner /Buyer
Mailing Address 5_1 0 u) iz 1" e� 4 ,
Property Address y' 4 l
(Verification required from Planning Department for new construction) ///!
City /State so �✓ 4j ' — Parcel Identification Number 070 037 6 0
LEGAL DESCRIPTION
Property Location l� ' /a '/4, Sec. _ , T V 9 N -R_Z_? _W, Town of Zve-1
Subdivision Lot # .
Certified Survey Map # , Volume , Page #
Warranty Deed # S , Volume , Page #
i
Spec house O yes O no Lot lines identifiable 9 yes O 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 expiration date.
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 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
I
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was
• x. 57 - _ 19 338,
N77 °49 33' E
t n
M - - 276.957
691.5
i
67 G
N i- 65 66 .N 2.57 AC.
NN V
D�
64
111,973 SO. FT.
2.04 AC. t0 2.79 AC.
� ai 121,711 SO. FT.
(� 2.10 AC. 88,645 SO. FT. - to
d
91,700 SO. FT.
!T W W
o�
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A, M ,
0 O N
T 0
0 N
N
/"� ��- - - - -- - -- -- --
/ 0 - S90 ° 00'- W 664. 27' -
/ '/
30_00
- - 195.00' 259. 27' - r
i
1
M PUBLIC - S I FEEL I � -
M
1 M
/ I
219.49' - - 220.72' - - 214.5 2'
\ / / Y n -N90 00'00'E 654.73'-
o °D
0 58 � 57 M
56
a 5 2.01 AC. 2.01 AC. 2.09
I
87, 555 SO. FT. 87, 557 SO. FT. W 91,121 SG
2.01 AC. w w 0 1I
O 87,555 SO. FT. 8 8 0
O 0
0 0 1.30 AC. EXC. ESMT�
z Oo z 56 SO. FT
z
I_
326.57' 219.50'
220.73' 225.4E
N89 ° 25 '26 "E t - 1324. 14� SOUTH LINE OF THE NWI /41OF SWI /4