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Home My WebLink About040-1236-40-000 ST. CROIX COUNTY ZONING DEPA T�► ,- AS BUILT SANITARY REPORT Owner .S' y { ' i i Address l City /State ,EZ / - rwdr7'� ,,. LQNI() T t� r. Legal Description: . s Lot Block ` Subdivision/CSM # �+ '�+ rt/, Sec. ,3--, T N -RAW, Town of PIN # QYo - �0 SEPTIC TANK -- IOJPJ LDING TAN INFORMATION: / Tank manufacturer 4�124J- Size ST/p£ Setback from: House 16 Well P/L -- Pump manufacture_ r_ Model Alarm location (HOLDING TANKS ONLY) Setbacks: Se , Vent to fresh 'take Water Line Meter location Alarm location r SOIL ABSORPTION SYSTEM: Type of system: Width � gm gr� 8' Number of Trenches Setback from: Hou , We ll ? /o�' PL Vent to fresh air intake > /s a � ELEVATIONS: Description of benchmark �z Elevation Description of alternate bm ark Elevation Building Sewer F1 ST/HT Inlet !G: S' ST Outlet , GJ PC Inlet PC Bottom Header/Manifold Top of ST/PC Manhole Cover rP7. 9 Distribution Lines Bottom of System O �l�_ O ( ) Final Grade Date of installation F Permit numbe �ZState plan number Plumber's signature -U License number -2 z /eep Date/2//yV..P Inspector ^ Complete plot plan R • Wisconsin Department of Commerce Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count §T. CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar�a Personal information you provice may be used for secondary purposes [Privacy w, TT ❑ TOUT, RICHARD l{vY s.15.04 (1)(m)]. Permit Holder's Name: ❑j & Village Town of: State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description: Parcel /DU. t')Z� { b` 236 -40 -000 TANK INFORMATION ELEVATION DATA A9800211 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic ,, Benchmark / Dosing Aeration Bldg. Sewer , / Holding St /1W Inlet i TANK SETBACK INFORMATION St /3F Outlet TANK TO P/ L WELL BLDG. Air i to ROAD Dt Inlet Vent take Septic ra $ NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe ,�f' 93.E Holding El Bot. System 7 � � ga ;7 i PUMP/ SIPHON INFORMATION Final Grade 95 4 Manufacturer Demand '1_ Model Number GPM TDH Lift F Iction System TDH Ft Forcemain Le gth Dia. Fi Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width lLength No. Of Trenches IT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS / G' DIMENSION SETBACK SYSTEM TO I P / L BLDG WELL LAKE / STREAM LEACHING Manufacturer: INFORMATION TypeO r CHAMBER Mo Number: System:' '/0' 1 'SG - /00 /t� //� OR UNIT DISTRIBUTION SYSTEM Header/ Mani old 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: TROY 3.28.19,SE,SW 534 GILBERT ROAD — COUNTRYWOOD LOT 53 Plan revision required? []Yes E3 Use other side for additional information. I c i L SBD -6710 (R.3/97) Date n e or's Signature Cert. No. Safety and Buildings Division V i scons i n SANITARY PERMIT APPLICATION 2 01 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. P.O. Box 7969 Code Department of Commerce Madison, WI 53707 -7969 0 Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x 11 inches in size. 4L x • See reverse side for instructions for completing this application State sanitary Permit Number 3/ &mot The information you provide may be used by other government agency programs ❑ Check if revisi s on to previ s application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMAT -PL EASE PRINT ALL INF RMATION Pro , y ner ame Property Location 114 1i4, S T" , N, R E (o® Property Owner's Mailing Addres Lot Number Block Numb W 6 1& 53 City, State oi l Zip Code Phone Number Subdivision Na a or CSM Num r II. TYPE F BUILDING: (check one) ❑ State Owned ❑ ity Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms El Town OF " s °v III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo Ze 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 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 JZ Seepage Bed 21 []Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure / 42 C] Pit Privy 13 E] Seepage Pit IA Y S 6 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 S D ,j 3. /t/ Feet p Feet VII. TANK Capacity Total # of Prefab. Site Fiber- plastic Exper. INFORMATION G in gallons allons Tanks Manufacturers Name Concrete Con- Steel glass App. New Existing structed Tanks Tanks e tic Tank f ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ I ❑ 1 ❑ 1 ❑ I ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of a onsite sewage system shown on the attached plans. PI mber's Nam rint) Plumber's SignjAps) I fflPtIVIPRSW No.: Business Phone Number: Z& —.3 S PI er's Add res treet, C State, Zip ode): Z a u� �z 3 IX. COUNTY /DEPARTMENT SE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Iss ing Age t Si nature (No Stamps) Approved ❑Owner Given Initial Z �j� Surcharge Fee) l M illi / Adverse Determination VV ! d� X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6= (fl. f tom) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Pkanber or rr�vrr0 Gvaa �SC�K� kY6J� •c tsv+ -d i /i�` !r �f 1�®r .let. � U �lt Z /At ter; y. o - I � � zs Le !q' eqq'uuh•e /,94, • = fwU / f Surilfc� S �o'� h- vir 0 = /000 Gam- r. C DAVE Perk Tester 6 PhwAw 43233 . Rosd ROBEIRTS. W�3�I�II�i 'S40$S ftono 74'3-J' 666 •I . I ----- ---- -- z c •� n •. w � 1 Y ri NIS u� Wiseonsin Department of Industry SOIL AND SITE EVALUATION REPORT V Pa e 1 of 3 LAbor and Human Relations g — - wivtsion of safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code ' r' COU Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must i / lude, but t t"rp ix not limited to vertical and horizontal reference point (BM), direction and % of slope, sale or PARCEL I.D. #; ,. : dimensioned, north arrow, and location and distance to nearest road. :a p@ d i, APPLICANT INFORMATION PLEASE PRINT ALL INFORMATION �', AE VI D BY / � DATE PROPERTY OWNER: PROPERTNKAT.IUN Richard Stout GOVT. LOT g,;t'1/4 SW 1/4, . e N,R 19 {oLor)W PROPERTY OWNER':S MAILING ADDRESS LOT # BLOC SUMO N)AINEt GSM # 1353 Awatukee Trl. 53 na ry Wood CITY, STATE ZIP CODE PHONE NUMBER ❑CITY []VILLAGE 19OWN NEAREST ROAD Hudson, WI. 54016 915) 549 -6731 Troy I Tower Rd. [ $ New Construction Use [ 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 .7 bed, gpd /ft .8 trench, gpd/ft Absorption area required 643 bed, ft2 563 trench, ft Maximum design loading rate .7 bed, gpd /ft .8 trench, gpd /ft Recommended infiltration surface elevation(s) 91.79 ft (as referred to site plan benchmark) Additional design / site considerations alt. site system el. = 91.35' Parent material pitted outwash plain Flood plain elevation, if applicable na ft S = Suitable for system CONVENTIONAL I MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem LAS ❑U ®S ❑U [3S ❑U �7S ❑U CAS ❑U ❑S ®U SOIL DESCRIPTION REPORT Boring# Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots D/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench `.,..1,., 1 0 -15 10yr2 /2 none 1 2msbk mfr gw if .5 .6 2 15 -31 10yr4 /4 none sicl lfsbk mfr gw if .2 .3 Ground 3 31 -40 7.5 r4 4 none sil lfsbk mfr cs na .2 .3 elev. 96 ft. 4 1 40-96 7.5yr4/6 none s osg ml na na Depth to limiting factor +96" Remarks: Boring # 1 0 -11 10yr2 /2 none 1 2msbk mfr gw if .5 .6 '4 2 2 11 -34 10yr4 /4 none sicl lfsbk mfr gw if .2 .3 Ground 3 34 -49 10 r4/4 none sil lfsbk mfr gw na .2 .3 elev. 4 49 -96 7.5yr4/6 none s osg ml na na .7 1 .8 95 ft. Depth to limiting factor +96" Remarks: CST Name Print Gary L. Steel Phone: 715- 246 -6200 Address: 1 200th. hve., New Richmond WI. 54017 m02298 Signature: Date: CST Number: 4 -23 -96 STEEL'S SOIL SERVICE Gary L. Steel 1554 200th Ave. CSTM2298 Richard Stout MPRSW 3254 SE4SW4 S3- T28N -R19W New Richmond, WI 54017 town of Troy (715) 246 -6200 lot #53- Country Wood N 1 " =40' BM-= top of 1" steel pipe C el. 100', top of marker stake C el. 103.5' �� i to t Iw - b .1 *. - A a' Ck GAry L. Steel 4 -23 -96 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CE TIF�ICATION FORM Owner/Buyer Mailing Address4 Yo Property Address S (Verification required from Planning Department for new construction) City /State _� 1G1+. 464-1 IleW Parcel Identification Number e fl/zy 5O LEGAL DESCRIPTION Property Location Sg ' /4, S� '/4, Sec. , , T -Z2? N -R1f_W, Town of Subdivision Lot # Certified Survey Map # , Volume , Page # �--- Warranty Deed # yy�ps� , Volume /��Z- Page # Y� Spec house ❑ yes ❑ no 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 the ee y r 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 X/V I �' Aml / e e cribe bove, by virtue of a wa my deed recorded in Register of Deeds Office. IGNATURE 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 6 ST CROIX COUNTY l SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address Property Address S3 (Verification required from Planning Department for new construction) City /State _ SYsI,� Parcel Identification Number ez g - yd LEGAL DESCRIPTION Property Location %., %<, Sec. , T N -R W, Town of Subdivision Lot # Certified Survey Map # Volume , Page # Warranty Deed # -- Volume , Page # Spec house ❑ yes ❑ no 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 masterplumber, 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 three year expiration date. SIGNATURE OF APPLICANT DATE OWNER CERTIFICATION I (eve) 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 OOH h 7a (Jt n di _ II Ii. d R ,w N 4s t i a m p N S n tv n p a I� O g v � 0 W 9 o 31 of v, ► (D a o FL- N ^ m " o W 1N s N " 3 3 .�, • W cn ♦ .0 rt. In b ,. 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