HomeMy WebLinkAbout040-1224-30-000 AV7 /10"S 0vs7 vc'r/'0A- jt,� )-R, q
ST. CROIX COUNTY ZONING DEPARTMENT
AS BUILT SANITARY RE 'I'�
Owner -3 G eup-if
s j r'Q Address _ _ y! B C !� / / f ",.� _
City /State /{ vD,s' p,,, 4' / . S'/O! CP f _ �` I /!',l r s �' 3' -�/ 7 �e 7
Legal Description:
Lot .3 Block Subdivision/ESM #
%, S&-) '/, Sec N - RW, T d
Town of ' i' , yD • /2 11/
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SEPTIC TANK -- -- DOSE CHAMBER -- HOLDING TANK INFORMATION: 1 � I ol)--
Tank manufacturer �les4 - CD /2S a � -
Size ST/PC /
Pump manufacturer Model
Setback from: House Well � /L
�"
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 ? S Number of Trenches Z
Setback from: House Well P/L Vent to fresh air intake
ELEVATIONS C S % S �P/ � % N � G ° T �/�^ -r-�— C
7 - 0 i1`�s
Description of benchmark Elevation /d 0 - d
Description of alternate benchmark 13,9 rro � D�e o cA 1p Elevation S 2-
�
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Building Sewer STAR Inlet 1� �o ST Outlet 7 0 0 PC Inlet
PC Bottom � Header/Manifbld Top of ST/PC Manhole Cover / 2 ' y- " 4 /s)
Distribution Lines () () ( )
Bottom of System () () P/0
Final Grade
Date of installation /Z/ ' permit number 30 7 ? 6 7 State lan num
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p her
Plumber's signature Z
Lic ense number Z S Date �/' f
Inspector 200 c ,s' /%N _
' L O Complete plot plan a
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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and Buildings Division Count ST. CROIX
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary "i
Personal information you provice may be used for secondary purposes [Privacy Law s.15.04 (i)(m)].
P GEUR IN ; meJOHN ❑ CIrY village ❑ Town of: State Plan ID No.:
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel TabMY- 1224-30-000
t, l (:x, o t\ D Qe Sv r
TANK INFORMATION E EVATION DATA A9800156
MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic ) 2 �� Benchm r
Dosing
Aeration Bldg. Sewer - 7 22 a _
Holding Inlet
TANK SETBACK INFORMATION ks t/ Outlet ,/ S,
TANKTO P/L WELL BLDG. Airintake ROAD Dt Inlet
Septi x.�� o�oZ NA Dt Bottom
Dosing - NA Header /Man. 7.A `78,/S�
Aeratio NA Dist. Pipe � . S /
Holding Bot. System'�
°7.7 6 -/_)-
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer D and �� cf,
Model N r GPM
TDH L Friction S ste TDH Ft
Forcemain I Length Dia. Dist. To well
SOIL ABSORPTION SYSTEM
BED / E Width length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIM DIMENSION
SYSTEM TO P/L BLDG WELL LAKE/STRE LEACHING Manufa
SETBACK CRAM
INFORMATION T&t Mod Number: -
S OR UNIT
DISTRIBUTION SYSTEM L'0+ L.-V.,#
er / ani old ,��o Distribution Pipe(s) t x Hole Size x Hole Spacing Vent To Airintake I DLc�k�s -6, Length Dia. Length ..Bite Spacing r
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over � a Depth Over xx Depth Of xx Seeded /Sodded xx Mulched
Bed /Trench Center Bed/ Trench Edges Topsoil ❑ Ye
,v s ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: TROY 7.28.19,SW,SE 418 CEDAR VIEW ROAD — CEDAR RIDGE LOT 3
(2:)
katn. revision required? E] Yes No Use other side for additional inform /
SBD -6710 (R.3/97) Date Inspector's nature Ce . o
SANITARY PERMIT APPLICATION 201 E. Wa shingtongAvesion
l
P.O. Box 7969
Department of Commerce In accord 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 S% C�OC v
than 8 vi x 11 inches in size.
• See reverse side for instructions for completing this application State Sanitary yP Permit _ Nu m ber
The information you provide may be used by other government agency programs ❑ Chec cT"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 T R v / ��� pe Location
.Sd t f � 5a ," 14 i.. SE 1/4,5 7 TZk ,N,R E(o W
Property Own is Mailing Address Lot Number Block Number
O O &,j1,0
Cit , State Zip Code Phone Number Subdivision Name ortTMrNUMber
11. T YPE F B IL ING: (check one) ❑ State Owned ° !t
D Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms ° vllWg OF y
1",PQ ^
111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 2 c•
` 1 E] Apartment/ Condo " 0 U r `L �-- J
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
S ❑ Hotel / Motel 9 ❑ Office/Factory 13 ❑ Other: specify
IV. TYPE OF PERMIT (Check only one box on line A. Check box online B, if applicable)
A) 1. X m 2. E] Replacement 3. ❑ Replacement of 4. E] Reconnection of 5. E] Repair of an
_____ste - _______System _____________Tank Only ____ ________ Existing System ________,ExlstingSystem
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 N Seepage Trench 22 In- Ground Pressure r �7 Pit Priv
13 Seepage Pit / �, 43 E] Vault Privy
14 E] System-In-Fill h wtr %OS �D%V0ffh 1�{1T & p 1 S
VI. ABSORPTION SYSTEM INFORMATION: 16D. aI�
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) � . �O Elevation
7 5 , 0 ?SQ . e� CP Feet Feet
Ca cit
VII. FORMATION in g allons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
New Existin Gallons Tanks Concrete strutted glass App.
Tanks Tanks
Septic Tank or Holding Tank / El ❑ 1:1 El 1:1 Lift Pump Tank /Siphon Chamber , t ❑ ❑ ❑ 1 ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber'sName:(Print) Plumber'ssi nature: (No Stamp) LA&PLMPRSW No.: Business Phone Number:
Plum �r s Address (Strr/Qt, Cit Zip Cod
CJ A D �� / f 5 - `�
, c7
IX. COUNTY/ DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps)
Approved Surcharge fee) O
pp El Given Initial
Adverse Determination
X. CONDITIONS OF APPROVAL / REAS NS FOR DISAPPROVAL:
SB68398 (R.11/96) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
1
ULBRICHT & ASSOCIATES CO.
655 O'Neil Road - Hudson, WI 54016 Reg. Designers of Engineering Systems
715- 386 -8185 Private Sewage Consultants
PROJECT INDEX
DILHR PLAN ID # /y/4- DATE
OWNER V PHONE 3 �Ct7 C!�
S /•�e ADDRESS ylg c�D, (f /L�G(J ILI• IJ��DSO•t_J
LEGAL DESCRIPTION 1-o T`4 - ' 3 - C�� 1(1
TOWN OF 7A'o V COUNTY ST. 4w
CSTM �- �Gl�/ 7—
LOCAL AUTHORITY/ SUPERVISION 57. e/tel x (� �"� • �al C11
PROJECT DESCRIPTION:
IV,rl � s7; r /IAP/
7f D /;4 ef
A�4
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A te""`- 1� 4 G ►'��'��t/� S 'r
Pg.l PLOT PLAN VIEWS
P9.2 SYSTEM CROSS SECTIONS & SYSTEM PLAN VIEW SPECS.
utbtteht & Ass a Coy �{tants
P,,,te sewe4
05 at4ett $d• 554015
Hudson. Nd
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Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page of 3
Labor and Human Relations
Division of Safety a Buildings in accord with fLHR 83.05,'Wis. Adm. Code
COUNTY
sT.CRoi X
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION R (� E (or WJ�
TAN ES ° .&/Cd R I'A wA HFN E B ROG1� GOVT. LOTSAV 1/4 S E" vo 7 T Z? N,
PROPERTY OWNER':S MAILING ADDRESS LOT # I BLOCK # SUBD. NAME OR CSM #
qe So. FdR Gf RcLE 3 -CA'DAR V DG-E
CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE OWN NEAREST ROAD
ji60S 01. 540tc. ( 715) .3P • IPS'S TRo c��� Ulfw IIFV,
New Construction Use [ Residential / Number of bedrooms [ ] Addition to existing building
[ J Replacement (] Public or commercial describe
Code derived daily Bow boa gpd Recommended design loading rate bed, gpd/ft trench, gpolft
i
Absorption area required ed, ft2 50 trench, ft Maximum design loading rate bed, gpd/ft trench, gpdM
Recommended infiltration surface elevation(s) 5 p 4 • 3 ft (as referred to site plan benchmark)
Additional design I site considerations Z! t --f P Fad 5
Parenj material "' $C5 '73 ` 1 [ oT S 1 . _ S0. [ o E SS Flood plain elevation, if applicable it
L c
SU = Suitable for system CONYZNTIO U L MOuW U IN•GR D U ESSURE A SYSTEM IN FILL HOLDING TANK
B
= Unsuitable fors stem - S Eal [] ED'S ❑ U 2s U [Is gi:r
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 Twich
6-6 10 y R 2. � ( �a S i' If S b k Awv fa
Aryx.}_nvfi% Z G_ /3 / o NR 3/ S i l, I f S h K S . �{ • ,S
Ground 3 13 - /o 412 3 /3 — 5 1 `F S bK •.i, fP S � • `( • S
elev. C ,S'
Depth to 5 to j /O Kle S . S • 1 O S q ? j • Is
limiting
factor
Remarks:
Boring # O , 7 !o l low � l� S j f 5 b� -F n� 2 4 s 1`F • `{ S •
I Y 12 I 11 �
10%1A 3/ S t `s. Zfs .� S •S .�
:.,> v_ Z3 1 o y R 3 / 3
Si 1. _ s bK �, - FR c s _• 5 . G
...:.:::::: ::..... .
3 G
Ground
elev. 3 - /d q �S l c S — • 1 i
Depth to
limiting G - �p S O S •
factor
Remarks:
CST Name _ Please Print R o a E Q T Lt Lt3 l G 4 T- Phone: 7 l S_ 3 �� . P 1609
Address: Coss O' �E "tL J?D. [ oPj a-3 W1. 5L401 � 5 y'S cSTM �.4�'2_
c..,, .e• nata• CST Number:
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer :YO H Q 6�E u /' k (1/ (Z — t{(ao • 2-000
Mailing Address 1 So S O �Eqldj,le: - rte. / *igY.!>(r7V -0
Property Address ��� C '/ zv/zf - w �• ���? -J vl s
(Verification required from Planning Department for new construction)
City /State ��5�� Parcel Identification Number a� - �� �-� • v
LEGAL DESCRIPTION D
Property Location 5� '/4, s� ' /,, Sec. - , T �'u N -R ( W, Town of ��
Subdivision4 #
Certified Survey Map # , Volume , Page #
Warranty Deed # 's -7//�, Z-- ,Volume � )4 Page #
Spec house ❑ yes no Lot lines identifiable X 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 h been maintained must be completed and returned to the St. Croix County Zoning Office within 30
days of a three yea expir i ate.
SIG A OF APPLICANT /
DATE
OWNER CERTIFICATION
I (we) certify that all sta hments on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
the propejjy described abov y irtue of a warranty deed recorded in Register of Deeds Office. n
SI A URE 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