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HomeMy WebLinkAbout040-1034-95-007 Z `' QI c ° O ° U `r o a 0 � i i o , 0 0 N i C �L (U O C Z Q I � z N � W Z •• O Z > � a`o 0) co > '''. 0. m 0o N z _ o I d' c U O z fn F- r N z C E 'p _ N N 7 m N Q N • N O O d .c _ o (�} Q U N Ma C O Q Z m z N zo " _ rz N H E N L a C o a z Cn 0 N d N N 0 0 O o o a -0 _ % N N E N Z co > I' � F- F- H Fy- m 0 0 0 0 d a Z o 0 • a a a dry s g -O o0 00 p o o N m rn rn } W -j U 0 0) 0) o p o m r !mil v, ° o z n ° o ° o ° o p_ ( h V N N N CD o °o a rn 00 LO y 8 °_' ¢ n %, m r L a '°. C O w a ° o Y L a M co o O M 3: m - O N N N N O) C T L m O O V • y' O O I - CO M O z y Z d' (n o - r� � � w � •E d I , m a dt a a w E .� c j� I' 0 t A U a 0 U) v ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT owner C 5T0 -r Rtio t Address 419 Vike iL. City /State Y-kwop �AZ� 5yG �� 8 r cqo� Z OU1 X Legal Description: Lot XP6 Block Subdivision/CSM # x-07= io 53 '/4 ' /4, Sec. 8 , TAN -R . 14 W, Town of _`Z o PIN # OV 00 SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION Tank manufacturer Vyi'mKS Size ST/PC l0W /-- Setback from: House �5� Well P/L 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: &-b Width 12 • Length 61 Number of Trenches Setback from: House y5 , Well X M P/L ?6 ' Vent to fresh air intake ELEVATIONS .w Description of benchmark 5Er4/ C'ORN&A _ 6T. Elevation 100 Description of alternate benchmark -T of 87oCK G vjumri a W Elevation 0/ 5.7 y Building Sewer DO • U 5 ST/HT Inlet ST Outlet ? K PC Inlet "^ PC Bottom Header/Manifold Top of ST/PC Manhole Cover 1 03. Z9 D i slution Lines O ! 8' • �a O O Bottom of System Final Grade ( ) !b Z 09 ( ) ( ) Date of installation x00/ Wermit number 3 d 76 5- State plan number Plumber's signat y " r` License number a a 3a �a Date / } l l �� Inspector 0D Complete plot plan �+ Wisconsin Department Commerce PRIVATE SEWAGE SYSTEM Count Safety and Buildings Di Y: INSPECTION REPORT S4 -Cra1 x GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar Permit No.: Personal information you provice may be used for secondary purposes (Privacy Law, s.15.04 (1)(m)]. . 3 c ,- 7 & 55 Permit Holder's Name: ❑ City ❑ Village © Town of: State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 1 00 To o� fi7 o - l03 `� -9S — Oo TANK INFORMATION ELEVATION DATA /984©04`/ TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. e ►�V$GK,�j �Opfl Benchma yy�! 1DS / 00 Dosing AIt B 105.0 - Aeration Bldg. Sewer 5- Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. genntake ROAD Dt Inlet �-• �vl,� Sept c 6 0� NA Dt Bottom --• �/„ Dosing NA Header /Man. G •S X8.55 Aeration NA Dist. Pipe 6 7Z' �8$ Holding Bot. System ' Y 7.55 GI l.`1 PUMP/ SIPHON INFORMATION Final Grade 3•�S Z62 Manufactur De d 2•Z r 2 Mod Number GPM TDH Lift Friction S ste H Ft oss Forcemain Lengt Dia. Dist. To wen SOIL ABSORPTION SYSTEM TRENCH Width length , No. Of Trenches PIT No. Of Pits Inside Dia. Li Depth DIMENSIONS DIMENSION SETBACK SYSTEM TO P/ L BLDG WELL LAKE / STREA LEACHING facture INFORMATION Type Model Number: System . 3 �`74 �� OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake : •• �a► A STIR " Z7 Z a r • Length _� Dia. length Dia. � Spacing 1 BOO SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Of xx Seeded/ Sod xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil No ❑ Yes ❑ No COMMENTS: (Include code isc ,persons present, etc.) LJ71 v ; P, Ate. 92 IM - — rb p d � 6" 610&K G. tPO4 , lPkA j S cvJC�'. 2 W>il v✓A. yl j A.4*N 1( -c �•� 1 `�I. AmA Plan revision required? []Yes 2 No � ,n / H Use other side for additional information. ( i 'I' SBD -6710 (R.3/97) Date Inspector's Signature ? * Wonsin Safety and Buildings Division SANITARY PERMIT APPLICATION 201 E. Washington Ave. P.O. Box 7969 Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code P Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County , than 8 v2 x 11 inches in size. j, 6p/ )K • See reverse side for instructions for completing this application State Sanitary Permit Number The information you provide may be used by other government agency programs E] Check if rev ion o p}evibu s application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION Property Owner Name P Location `( E 1-- Nti DA fa AjZAM%1\1 AlW i14 W, C_ 1/4, S T j , N, R E (or)dD Pro ert Owner's Mailing Address Lot NumJ�er Block Number 6 7 /1 cw PT" � �, I Cit y State Zip Code Phone Number Subdivision Name or CSM Number ti' a/✓ s'y ( ) la - 285 ll. TYPE OF B1 11ILDIN(5i: (check one) ❑ State Owned it Iyy Nea est Road Public 1 or 2 Family Dwelling - No. of bedrooms [ Village OF III. BUILDING SE : (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 6 4 1,0 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. i x 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 t4 Bed 21 ❑ Mound 30 ❑ Specify Type 41 [ Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit (Z'xS�f 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/da /sq. ft.) (Min. /inch) r Elevation q ® (0 /3 1 9 46 Feet /07— Feet Capacity VII. TANK in Ca gallons Total # of r Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Exist in structed Tanks Tanks Septic Tank or Holding Tank hon /� C1 , ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamberl ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) I Plumbgr's Signature: (No Stamps) MPfRRPR5GG'IQo.: Business Phone Number: W '7 L Plumber's AcAress (St eet, City, State, Zip Code): S 4 0 , IX. CO / EPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate I ssued Issuing A t si ature (No Stamps) Surc Approved []Owner Given Initial / Adverse Determination `�� harge Fee) ,/4� X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD -6388 (R 11196) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber A b J � R� N 3 0 � tr tT� a a ry N� J � w li � zw o � I� Q a� o � N O b � � m y 1A n r o Q � l V'1 � Labor and N4jma R lations use SOIL AND SITE EVALUATION REPORT Page I of 3 Divsion of safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but J r f 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 C S G LOT N I4,3 1/4 N C 1 /4,S T T z�' ,N,R q E (or) W PR PERTY O ER':S MAILING ADDRESS L6 BLOCK # I SUBD. P ME OR CSM # TF Cj rROJ��� CS J CITY„ STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE OWN NEAREST ROAD p(j New Construction Use [ Residential / Number of bedrooms UtAJ4 [ ] Addition to existing building j J Replacement [ J Public or commercial describe Code derived daily flow gpd Recommended design loading rate 0.7 bed, gpd/ft C,� trench, gp d/ ft 2 Absorption area required bed, ft tre 112 Maximum design loading rate bed, gpd 1ft trench, gpd/ft Recommended infiltration surface elevation(s) SE, iJA � 6 it ft (as referred to site plan benchmark) Additional design / site considerations Parent material Flood plain elevation, if applicable It S = Suitable for system c0 VENTIONAL OUND N? ROUND PRESSURE T- BADE Y TEM IN FILL HOLDING T K U= Unsuitable for stem S❑ U S❑ U S❑ U I S❑ U S❑ U D S I SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD /ft Boring # Horizon Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Tmr& Ground / y k 4 `_' (2) rK j 7 elev. ! Depth to limiting J�ctof� > 6 Remarks: Boring # 4r r <.. .: $ 8 ) 26 Ag l ow 313 � S (, � sbiK n 7 r C uj I. os 0�� Ground elev -1 16Y 4 A s 0 1 4$ lo .4S ft. Depth to limiting fa for ` Remarks: CST Name: — Please Print " � alqS� rn T " Phone: ~ It? A ddress: (ate -k 9 1 Signature: Date: hqY n d CST Number: `/T 4 .PR6PERT,YOWNER 1 0EP2 &Z464A: SOIL DESCRIPTION REPORT Page 2 of PARCEL I.D.# NW AA - �V/ 9 (LMO. Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Tmr& Ground Z 29-12 16M 4-A 0 Al co 0S. elev 161 ft. Depth to limiting factor Remarks: Boring # rA Cr eh, Cr 1 : g :0 'S BMW Ground 0,7 U % ,414 IT elev. lov (S,7 : 6,% /66,77 Depth to limiting factor Remarks: Boring # 16ye, V1 C w 0 I 6V 14 - Z be t-h k4 C, 0 s ox 3?-0 16 4 4 Ground elev. /(N24 ft. Depth to limiting f Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(R.05/92) LASLrM�,vT 1 �y z p F2 I J �1 1 � � I 1 z � s c i N n , I z N o I ► N � rA ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer {, o,,, cwJ i A i n1 Mailing Address l'3'7 Property Address __ 77 (Verification required from Planning Department for new construction) City /State A f s� r.J 1 ' . 5't l o / l Parcel Identification Number 6 f6 -107Y . d 0 7 LEGAL DESCRIPTIO Property Location N W ' /4, /J !i,, Sec. _7 , TAN-R R 19 W, Town of Subdivision 4 er o Z r53 , Lot # 1 0 Certified Survey Map # (0 29'53 Volume , Page # Warranty Deed # 31 w Z�- , Volume _ /D , Page #_. Spec house ❑ yes 3 no Lot lines identifiable N 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 licensedpumper 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 standard: 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 o the three year expiration date. SIGNAtURt 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 vi of a warranty deed recorded in Register of Deeds Office. y� SIGNATURE F 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 • c j All 9 DEC 1 2 1994 a J AM Reglste�o� �• 524247 sLcro F" I ED S UP V E Y MA CEP T I Located in the Northwest 1/4 of the Northeast /4 of Section 8, " 28 North, .Range lg West., Town of Troy, St.Cro x Coun Wis onsin NE Corner U) Section 8 East line of the NW 1/4 of to the NE 1/4. M N S 00 01' 28 "E UNPLATTED LAN_D_S_ S 00 ' 28 "E - Don under the direction of, 3 5 23.98' 317.72 ' a and Owned by: w � a CD m Ai J. Cernohous IL ®11- 5 HI 455 Cty Trk "FF" N [-i 1 Hudson, Wi. 54016 ifieludi N1 /4 Cor - 1 1 1 060 S Ft Q n q• . (2.55 Ac. Z ,�.� 01111uff Excluding right - of - way. ) �� a; ��•��� c0N��',, HARVEY Q. �`1y �� JOHNSON s -- — � -- S -18 9 HUDS Cn co io. Lo W S 00' 09' 49 "E 251 .72' ^' �.� IR z CO �1 030 a � W ®T 6 a O �� Ei APP Q1� ;0 p J $ w 11'� 87, 570 Sq. Ft. (2.01 Ac in v .0 a� DEC 1 2.'94) o 'HIV Excluding right -of -way. °D • • 41 a) ' — �" alb 'v, m >+I S1' . CROIX COUNTY w N WI �I Z m womprohenslvo f'l�tuiH aa. v zo A�.'I Zoning and o m n mI Parks ComtithlOo �It N 100' ROADWAY SETBACK —�� o m 019 W I It not rvcorr7�3 ..� 4 HI `�I within 30da'y -s N a NI EL I a¢proval'8a'ta E+l OI imprOv al shdVot 0- ►? W I I ntA & void j 251.72' 66 .00_` ° a 00'09'49 "W 317.72• -- — — — — — • 0 OUTS 1 (RESERVED A ; o OT _ ecess easement from :auc[ N to FOR FUT ROA ) : c 1° 2'46 34' ' N00 "W N 00'09'49 w — — — — -a (N 00 "W )'