HomeMy WebLinkAbout040-1226-20-000 • ST. CROIX COUNTY ZONING DEPARTMEN 4 Y�
AS BUILT SANITARY REPORT
Owner j.,. , -9 Lm r /;z C c y eil
Address d S'31 .6y IQ9
City /State 11A ds.,,r/ /.� % COC
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FICE f; �
Legal Description:
Lot 1� Block Subdivision/CSM #
'/< '/. c Sec. - q — , TAN -R,�W, Town of A ?,-d u PIN # 0;(0 !o) �
q. a g. E , 7.
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION
Tank manufacturer V `doves Y�/ Size ST/PC 1,941 Setback from: House /_� ' Well 5�-' P/L YG �
Pump manufacturer Model
Alarm location
(HOLDING TANKS ONLY)
Setbacks: Service road Vent to fre ater Lin
Meter location
Alarm location
SOIL ABSORPTION SYSTEM
Type of system: 2 a Width 5 Length 2 Number of Trenches
Setback from: House Well P/L Vent to fresh air intake
ELEVATIONS
Description of benchmark Sm e. / / S Elevation OU .
Description of alternate benchmark Elevation
Building Sewer le,,2 P3 ST/HT Inlet aV, ST Outlet , /d- ,3Y PC Inlet
PC Bottom Header/Manifold % `Y Top of ST/PC Manhole Cover S -3
Distribution Lines
Bottom of System
Final Grade ? ( ) ( )
Date of installation / 3/ Permit number O� State plan number
Plumber's signature L4 - License number .ZQ 9 ' 9 d Date
Inspector Z"
Complete plot plan Or
' Wisconsin Department of Commerce
Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count �§T . CROIX
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) sanita7delTbW-:
Personal information you provice may be used for secondary purposes [Privacy LkWI s.15.04 (1)(m)].
Permit Holder's Name: I ❑�&[] Village E] Town of: State Plan ID No.:
.W. HOMES, INC. T UY
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel 6
� Ov oC� To 3 i
TANK INFORMATION ELEVATION DATA A9800096
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
eptic M'A % Prec,_% - f NI-60 Bench r 12- q1 A,210 too
Dosing A0 , 6 q•25 /1) •l
Aeration Bldg. Sewer q'. /a
Holding t Inlet 4. -7 0
TANK SETBACK INFORMATION St dot Outlet I0.Cq Oa 3
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic (p��` (p� (�j` NA Dt Bottom
1 �+
Dosing NA Header / Man.
Aeration NA Dist. Pipe (Zp 1 I .Z� lC>
Holding Bot. System
IZ.• Od•37
PUMP/ SIPHON INFORMATION Final Grade 7.7 1
Manufacture Demand 5111 • yyvAy%kte v--v, 7.oa /O
Model Number GPM
TDH Lift Friction Syste TDH Ft
Forcemain Lengt Dia. Fi Dist.Towell
SOIL ABSORPTION SYSTEM
BED / EN Width i Length C No. O Trenches PIT No. Of Pits In a Dia. Liquid Depth
DIMENSIONS J DIMENSION
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Ma ufacturer:
SETBACK CHAMBER
INFORMATION TypeO . / 'r ��f '� OR UNIT Mo el umber.
Syste Qdl `I
DISTRIBUTION SYSTEM
Header / M�; ifold +� Distribution Pipe(s) f x Hole Size xx Hole Spacing Vent To Air Intake
Length Dia. Length 75' 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 9.28.19,SE,SW 531 BRIANA LANE — GLOVER HILLS LOT 12
�l zz U 10 115� SGT
J � 4 6� S1 11 -
3, ACA- 4o iMA`i -, �ZiLf�l�eo ca�ten cSlne� GI c3�✓��v�fr�r �iPe.
�+ �w 1 + l 3
Plan revision required? n �No
Use other side for additional information.
SBD -6710 (R.3/97) Date Inspector's Sign re CeFt
��/► SANITARY PERMIT APPLICATION Safety E and nnI gtonA ve Sion
risconsin
In accord with ILHR 83.0 Wi . A P.O. Box 7969
Department of Commerce 5, 5 dm Code Madison, WI 53707 -7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 vi x 11 inches in site. 1c Ya % x
• 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 3o-77d8
❑ 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 RMATION
Property Owner Name Property Location
ri,J v y i �' G 1 LzS 1 /4, S T oZ , N, R E (or)
Property Owner's Mailing Address Lot Number Block Number
City, State Zip Code Phone Number Subdivision Name or CSM Number
Alive I
. TYPE B ILDINI : (check one) ❑ State Owned E] Itia Nearest Road
Public 1 or 2 Family Dwelling- No. of bedrooms Town of JY�
111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Numbers
1 ❑ Apartment/ Condo 's yo a
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. Q 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 USeepage Trench 22 ❑ In- Ground Pressure , 42 ❑ Pit Privy
13 ❑ Seepage Pit � �` 7� 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
6 Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) T/ /py, ( Elevation
r f>7 �C:t 2 / 6�, S Feet ( °7` , Feet
VII. TANK Capacity
INFORMATION in gallons Total # of Manufacturer's Name Prefab. Site Fiber- Ex
New Existin Gallons Tanks Concrete Con- Steel glass Plastic er.
A p p
structed
Tanks Tanks A
ptic Tank °u Wdwg & Pa�de I ;ACS -ev v M ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ 1 ❑ 1 ❑ 1 ❑ I ❑ 1 ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: (No Stamps) MP PRSW No.: B Phone Number:
. �
Plumber's Address (Street, City, State, Zip Code):
6-) ,, Qr!v
IX. COUNTY/ DEPARTMENT USE ONLY
E] Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps)
�J Approved ❑ Owner Given Initial / f�f� Surcharge Fee)
A
Adverse Determination J eJ � � �s�
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD -8398 (R,t 1196) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Muarber
I Ila) 2 Io a ev
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Wise -:nsin Department of Indusey SOIL AND SITE EVALUATION REPORT Page of 3
Labdr and Human Relations
° Division of Safety & BuikSngs in accord with ILH R Adm. Code
I COUNTY
Attach complete site plan on paper not less than 8112 x 11 ' e stza. Plan e, but
not limited to vertical and horizontal reference point (BM), n and % of�lppe, PARCEL I.D. #
dimensioned, north arrow, and location and distance to roads,/,
APPLICANT INFORMATION- PLEASE PRINT A IubNFORMAT ��� 3 y t R Y, lE �g
PROPERTY OWNER: G el StS.J 1v �'�I - PROPERTY L($, f�T E W
l N
`• 1/4 $jtJ 1 /4,S 9 T Z$ ,N,R
�Or\1 � L lit , E0 R ',' `�
PROPERTY OWNER :S MAILING ADDRESS # # SUBD. NAME OR GSM #
y S O M . (=> L0\)
CITY, STATE ZIP CODE PHONE NUMBE ,, / ILLAGE MOWN NEAREST ROAD
uDS o�, tiv I 5 Y of L (�l s) 3a 6_ t 3 T jZ,p g2lP1tV L KfJe
[kJ New Construction Use N Residential/ Number of bedrooms Addition to existing building
[ ] Replacement [ ] Public or commercial describe
Code derived daily flow � So gpd/B EDR(jO" Recommended design loading rate bed, 9VW � • � trench, 9pd/ft
Absorption area required — bed, ft trench, ft Ma)amum design loading rate o•'� bed, gpd /ft 0 8 trench, gpolft
Recommended infiltration surface elevation(s) 522 ►-joTIZ 00 'Prr&e- 3 , ft (as referred to site plan benchmark)
Additional design / site considerations F-st
Parent material Flood plain elevation, if applicable N- A • ft
S = Suitable for system CONVENTIONAL I MOUND IN- GROUND PRESSURE I AT -GRADE SYSTEM IN FILL HOLDWG TANK
U = Unsuitable for s S ❑ U ®S [31.1 ENS ❑ U ®S ❑ U IRS ❑ U ❑ S O U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Y Roots GPD /ft
Boring # Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Tmnch
O - LO 20`-12 Z Z M S blz 1 N1 o - S
Z l0 -L8 L O wR z 1 2 - L Z Y L p` �n� i C g - - O. Z.
Ground 3 1$ - °tZ lks -t VL V1 -- S (3 S
elev.
\03 fL
Depth to
limiting
factor
Remarks:
Boring #
o VL % _ ` Zu r o Z
-K IL 3 t 2 L Zm p 1 wt`� a.S
Z 2 t i -Z� 1 b 2 3] Z L Z ►n b� wt C-S
3 Z)$9 0.1 0.8
Ground
elev. -
l o3.S It
Depth to
limiting
factg
Remarks:
CST Name: Please Print Phone:
Arthur L. We erer 715- 425 -01.65
Ad dress :
eg�r Te_stn &- _DQpgn Service,. -P.O. Box ]4 River Falls, WI IM kt
- -- -- _ .
PLOT PLAN Page 3 of
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CST Signature 'Date s Telephone too; . CST #
• ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer 7�j ei✓ ,,, es
Mailing Address X09 J )Oa, <.,11
Property Address _ + .3l ,L��e a
(Verification required from Planning Department for new construction) 3 Vv- C—
City /State a , Parcel Identification Number 4!2 'KY - 12 A .20
LEGAL DESCRIPTION
Property Location S1 r /4, S4) r / a, Sec. �� T -R l W, Town of
Subdivision Lot # /�;k.
Certified Survey Map # Volume . Page #
Warranty Deed # 5` Volume / 3 / 3 . Page #
Spec house 29 yes ❑ 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
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
thrte year expiration date.
o �f p L� � /�(/ O
SIGNA 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
n�;: rty s cribed 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
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