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Home My WebLink About040-1214-20-000 ST. CROIX COUNTY ZONING DEPARTMENT' AS BUILT SANITARY REPORT Owner n Addres .� ,Co v e ss , 7 `, sr CROIxIQ`QS � COON �l City /State -� d ri o �> ; ZO NING OFFI(;e Legal Description: << Lot Block Subdivision/CSM # - e v 4',' J '/, 5 �.� 1 � o Sec. ,L, T,�N -R�f W, Town of a- PIN # SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer 1y 'd w -e 7 Size ST/PC 1.241 Setback from: House g Well ' P/I, S 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: c - --/ Width S Length X Number of Trenches 2 Setback from: House vz o' Well P/L �6 4 Vent to fresh air intake , A ' ELEVATIONS Description of benchmark sa r ► �c - / Elevation /a o • " Description of alternate benchmark 9 s'� Elevation fs 617 Building Sewer ST/HT Inlet .�? 7.3 ST Outlet 9,�', 3 7 PC Inlet PC Bottom Header/Manifold Top of ST/PC Manhole Cover 9Y ��- Distribution Lines Fy �� (,2) �, $?If ( ) Bottom of System Yo d3 Final Grade () () ( ) Date of installation G / F/ - ffiPermit number -3 State plan number Plumber's signature �� License number 4!,f -P - 7 , 7qO Date / Z/9 Inspector zfo �i Ytge�/ complete plot plan Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County Safety and Buildings Division 8T. CROI X INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary ®rrfr7t�g: Personal information you provice may be used for secondary purposes [Privacy L , s.15.04 (1)(m)). Permit Holder's Name: f] Village E] Town of: State Plan ID No.: RASMUSSEN, MARVIN CST BM Elev.: Insp. BM Elev.: BM Description Par I T 1214-20—Q I TANK INFORMATION ELEVATION DATA A9800145 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic ? ►^e c" I2,00 Benchmark ?� � �S Dosing ��T • �.$d' q -9 -,P. Aeration Bldg. Sewer Holding St/ Ht Inlet 5. a TANK SETBACK INFORMATION Outlet TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Se �- NA Dt Bottom using Header/ Man. �,.-- vP •q8 Aeration NA Dist. Pipe�� Holding Bot. Syste a PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand C7(, Model Numbe TDH Lift L iction System TDH Ft Forcemain Length Dia. H Dist. To well SOIL ABSORPTION SYSTEM BED/ EN H idth 1 Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid epth DIMENSIONS 5 - 7 -!� Z DIMENSION SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHI Manufactur SETBACK CHAMB R INFORMATION Type O 5 1 6" . / Mod tuber: Syste OR UNI DISTRIBUTION SYSTEM Header / Man Iifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length it Dia. Length '75 Dia. 1 4 ' + Spacing �, AST wt - ,cf o &- 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 2 Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: TROY 16.28.19.1026 , SE,NE 364 LO ER ROAD n �� ti0t 4C010 P, y* l gs Plan revision required? Yes No � ,� 01$ (TL� ( f Use other side for additional informs ' n. r SBD -6710 (R.3/97) Date Inspectors Signature Cert. Safety and Buildings Division NVIsconsin SANITARY PERMIT APPLICATION Po1.. WashingtonAve. 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 than 8 112 x 1 inches in size. rc Y'a % X • See reverse side for instructions for completing this application State Sanitary Permit N um b er The information you provide may be used by other government agency programs E] Check if risi�topevious 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 ti4 /, 1/4, S T." , N, Rr E (o W Property Owner's Mailing Address Lot Number Block Number 3Y 4.J u,roh S 9 Cit , State Zip Code Phone Number Subdivision Name or CSM Number II. TYPE OF BUILDING: (check one) ❑ State Owned C it y Nearest Road ❑ Village Public g 1 or 2 Family Dwelling - No. of bedrooms Town o f Yo- V v 111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number( 1 ❑ Apartment/ Condo Q _ /;z / 2 - d 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 online B, if applicable) A) 1 _ New 2. ❑ Replacement 3. [] Replacement of 4_ ❑ Reconnection of 5. C] Repair of an ,____ystem ________ 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 w S , 42 E] Pit Privy 13 E] Seepage Pit X 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 f r a � Required sq. ft.) Prop (sq. ft.) (Gals/day/sq. ft.) (Mjn�./inch) 'T/ _j ' - / ,E lf yon i Fee Feet VII TANK Cal pa i in gallon Total # of Prefab. Site Fiber - Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con Steel glass Plastic App New Exist in strutted Tanks Tanks e ti Tank k add ( 7 V 11 El 11 11 El Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VI11. 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) MP PRSW No.: Business Phone Number: W , 7 1 a ..4 S C H �H ev L� .?7fF 1 ,7, - 6 Plumber's Address (Street, City, State, Zip Code): S'c o a .1 ®_c,/ � 6 IX. COUNTY / DEPARTMENT USE ONLY E] Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued 1 i gent Signature (No Stamps) Appro Surcharge Fee) 5 I w � pp ❑ Owner Given Initial oo /� Adverse Determination � / X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD -6398 (8.11/96) aSTxisunow: original to county, one copy To: safety a sudelop OiwWon. owner rrombes �, e5Z -e v 2) 4d mz F 7V6'p,' LAJ q I Lo� f"9 Wisconsin Department of Industry Labor and Human Relations SOIL AND SITE EVALUATION REPORT Page I of 'S Drtision of Safety 8 Buildings in accord with ILHR 83.05, Wis. Adm. Code • COUNTY Attach complete site plan on paper not less than B 1/2 x 11 inches in size. Plan must include, but S �, C1ZA JSC 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 V ? _ h U S S ``l.) GOVT. LOT S I 1 /41Je 1/4,S L 6 T ZB ,N,R I q E (orJ3 PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # '^) 3 '?_w QTR S L .D D R , 3 3 — C,�.av � S`ftmo N Zv` a CITY, STATE ZIP CODE PHONE NUMBER ❑CITY []VILLAGE QTOWN NEAREST ROAD R1u EvL F W I SV o z.z 3 & 3 6 'S - Z2,p Govt SAID QQ New Construction Use [>(J Residential / Number of bedrooms y [ ] Additkn to eAsting building j J Replacement [ J Public or commercial describe Code derived daily flow b o'o gpd Recommended design loading rate - bed, gpcW 0 • % trench, gpd/It Absorption area required — bed, ft -1 50 trench, ft Ma)dmum design loading rate o- - 1 bed, gpd/ft 0• b trench, gpolft Recommended infiltration surface elevation(s) S EI�E - �Ak6 N 3 o F 3 ft (as referred to site plan benchmark) Additional design/ site considerations %Te N o*T )n t N s u O►J PhG L- 3 OF 3 Parent material ovtM S ftx. a G mow el.. Rood plain elevation, 'tf applicable N.N. ft S = Suitable for SySti@m CONVW IONAL MOUND Wai0UND PRESSURE AT WDE SYSTEfd IN FILL HOLDW. TANK. U= Unsuitable for 0S ❑ U IRIS ❑ U IM S❑ U LRr S 1 U 29S ❑ U ❑ S 911 SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure. Consisfietce Bourd3y Roots GPD /ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Tmndh J 0 -t3 \o� V_ Z ,I Z Si t Z S bw, ,.;:t't�: Z � 3 - Z3 I O `'t tZ 31 to — S t 1 Z '� S ��c �r► 'F► <. S � o. S D, b Ground 3 2, 3 - S 3 -). S 1 7 2 3 / y — S ` \ C S `rn v �� Cs - a • �( a . S elev. a $.`/ v0"12 1/6 o.b Depth to limiting factor I .Remarks: Boring # ` n o - t1 I O `12 ' S 1 ` - zf 3 `^q'F Cuv - o- S o• 6 Z Z 11 -39 to `t 3) 6 — g j 1 Z`f S w\�� eS o, S o•L 3 1 '19-SS 7 S Ye �1y — s 1 �s�k �rtv`ft- eS o �(so. S Ground elev. ( 4 SS -111 to tZ Y — g S wi I _ e 3•l It al Depth limiting factor 4 1 f »i ` r 1 Remarks: T Name: Please Print Arthur L. W e e r e r Phone: 715 - 4 ,2,5 O egerer Soil Testing & Design Service -P.O. Box 74 River Fall ,- _54022 Sgnature: Date: _ �5f �tt�myert `7'Le�c `k z`3 z - li - -) I, [ 9 `1 0576 PL P LAN Pa 3 of 3 s l yo' d , Q/ J F CL 8o- 0 B.z <'`La7 B.3 S dti r l 5 � to.I , o►v O Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page I of 3 Labor and Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code • COUNTY Attach complete site plan on paper not less than 8 12 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. O Li k2i -1 Z APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION h U S S �1 GOVT. LOT S 114 "E' 1/4,S 1 (, T ZS ,N,R ) 9 E (or� PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # S t. D E D R • 3 3 S'(vMO tv CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE ®TOWN NEAREST ROAD {R,I( -) w I SVDZZ PIS) 'fu - 3631; � 1 Gk_b\3Q_R_ �A►�D P4 New Construction Use Residential / Number of bedrooms y [ ] Addition to e)asting building ( J Replacement [ J Public or commercial describe Code derived daily flow boo gpd Recommended design loading rate - bed, gpd/ft 0 • % trench, gpd/ft Absorption area re0red - bed, ft -1 SO trench, 111 Ma)&num design loading We o- - 1 bed, WW — ?J trench, gpd/ft Recommended infiltration surface elevations) SEI�E etc S E 3 o F 3 ft (as referred to site plan benchmark) Additional design /site considerations %Q iv o I 110 I N s u oN Ph-s 3 o F 3 Parent material ova Si1x,\�i 8 G M A et Flood plain elevation, 'rf applicable N • A. ft S = S for Sys CONVENTIONAL MOUND W010" PRESSURE 5AT-GRADE SMW IN FILL HOLDING TANK. U= Unsuitable for Os ❑ U 0S ❑ U HS ❑ U S❑ U [q S ❑ U ❑ S IfU SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure. Cor>sistertce Bandery Roots GPD /ft in. Munseil Qu. Sz. Conn Color Gr. Sz. Sh. Bed Tmnch ( 0 -\3 v Sit z 45 bk "-�I^ C. -_3 - o•s o.b Z 13 -Z3 10 `� tz. 3l � — S t 1 Z '�' S �k w► 'F►- C S � o. S �. 6 Ground 3 2 3- S 3 7. S 'y 2 3/y - S \ C S Cs 6 . S elev. Cl fL t4 53 -113 10` 2 Y/6 s� rn \ - o.� o,b Depth to limiting f�actto .Remarks: Boring # O `12. -2 - / Z -` S 1 ` Z'F �k `^n'F>^ CLv Z to y2 3) — s � I Z�Sbh W,T� . c.s 3 3 9-SS S Ye 31y �C- S ) 6 k vnu S Ground elev. y SS -111 to Lttz V/6 - g S ►vt I - o -'� v9 e 3-"I fL Depth to limiting factor Remarks: T Name: -Please Print Phone: Arthur L. We erer 715 -425 -0165 egerer Soil Testing & Design Service -P.O. Box 74 River Falls,WI 54022 Signature: Date: CST Number: `113 Z9 Z `1 3 M00576 • PLOT PLAN Pa 3 of 3 S l y o ' l J CL to = � 0 8, 4 3 ZbA o � r�l r � e P" �, 0 c3 ST CROIX COUNTY • SEPTIC TANK MAINTENANCE AGREEMENT AND - OWNERSHIP CERTIFICATION FORM Owner/Buy r ( A/ els cc Ma iling Addre c ,h ' , s W . C-4,. A) c, A � �. �; �'t � i "eft ,�s W , S�/� "✓ �1 Property Address .t 33 3 (Verificati Plate D epartmen t for new construction) City/State � � N, �'' Parcel Identification Number _ U LEGAL DESCRIPTION Property Location .S E %., Alc- y., Sec. _ LL-, ULNAILW, Town of Subdivision G 1 c u F k S Fj �, n Lot # 3 Certified SwTey Map # Volume Page # Warranty Deed # Volume p age # Spec house p yes Q no Lot Lines identif able yes ❑. no SYSTEM JANCE IwPvoper and nuhdenanc eofyourceptkq *Mooaldranitia its I rPnt2tiu+ efaj*hretobaadlewastes .Properaosiaftanoe con isb " the f metioa of a � � � septic tac Y or took, if receded by a Iioeased pn� What y= put into dw system ft* as a utatment suge in the waste disposal system, masterp 1110 PrnpatY owner agrees to to St Ckvbc Zoning Dq= tmrat a eertifration fir, by the owner and by a is in proper operating oonditi p � a P� that (1) &e on -site wastewaterdisposal spsta after .C�nooessazy), the septic taalris less than U3 full of shedge. Uwe. the wed have read the above reqmicements and � to maiatzia the private sewage disposal h set fo system with the tstandards rth, erein, as set by the Depattment of Commerce and &C of Natural gatin dW Y optic system has been . Staoe of Wisconsin.. CertWc ation days of the three year expiration date, mast be to the St Croix County Zoning Office within 30 SIGNATURE OF APPLICANT --- DATE OWNER CE ICMON 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 pmperty described above, by virt of a warranty deed roeorded in Register of Deeds Office. /�sErT2i�Y / .*l.c?iG�a : -_"—'� S �1lj G'��...�' ✓7''c(- Lsy'�'�s ^—� SIGNATURE OF APPI:ICANT /-�'/ q DATE « « « « «« Any inforniation that is ails - r'ePedmay result is the sanitary permit bed revoked by the Zoning Department. ««s «as ss Include with this application: a stamped warranty deed from the Register of Dads office a copy of the certified survey map if ref crence is made in the warranty deed GLOVER STATION �. '' N \ �O cn . W .+ ni \ t9Z ° N i m Z No \ a \ ��` o a 0 G o < 32 ti� \ z m �', ► \ , S.F. , w ct U 90 000 S �s+ 0- �\ LL i �� 2.086 AC . f� w 3 � Q 00 0 rya \ c 35 ,�O• E °� \ w o �, \ 101. 435 S.F. 62Q X00 y� w w 2.329 AC. O• \ to <�2 O \ cn O \ 20• E 61 \ \ CO L \ o� t 22 - tri \ � N •� 33 _O N 143.696 S.F. to p , 3.299 AC. ,p\ fu 3 4 �► \ O `�o -v\ w 126.398 S.F. �''-"o \ \ 44 m 2.902 AC. (n \ v \ n O �63.g2q / 6 6' 2 20 %A \ a �v 4 273.65' 19 ..-- -" / 5 ro ROAD fa 1 f --' POINT OF BEGINNING Ln 2 UNPLATTED LANDS f oc EAST -WEST 1/4 SECTION LINE z 4508.18' 7. 5232.71' N 89 11'23" W 1/4 CORNEA E 1/ '" SECTION 16 _... .,,._