HomeMy WebLinkAbout040-1230-10-000 ST. CROIX COUNTY ZONING DEPARTMENT
` AS BUILT SANITARY REPORT
Owner , s
Property Addres < ` ,
City/State
Legal Description:
Lot -- Block _ Subdivision/CSM #
%4' /., Sec. //,', T-
ZR N -R-4qW, Town of PIN #
SEPTIC TANK -- -DOSE CHAMBER -- HOLDING TANK INFORMATION
Tank manufacturer Size ST/PC I Setback from: House _,Zg'_ 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: Width Length Number of Trenches
Setback from: House ;sus" Well PAL so Vent to fresh air intake r
ELEVATIONS
Description of benchmark ' ,i - Elevation
Description of alternate benchmark Elevation 12 �J, j
Building Sewer , /7._�� ST/HT Inlet ,91;� ST Outlet s' 7 PC Inlet
PC Bottom Header/Manifold Z2 Top of ST/PC Manhole Cover 91,7-
Distribution Lines () &1-21 () ( )
Bottom of System
Final Grade
K.:
,✓. -^-° , tst;dlPiTY z�
f ,.
Date of installation A211 P m nu ber State plan num`
Plumber's signature License number Dat
Inspector r9A�
Complete plot plan Q
{
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County:
Safety and Buildings Division
INSPECTION REPORT ST. CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) SanitarDT999.:
Personal information you provice may be used for secondary purposes [Privacy L , s.15.04 (1)(m)]. 4bbt�3322ii
M �g H- older's�tarpR,;, �KU7r^ Village Town of: State Plan ID No.:
ESI CST
BBNN Elee'v : C Insp. BM Elev.: BM Description: ttU Parcel Ta4No_:1230- 10-000
ll(r � lP1.0 �,+ U U
TANK INFORMATION ELEVATION DATA A9800577
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septi (� �� Benc a (I . {�� �to �. pb'
Dosing 4 7a c uM 7 v q,
Aeration Bldg. Sewer
Holding St /40 Inlet
TANK SETBACK INFORMATION V St /4 Outlet
TANKTO P/L WELL BLDG. ve tto ROAD Dt Inlet
Air Intake
ept tq NA Dt Bottom
Dosing NA Header /Man. G� y'( 12 •Ocl(Q(. /
Aeration NA Dist. Pipe CND $7 ) 2.1 5'
a--
Holding Bot. System '1�•Y� 4.0 gt
PUMP / SIPHON INFORMATION Final Grade V q
Manufacturer emand s{.[N��C a�3 -Ofo 1611
Model Number GPM
TDH Lift Friction ystem TDH Ft
oss ead
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BEOnRENCH Width r Length r No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
7.5 DIMENSION
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEA G anu acturer:
SETBACK C AMBER
INFORMATION TypeO � F ,/ ` ._ M um er:
Syste :6k
DISTRIBUTION SYSTEM
Header / Manifold r , Distribution Pipes) r r x Hole Size x Hole Spacing Vent To Air Intake
Length _&L Dia. { Lengt Dia. Spacing "-(),A 2, °r
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 I6.28.19,NE,SW 345 SOO LINE RD — GLOVER STATION LOT 66
p 6l ( i ►�� sec 4r
a X414 &#A i �.d ('0mk & �± q � .Wx«
runt -6 acoa�d�lk
r Ij
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Plan revision required? ❑ Yes to No 7 .
Use other side for additional information.
SBD -6710 (R.3/97) Date Inspector's Signature rt No.
V isconsin Safety and Buildings Division
201 W. SANITARY PERMIT APPLICATION p O Bo W Washington Avenue
Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 -7302
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 1/2 x 11 inches in size.
• See reverse side for instructions for completing this application State Sanit ry Permit Number
AIfwSB
Personal information you provide may be used for secondary purposes ❑ Check 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
Prope Owner Nam Property Location
le
1/4 1/4, S T , N, R E (or)
Property Owner's Mailing ress Lot Number Block Number
City, S Zip Cod Phone Number Subdivision N m r CSM Num r , eAll�' ( ) z
II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ !ty ge Nearest Roa
Public 1 or 2 Family Dwelling - No. of bedrooms J Q l o Villa Town of o ,�
I11. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo 1 0 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. IN New 2 ❑ Replacement 3. ❑ E] E] Replacement of 4 Reconnection of S. 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 RrSeepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 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. /' ch) Elevation
1 1 S g' Feet Feet
VII. TANK Capacity
in gallons Total # of Prefab. Site Fiber- plastic Exper.
INFORMATION New Existin Gallons Tanks Manufacturers Name Concrete Con- Steel glass App.
structed
Tanks Tanks
Septic Tank or Holding Tank — , ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ 1 ❑ 1 ❑ 1 ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the ndersigned, assume responsibility for irwtall4tion oft onsite sewage system shown on the attached plans.
Plum a Name: (P Plum Cs gnat St MP /MPRSW No.: Business Phone Number:
Plumber's Address Strget, City tate, Zip e):
5 �) _ `t
IX. COUNTY/ DEPARTMENT USEONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued Issuing Agent Signature (No Stamps)
Approved ❑ Owner Given Initial Surcharge Fee)
Adverse Determination -�
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD- 6398 (R.11/97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, plumber
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Wisconsin Department of Industry SOIL AND SITE E V A L U AT.I O: N . R / � T Page \ of 3
Labor and Human Relations
Division of Safety & Buildings in accord with ILHR 83.0�Y Wis. Adm. C 4d4
NTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in stye- P)an must include; but ST CC�O j X
not limited to vertical and horizontal reference point (BM), direction an46A of slope; scale or LLD. #
dimensioned, north arrow, and location and distance to nearest road I
APPLICANT INFORMATION- PLEASE PRINT ALL INFORMA tit>�,
AEVI D BY DATE
PROPERTY OWNER: ,ROPERTY
C • V't • T84 E" � 1��1J1J \ S S C L Z Nt? 114, S 1 /4,S � b T Z8 ,N,R 19 E( W
PROPERTY OWNER':S MAILING ADDRESS LO L 0 NAME OR CSM #
— 1 l O N . ►r't tit ►� 3 �" . b b — G Lb\) 21Z STtM W LI `CN PtDO t1pON
CITY, STATE ZIP CODE PHONE NUMBER E]CITY ❑VILLAGE MOWN NEAREST ROAD
R.LULIZ. C-�5, W I S OL (7157 1 I11S- B t 61 p 1-( I sua L_ vu L- Vz*b
[S(] New Construction Use.14 Residential/ Number of bedrooms 4 [ ] Addition to wdsting building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow 6 0 o gpd Recommended design loading rate c' • S. bed, 9pd/ft n. 6 trench. gpdt
Absorption area required \ %.iwo bed, ft \Od0 trench, ft Maximum design loading rate o. S bed, gpd/ft 0. 6 trench. gpolft
Recommended infiltration surface elevation(s) SM P" t 3 ft (as referred to site plan benchmark)
Additional design / site considerations ?.Ztam M Cam/ th 3 - rgZxj e_"S - RCN S ' x b - ) ' w AJ 6 .
Parent material Set I MigvT' oUtZR S f'pv*\)y oj' ft -S H Flood plain elevation, if applicable N - P'. . ft
S = Stritable for system COWENTIONAL I MOUND W GR WD PRESSURE AT -GRADE SYSTEM IN FILL. HOLDING TAW
U = Unsuitable for system I je S ❑ U [a s ❑ U ®S ❑ U f$ S ❑ U ®S o U IDS Va il
SOIL DESCRIPTION REPORT
Boring# Horizon Depth Dominant Color Mottles Texture Structure Cor>SrtoeBar>vary Roots GPD /ft
in. Munsell Qu. Sz. Cora Color Gr. Sz. Sh. Bed Tmnch
_. Z g - 1 O `iR 3! S!I z'Fsl�k ►�`F4 cw o•S o.
Ground 3 V) -30 Slip- Sty s 1 5 b VK vit � S 0 .4 ti•S
elev.
Depth to
limiting
factor
x$z3'
Remarks:
Boring #
o - 10`I it- 3lt - SY1 Z`F wT1-
1 3 2- 31y - S L ( Z \ S d{c Yat'�}• Cw u S U. �,
t� -ZS - ). S `1 R Sly S) \ M s bk Vl U c S o y 0 5
Ground
elev. o• S ' n. (.
2 S-�7 �- S'ttZ i� /6 `�S V g9 ►�
cl 6t4.'O ft
Depth to
limiting
�8 rc
I
Remarks:
T Name.— Please Print Phone:
Arthur L. We erer 715 - 425 -0165
M egerer Soil Testing & Design Service -P.O. Box 74 River Falls,WI 54022
Signature: Date: CST Number:
G �( -30Z- 66 1 - �� -� S M00576
• PLOT PLAN Page 3 of 3
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NOTE: House to be at least 25' Z
' from trenches. Well to be w °lo
at least 50' from trenches.
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�UEI 10:53 EDINA REALTY RIVER F TEL :115 425 0331 I P.003
Laabw and Human Aelatiien SOIL AND
Dihsie., of Saie1y A e,irdngs SITE E V ALUATION R E P O R •r in Scmrd with ILHR 83.aS. WIS. Adm. Code
Attach aomplele site plan on COU
Paper not less than point (B t 11 inches in size plan must i S
not limited to vertical and horizontal refer point , Cr nclude, but C�• I x
rection and % of sbPe, scale or
dimensioned, north arrow, and location and dstance to nearest road. PARCEL w.
APPLICANT INFORMATION PLEASE PRINT ALL INFORMATION
REVIEINEO 8r DATE
PROPEM Y OWNER:
C./� . 6�f � �� PROPEATYIOCATION
PAOPERTYOWNEA MVUNG ADDRESS � l S Sc ` Z t81` MLr uI SW 111•S 1 T
Cr Y � N . *I Fw Aj % T L T 6 BLOUC I SUBD. NAME OR CSM 1 �� 1 � E ( W
DP CODE PHONENUMBEA G LCVQIZ x'17 �� RC T1
R t UL /�-l.L S h1 I S o LZ (719 LI Z.S - 4 1 1� PILLAGE OWN N T ROAD
M New CarsltiMan ° Y S° !_ �' Ro1+•p
�• U4 Re�den681 / Nor of pedroorrLt y
t I Replaottreent I I Pubic tar aomnWCW aesmbe I I Add" Jo e*"
!
Cage dtlriuet! daffy Row 6 0 O ypd R
Absarpian area "*W A00'"merded de* taadeg rate Ded, gptlAlZ o. 6 g 2
"aquir'ed b
`� ed R a �� n2 m
Reoorm,axW ini t'afim =We BSI Uo de9gn ba6tg rate O, S bed �2 �• b
Aditna dm* /side o nW.A e 1 3o+J I� R (as rekired b site Pbn bwdvrAIM 9P 2
Parent rnlefelal S S S �X b Le1. +6
S = Suiuble br sptem Rood P&n elcrarixt' E
WS C3U 08 0
SOIL DESCRIPTION REPORT oS PjU
Boring; Horizon Depth Dominant Color Mol>!es Structure in. Munsa (k, Sz: Cons color TeaRurt, � � G P D AV
1 �$ tOtcZ-
31 z _ Gr. SL SIt_ �tlrt�, Q-ools Bd stir
Z 8 -11 107 2 3/ 1i,
o. e v, l
Ground 3 11 - 7,Sy 3/y
9 61.5 K S `� It SrIC
Depth to "� S 0 5 9 �,, 1 o• S; o.
limiting
factor
?8a
Remarks:
Sodng a
Z S -Ly 3,y
s lit Z`Qs6k- ck,, o•s}o.l
elev. �
� 3bk M1 V. cg � O• ;p.
2S47 '7. V • $
DePQI b
firti�tg A
,r
Remaft:
No -r—p1me P►i�t
cmil-or q^41 —
Arthur L. We erer 1010r:
71 -4
10:53 EDINA REALTY RIVER F TEL :715 415 0331 I P.004
"AOPEM OWNE 3-f —
A 3 Ct ,rt SOIL DESCRIPTION REPORT
PARCEL I.O. # Pape Z of
I
I
Boring # Horizon Depth Dominant Color
In. Munson p� S� Coot robr To a Structure Consistfnaa G P D /1t
MD ar- Sz. Sh. Roots IL ed mr& 3 [ t . 8 Z
9-1.9 Z s bk c o. s e. I.
1o�a si siI Z*'Sb ��M �- r 0.5 0.
-l ey. 3 ►9 -�Z 1.5 4a. 31y
y. It
3 10- 3bk yM V �` C' o, v o•S
)epth to
:miring
act o� + ,� I
� f
Remarks:
oring #
Stamm y 1 0.9 lo, >z sit s��l Z sbk ►h`��. c _ o. s
? 9 -Lo l O'7 R 3 ly I°
� z� �. y �
3 S a 3�y c o•S o.
pound s 1 1 abk 1M v
` 3 - I 2� -8 �• S y 2 V16 'fi- Cs• — o• Y I o. S
,pth to
A ng I -tor
I
Remarks: I
ring # i
Cr
SO
- Z
Co-j IL '� z b�c wr'Fti c S _ o• s 1 4. 6
:Una 3 Z& -n fZ ?t c
_: j IL 3S. 8 7- S 44 2 Ylb y S e S 6k
)[h to
ing IK v
or
I
Remarks:
4 Z k 10,fa Z 3. L
1 0-8 tv`tQ 312 Si
ail
s 4 1 P- 3 Z'�
_ S (L 33 .x'8 7. S y v/C 3) l c 56k
to $ N o =
g V
�u
Remarks:
30 A.oSA2)
" 1
(TUE) 10:54 EDINA REALTY RIVER F TEL:715 425 0331 I P.006
f �.
PLOT PLAN pag 3 of 3
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NOTE: House to be at least 25' 151.1
�• from trenches. •Z
at l from east 50' Well to be w °lo
trenches.
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OCT -09 -98 10:02 PM 9ELISLE EXCAVATING 7152473038+ P.01
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
r -Jr C4 OWNERSHIP CERTIFICATION FORM
Owner/Buyer /.�►� &rneS
Mailing Address eve *A) r6`�2p
Property Address 1 a /,-,, " 9
/ / (Verification required from Planning Department for new construction)
City /State 1 / / / / ] AOon Parcel Identification Number
LE GAL DF.SC PT)CON
Property Location �� /., S� /,, Sec. �, T A N -R_Z_FIIS� Town of
Subdivision _ e ro"? Lot #
Certified Survey Map # , Volume Page #
Warranty Deed # , Volume __ , Page #
Spa house 13 yes �n0 Lot lines identifablexyes 0 no
$X►� 'EM. 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 pu mptrr. 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 fotsn, signed by the owner and by a
master plumber. journoymanplumber, restrictedplumber 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 fall of sludge.
Uwc, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the studards
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 34
days of *a three year t"tion date.
StO NAI'UltrOF APPLICAW — DATE
OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (an) the owners) of
the property deserib d above, by virtue of a warranty deed recorded in Register of Deeds Office.
IGNA OF APPLICANT DATE
E .�
•••••• 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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Page 1 of 1
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