HomeMy WebLinkAbout040-1072-40-000 • ST. CROIX COUNTY ZONING DEPARTMENT
AS BUILT SANITARY REPORT
Owner _!'faoJ iMAiArilA 44;
Address 37 r =H r
City /State 4 41 /, S oei LJ r S"yo i�
Legal Description:
Lot Block Subdivision/CSM #
'/+ E '' /, A/w. Sec. /4 , T 24 N -R sq W, Town of �o y PIN # 0 - I D '1 - TO 40
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: 6
Tank manufacturer G-.)lE -5,T Size ST/PC/- / Setback from: House/ <" Well -'QT' P/L
Pump manufacturer — Model —
Alarm location
(HOLDING TANKS ONLY)
Setbacks: Service road Vet to fresh air intake Water Line
Meter location
Alarm location
SOIL ABSORPTION SYSTEM
Type of system: 61PAV Ty Width 5 " Langer Number of Trenches
Setback from: House - S' Well 9'2' Vent to fresh air intake 9S'
ELEVATIONS
Description of benchmark �- � C A 7 00 1 P or Cx sr 4 Elevation 100-oo'
Description of alternate benchmark Elevation
Building Sewer 98. y ST/HT Inlet 9'I. �/o' ST Outlet 97. '
PC Inlet vA
PC Bottom NA Header/Manifold 'FE- 4 7 Top of ST/PC Manhole Cover ff 9s'
Distribution Lines (A) 9S-.
Bottom of System (A+) 93• oa ' (g) 5?. oo • ( )
Final Grade (h) ", (g) F,�. " ?' ( )
Date of installation z /yam Permit number 30 7?o iG State plan number
Plumber's signature yte,
License number 5 S
S Date q 071K
Inspector '�� `� 3'l
Complete plot plan or
Wisconsin Department of Commerce \
Safety and Buildings Division PRIVATE SEWAGE SYSTEM County:
INSPECTION REPORT ST CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary 3�r�i►yo
Personal information you provice maybe used for secondary purposes [Privacy La s .
U 11
.15.04 (1)(m)]
G AGN Holder RON & MARTHA MO P ❑ Village Town of: State Plan ID No.:
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel T
, - ,_ I`4 1072 -40 -000
TANK INFORMATION LEVATION DATA A9800005
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing
Aeration Bldg. Sewer
Holding St /Ht Inlet o- 9
TANK SETBACK INFORMATION St/ Ht Outlet
vent to ?'
TANKTO P/L WELL BLDG. Air Intake ROAD Dt Inlet
Septic ' /po' s8 j 0 i
NA Dt Bottom
Dosing NA Header /Man. 9. 5 3 - X13.'>
3.9
Aeration NA Dist. Pipe +'7 y 3 -S3
Holdin Bot. System /m, .1?� 9s,o /'
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
00 7 9 ,
Model Number GPM
TDH Lift Fri 'on System TDH Ft
Force ngth Dia. Fi Dist. To well F__1
SOIL ABSORPTION SYSTEM
DIMEN tjHWidth No.Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMEN I N BLD SETBAG WELL LAKE / STREAM LEACHING Manufacturer: INFOR CHAMBER Mode Number:
>/5 ,cJ OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length Dia. Spacing
C� 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,;b- 4 "" Bed /Trench Edges a -` Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: TROY 18.28.19.276B,NE,NW 378 COUNTY ROAD F
Plan revision required? ❑ Yes [ / No
Use other side for additional information.
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SBD -6710 (R.3197) Date spector's Signature Cert. No.
Safety and Buildings Division
N* S ANITARY SCOnS PERMIT APPLICATION 2 01 E. Washington Ave.
In accord with ILHR 83.05, Wis. Adm. Code P.O. Box Wl
Department of Commerce Madison, WI 53707 -7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 81/2 x 11 inches in size. t51- tC" j X..,
• See reverse side for instructions for completing this application State sanitary Permit Number
30 W (
The information you provide may be used by other government agency programs ❑ 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 RMATI N
Pro rty Own N � me , Property Location
pct /v( 7 4:;�, of f/J5`114 ij(,- ) / /'Q T ,N,R E(or 1/
Property Owner's Mailing Address Lot Number Block Number
9 S CTrf F .
Ci , State Zip Code Phone Number Subdivision Name or CSM Number
OSo,J w E Syo/ 1 0 1:5 - ) 38fr-3o9G
I ll. TYPE F BUILDING: (check one) ❑ State Owned ❑ C it y Nearest Road
� �
❑ Village C _rt
Public 1 or 2 Family Dwelling - No. of bedrooms own OF / /( o y
111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo -107 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 on line B, if applicable)
A) 1. ❑ New 2. Replacement 3. Q Replacement of 4_ Q Reconnection of 5 ❑ Repair of an
_____System __ --- ystem_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
12XSeepage 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. /inch) t Elevation
y�0 '7160 SQ. Fr. �O - <v. Feet !S Feet
VII. TANK Capacity
in gallons Total # of Prefab. Site Fiber- Ex er.
INFORMATION Gallons Tanks Manufacturers Name Concrete Con Steel Plastic p
New Existing structed glass App.
Tanks Tanks
e tic Tan r 4&khrqTmyr 4qS0 1:1 El ❑
Lift Pump Tank /Siphon Chamberl El 1 11 1 1:1 1 1:1 1 El ❑
VI11. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plum s gnat �Ps MP/MPRSW No.: Business Phone Number:
Plumber's Address (Street, City State, Zip Code):
1� �� '57 !Y , ` /J sdC� -, ." ,
IX. COUNTY/ DEPARTMENT USE ONLY
E] Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps)
/ Surcharge Fee)
® Approved ❑Owner Given Initial ! g� e% L'9--/
Adverse Determination IWL�
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBI fit 11" DISTRIBUTION: Original to County, one copy To: Safety & Buildings Divisielr, Owner, F%md er
' � �t..�M �'trt , PK - flitSE %'�N� • . •.
vo�
�X S 1.5 e-
•PLB 67
PLOT B CROSS SECTION PLANS
ZAPPA BROS. EXCAVATING INC
l� x 515 i i•�l� �/ « PW.MBING UNIT ..
P ROJECT
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IVES../ / e?SD �.K. GcJ.ESy�e � j� ?.�► /< �.4jtTY ��ff /I�>D..�cE.NL�
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NO
S SCALE
FRESH AIR INLET AND OBSERVATION PIPE
��— APPROVED VENT CAP
MAXIMUM 12'
ABOVE FINAL GRADE 1
MAXIMUM OF 42' ABOVE 4' CAST IRON VENT PIPE
PIPE TO FINAL GRADE
MARSH MAY OR SYNTHETIC COVERING SIGNED:
LICENSE: �9
MINIMUM 2 AGGREGATE
OVER PIPE DATE: — rj — S^�'
DISTRIBUTION PIPE
LAGG REGATE TEE
SOIL TESTING BY:
ELEVATION BED TE T 18 R SOIL A TP PE • PERFORATED PIPE BELOW
FT COUPLING TERMINATING
AT BOTTOM OFSYSTEM
aod Ru man a Industry,
Labor ar anil, u SOIL AND SITE E V A L U AT O N 3 E PORT Page of
Lab Rela ��
Division of Safety &Buildings in accord with ILHR 83.OS�VVis. Adrtn, Ct�d@`.
l' ,. P COUN 14 Attach complete si te plan on paper not less than 8 1/2 x 11 inches in .ize: Plan �i�01 mtfii]plur8) but'',' . not limited to vertical and horizontal
reference point (BM), direction hd'p /o of slope, sc#
dimensioned, north arrow, and location and distance to nearest road /A -► — Y DATE
APPLICANT INFORMATION- PLEASE PRINT ALL INFORM TIpN 1t � P OPERTY OWNER: te? P ION
AQTul� /'
y A 4 �t; "GOVT. LOT U4 W1 14,S a T Zl N,R / 9 E (or) W
P ERTY OWNER':S LING ADDRESS tOt # QtK` '` BD. NAME OR CSM #
t�ltl �v•
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE JrOWN NEAREST ROAD
(] New Construction Use] Residential / Number of bedrooms [ ] Addition to existing building
Replacement [ ] Public or commercial describe
Code derived daily flo es -- ' � . G Recommended design loading rate 6 .� bed, gpd/ft trench, gpd/ft
Absorption area required bed, ft - (rich, ft Maximum design loading rate a bed, gpd /ft gpd/ft
Recommended infiltration surface elevation(s) 92.0 Al 963 It (as referred to site plan benchmark)
Additional design / site considerations
Parent material Flood plain elevation, if applicable It
F = Suitable for system � 0 I VENTIONAL MOUND IN OUESSURE AT -GRADE EM ILL
= Unsuitable for stem ®S ❑ U S � U X HOLDING T K
S ❑ U ND PR I0 S
S ❑ U SYSTEM IN F U ❑ S U
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 nerndl
3
I -i9 / i2 / Z ,�t sbe n� r e.5 / O.s 0.6
$, 19-44 — L 6 K
� > yt2 3 5. 2 rh � ��r c s 1 � d S D. G
Ground $ 44 - S 5' — LOYR 4 _ S /VI M / C S
elev.
C a , i ft. $3 S - 1 y 41 4 S SG "' O .S O . c
Depth to $ -13!�_ �} S SC ,�, r 0.7 O
limiting
fac r
Remarks:
Boring # ,
Z 1 y e k2 S, c
Ground -�2 I bye 0,5 D.
elev.
loft IK b g O�
Depth to
limiting
Remarks:
CST Name. =Please Print Q N WSO �J Phone: �� a
A ddress: Po 6 W L) & SOhj tJ I f ku %
Signature: Date: f 1f �(- CST Number:SA.4
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STC -105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER —7 2,
MAILING ADDRESS
PROPERTY ADDRESS
(location of septic system) Please obtain from the Planning beet.
CITY/STATE z&'
PROPERTY LOCATION A l25 1/4, A4,1 1/4, Section X? . T —M M_ N -R ,1�
TOWN OF ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
CERTIFIEDSURVEY MAP , VOLUME ZLPAGE , LOT NUMBER______
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 licensed septic tank pumper. What you put into the system can affect the function of the septic tank
as a treatment stage in the waste disposal system.
St. Croix County residents may be eligible to receive a grant for a maximum of 60 of the cost
of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that owners of all new systems agme to
keep their system properly maintained.
The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner
and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1)
the on -site wastewater disposal system is in proper operating condition and (2) after inspection and
pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum.
I/We, the undersigned have read the above requirements and agree to maintain the private sewage
disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR.
Certification stating that your septic has been maintained must be completed and returned to the St. Croix
County Zoning Officer within 30 days of the three ye piration date.
SIGNED:
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
STC - 100
This application form is to be completed in full and signed by
owner(s) of the property being developed. Any inadequacies will
only result in delays of the permit issuance. Should this
development be intended for resale by owner/ contractor, (spec
house), then a second form should be retained and completed when
the property is sold and submitted to this office with the
appropriate deed recording.
Owner of property
Location of property A/W 1/4 1/4, Section / T.V' (1 N -R _Z,9 _ W
Township Mailing address
Address of site _ Q_-
Subdivision name Lot no.
Other homes on property? Yes L
Previous owner of property y r
Total size of property s �5 �5 C e4c-_S
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? _k yes No
Is this property being developed for (spec house)? _YeS j/ No
Volume and Page Number as recorded with the Register
of Deeds.
---------------------------------------------
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a
certified survey, if available, would be helpful so as to avoid
delays of the reviewing process. If the deed description
references to a Certified Survey Map, the Certified Survey Map
shall also be required.
PROPERTY OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the
best of my (our) knowledge that I (we) am (are) the owner(s) of the
Property described in this information form, by virtue of a
warranty deed recorded in the of ice of the County Register of
Deeds as Document No. and that I (we) presently
own the proposed site for the sewage disposal system or I (we)
obtained an easement, to run the above described property, for the
construction of said system, and the same has been duly recorded in
the office of the County Regi er o Deeds as Docum nt No.
•
gigiiiture of Applic nt Co Applicant
Date of Signature Date of Z S