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HomeMy WebLinkAbout040-1105-20-000 !' '"- ST. CROIX COUNTY ZONING DEPARTMENT /'I,� =` AS BUILT SANITARY REPORT Owner Address e J ! 1? ? City /State 2re, /(s lie � ST CROt COUNTY ZONINGOFFI. Legal Description: , y Lot Block ltlq Subdivision/CSM # /�i'f> , /y �cre Y. '/. i+�� , Sec. r �, T _ N_RZW, Town of r PIN # Oy /o z( _ SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: l� Tank manufacturer 1, e l s c� Size ST/PC / Setback from: House 19 Well YS P/L /oo Pump manufacturer — rir/ 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: r,-e, c-1t Width 3 Length 9/ Number of Trenches S Setback from: House 8 y' Well 1 40 'f P/L loo '/- Vent to fresh air intake ioo ELEVATIONS Description of benchmark ��p 31y "' ,211c Elevation / oo Description of alternate benchmark "l k le5aA r s�'1/ Elevation /04 Building Sewer ST/HT Inlet Qc��o ST Outlets 'P7 8z PC Inlet PC Bottom Header/Manifold IP6 , 54 Top of ST/PC Manhole Cover Distribution Lines (7,) F6,3 Bottom of System (p) 38 Final Grade Date of installation 7 / Z2/ Permit n mber c?o 76 6?8 State plan number /y Plumber"Sa License number Date l 2z/�8 Inspector Complete plot plan ,r NOTICE: Please provide the following: • A plan view sketch showing everything within 100 feet of the system. • Two horizontal reference points to center of septic tank manhole cover. • Show alternate benchmark, if applicable. 6//7c/ = /vv PLAN VIEW o 0 o+ � � i� I E ,1 j '' I �{r A 1 a YJ� b_ / 4 �x v3 A_ t - A IA. 0 M s ,, NI . INDICATE NORTH ARROW Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County Safety.and Buildings Division INSPECTION REPORT ST . CROIX GENERAL INFORMATION (ATTACH TO PERMIT) Sanitarl"W: Personal information you provice may be used for secondary purposes [Privacy L , s.15.04 (1)(m)]. B P r �gi�der'j'?f � IAEL & THERESA [+R8,p Village E] Town of: State Plan ID No.: CST BM Elev.: / Do Insp. BM Elev.: BM Description: Parcel tP01IL;1105- 20-000 TANK INFORMATION ELEVATION DATA A9800077 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. �3to7 �o� p iI Z� Ben ar „ Dosi ng L . e> *V .7 q,, Aeration Bldg. Sewer p o Holding it Inlet 7a S•5`8 19 . TANK SETBACK INFORMATION t UWOutlet ,S /o B TA O P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake eptic tr Z5 NA Dt Bottom Dosing NA 7.2� - 7.1 - 7 !+r Aeration NA Dist. Pipe _ 1 1 14 , ;; Holding Bot. System Ya. '� -7 9 9'W 1 PUMP/ SIPHON INFORMATION Final Grad,' 3Z `�,Zys s3 98 7 Manufacturer De d °P air 'rQ- ?SAS Model Nu er GPM ck '1 "S 7.2 TDH I Lift Lriction System DH Ft w•• ?� ,'� �.?j? 60C. 3 Forcemain Lengt H Dist. To Well SOIL ABSORPTION SYSTEM BED THE width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid pth DIMMSMS All. 2S DIMENSION SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHINGManufacturer: SETBACK CH BER INFORMATION Typ ! ! Mo a Nu 5y a vG�+'& �� OR UNI DISTRIBUTION SYSTEM v iiA o / 4; a 69 (Z w, er /Manifold oP Distribution Pipe(s) , t,�/ , x Hole Size Hole Spacing Vent To Air Inca e Length Dia. Length 2S Dia. 3 T Spacing 1 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 27.28.19.417,NW,NE 193 S. GLOVER RD Plan revision required? �Ae? Use other side for additional information. SBD 6710 (R.3/97) Date Inspector's Sign e o Safety and Buildings Division If SANITARY PERMIT APPLICATION 2 01 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box I Department of Commerce Madison, W W 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. • See reverse side for instructions for completing this application State Sanitary Permit Number 30-7 6B'doc"' 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 RMATION Property Owner ame Pr perty Location f �� �ti /4 �� 1/4, 5 }7 T Z$ , N, R ( f( Nor 'Ps Property Owner's Mailing Address Lot Number �� Block NUFnber l e✓ �/ City, te. Zip Code Phone Number Subdivision Name or CSM Number - kJLAW s G� Sfeo z z 1 ( ) It* - �� II. TYPE F BUILDING: (check one) E] State VII State Owned ❑ i Nearest Road age Public 1 or 2 Family Dwelling - No. of bedrooms " Town OF Ti 0 III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo C9 Yo — 110 - 5 — zo 2 ❑ Assembly Halt 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 MNew 2_ ❑ Replacement 3_ ❑ Replacement of 4_ ❑ Reconnection of 5_ ❑ Repair of an ______System System Tank Only _____________ ______________ Exi sting 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 NSeepage 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. SvYs em Elev. 7. Final Grade / Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Tl Y,d Elevation (Q O� Z' pL� %a 7 y • '17 I T z y 5 Feet 9S Feet VII. TANK Capacity Site in gallons Total # of Manufacturer's Name Prefab. Con Steel Fiber- Plastic Exper INFORMATION Gallons Tanks concrete glass App New Existin struited Tanks Tanks eptic Tan 2.00 � �.5 ` P. � � � 1:] Lift Pump Tank /Siphon Chamber 1 - � � ❑ � E VIII. RESPONSIBILITY STATEMENT I, the undersi -gned, assume responsibility for installation of the onsite sewage system shown on the attached plans. PI ber'sName: (Pr ) Plumbe 's Signature: (No tamps) t MP/,�y1p�S1C{P1e : Business Phone Number: r�r 1 772 Plumb is Ac dress (Street, Ci y State, Zip Code): 3 B ao >k IX. COUNTY / DEPARTMENT USE ONLY ❑ Disa roved Sanitary Permit Fee (Includes Groundwater pte slue ISSU ent Signature (No Stamps) pp Surcharge Fee) / [Approved ❑Owner Given Initial � G� 3/ Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD -8398 (R.11/96) - DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber JOB • itxci Y ��.Xl Yr ���� S TIMM EXCAVATING SHEET NO. OF 2- Route 1 Box 192 WILSON, WISCONSIN 54027 CALCULATED BY / "`� DATE (715) 772 -3214 (715) 386 -5443 MPRS #3224 WI MPCA #696 MN CHECKED BY DATE SCALE ..... re } _ —� ...................... . l -... .... ...... 3 P7c�ts., 3 nL .. ........ 8 • .. L� �. ..... �r! /n cr���7 T�E S•r�'� U (/ n. �rr ..�......... m.r 3y, .... b } .... . 'C ........... T ... .. iz T� . u tl ry- /� 1�?a 85 i ...... _. . , :....... r ..... .......... ....... ...... -.. - -, -. - - -. .... ...- . ...... , ....... .. - -. ....... ,. ,.......... ,.. .......... ! e: ,. .......... .. .... ,.,., .. 17� o._ P 3 .:. PRODUCT 205-1 �Inc., Groton, Mass, 01471. To Order PHONE TOLL FREE 1- 800 -225 -M JOB TIMM EXCAVATING SHEET NO. Z OF Z Route 1 Box 192 WILSON, WISCONSIN 54027 CALCULATED BY GATE (715) 772 -3214 (715) 386 -5443 MPRS #3224 WI MPCA #696 MN CHECKED BY DATE SCALE . y G r .._ v __ Z ' C ,U...... 3 , ........ _ 3` ...... PRODUCT 2051 Inc„ Groton, Mau. 01471. To Order PHONE TOLL FREE 1- BOO -225 -M Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page 1 of 3 Labor and Human Relations r Division of Safety & Buildirgs in accord with ILHR 83.05, Wis. Adm. Code _ COUNTY Attach complete site plan on paper not less than 81/2 n& i Ian must include, but Ste' C kzo 1X not limited to vertical and horizontal reference point f pe, scale or PARCEL I.D. # dimensioned, north arrow, and location and dista e t arest r"�,. f `' D 4 1 3 - k 1 Q� S - ZO APPLICANT INFORMATION PLEASE PR N ,r LL I IN y RE DATE PROPERTY OWNER: ; = PR TY LOCATION 199 _ NIQ 1/4 M E 1/4,S Z T Z-8 ,N,R l c l E (or WC PROPERTY OWNERS MAILING ADDRESS -, GOUNTY L¢.,'It BLOCK # SUED. NAME OR CSM # CITY, STATE ZIP CODE OM1_ MBER COY []VILLAGE ®TOWN NEAREST ROAD 2oSFV��L�,r -,f.� sstt3 (6 TCU�`1' s. IR. '\_LutlD [)4 New Construction Use (x] Residential I Number of bedrooms [ ] Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow y SO gpd o , Recommended design loading rate 9 l bed, gpcW • q trench, gpd/ft Absorption area required I, t Z S bed, ft 90 o trench, ft Maximum design loading rate' - y bed, gpd/ft - S trench, gpd/ft Recommended infiltration surface elevation(s) s Ziz Pty G ti` 3 ft (as referred to site plan benchmark) Additional design / site considerations f=oR y $D" s«w6 -US �e 3 •nom C"_S , cN S'x eo' l W c _ Parent material s N0,p4 o u`r h S N Flood plain elevation, if applicable tv A . ft S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem ®S ❑ U � S O U S O U G$S El ❑ S ®U ❑ S J@ U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD /ft Boring # Horizon in. Munsell p Sz• Cont Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed tench o -zy lo�-t i�_ - L L z S (-IS •6 ew • S •6 Ground 3 4i _50 Z.SyfZ 3ly S 1 Sd1T wIv e S - •y S elev. 13 ft y SO - �.s `fTZ y `Fs o 9� wI 1 • s • b Depth to limiting f'C8 Remarks: Boring# ioLlR Z �nf cs 1 v s •� . � Z ►1-Z -�{ lC�`�cZ 31 y � st 1 Z `F s�k w►'�►- �l , 5 • � 3 z� - Yy S `i 3/y s l 1 c sbk ref v`f� eS •mot: • S Ground elev. q R-S ft qy -90 7 .S .S -tIZ (/ /L - 'Fs o Sg �) - Depth to limiting factor > 90 Remarks: CST Name: — Please Print Phone. Arthur L. We erer 715 - 425 -0165 egerer Soil Testing & Design Service -P.O. Box 74 River Falls,WI 54022 Sgnature: Date: CST Number: M00576 PROPERTY OWNER -.Q1P`\1-Q SOIL DESCRIPTION REPORT Page Z of PARCEL I.D.# OLIO- 1105- ZO Depth Dominant Color Mottles Structure GPD/ft2 Boring # Horizon Texture Consistence Boundary Roots Bed Try in. Munsell Qu.Sz.Cont.Color Gr. Sz. Sh. r _ q to tZ z1z — s� zm sek mf- es lc . S . 6 R-\.s \O Litz_ 3/y — S; l 2 sbk >n c1,Q s 6 Ground y2 3ly - S ) 1 0- Sbk h, L)'t- CS - y • 5 elev. 100.3 ft. l4 3y-87 11•S u/(, S 6 gg M ) S 6 Depth to limiting factor >87 4 Remarks: Boring# -V a 1.0 LI 1Z z/z — s 1\ z hi 5 bk h1$- c S 1 \r , s Z 1 -k-16 10 y Iz 3ly s; `� k w)`�- c - . 5 • 6 .............. 1 Z. sd w 3 j6-s7 7-S ?/y — s \ cSbk myfi. c - .y • 5 Ground elev. L S y-$9 S Le R ti a u S 9 IAA -- • S 917.0 ft. Depth to limiting factor >59 Remarks: Boring # 0-10 VW-12_ 2AzZmsb1f "Cif. -S \)' . S . 6 S Z It)- o 10 It Sly si 1 2 C 5\P vr"`f‘. ew - • S • 3 zo-uy ,•S yc .. 3/y — s) \ c_5 muF - �s - LI •S Ground q4v.ft. `[ Li tl -40 `) S Y2 tili. O S9 Nen I - S • Depth to limiting factor 9 b Remarks: Boring# Ground elev. ft. - Depth to limiting factor Remarks: SBD-8330(R.05/92) PLOT PLAN Pa 3 of 3 SCALE 1 "= 4p ' g — F'1. 103.6 an, MP of- Sr�lZ Femme- � PR- 6P�R�l Llt✓� „� � R� +cF Pca�-; e EL Von .o' 0" G" mgt+ 31y'I bi A f'vC P1P�'. (U o , y J rJ 6 qI kTl.lOp 3 o ni O 0' 13.3 O I 0 ( 3- �+ I a B -5 t3. \ o / r o - (3.2 an,q - s dv ,2 7 o v vS� tlr► wC L 'rU ? 10.0 SO UT){ OF 11Z -C)v CV4 -eS- - _ -- . (715 ) 425 - m 6s %4 00576 CST Signature Date Signed Telephone No. CST # Wisconsin Department oflndustry SOIL AND SITE EVALUATION REPORT P 1 of 3 Labpr and Human Relations — Divisioh of Safety & Buildngs in accord with IL.HR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point (BM), o slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance t 0 4 0 - k 1 O S - ZO APPLICANT INFORMATION- PLEASE PR IN 4,L fNFOR4ATIO 0 REVIEWED BY DATE !L• ?•R7 PROPERTY OWNER: �, x`' PR Ef3 LOCATION ;: c NW 1/4 ICI E 1 /4,S 2- I T z-8 ,N,R 1 cl E (or wC PROPERTY OWNERS MAILING ADDRESS i „_ ?, LOT # -- BLOCK # SUBD. NAME OR CSM # 1`135 1�L UtSTA b tU� ST CROIX CITY, STATE ZIP CODE RHOM NU ILLAGE ®TOWN NEAREST ROAD R.u`r S- Gw j)4 New Construction Use jj Residential / NumbertnoAt Addition to existing building j) Replacement [) Public or commercial describe Code derived daily flow `l 5o gpd o hr, , Recommended design loading rate _ bed, gpdfft • `I trench, gpd/ft %o op c, Absorption area required t L Z S bed, ft 6 o trench, ft Maximum design loading rate' - y bed, gpd/ t S trench, gpd/ t Recommended infiltration surface elevation(s) S e PA s F 3 ft (as referred to site plan benchmark) Additional design/ site considerations l=oR y B�D" 3tu-6- Use - `V_e - Ctfs , cH S'x eo' lauc Parent material 'S+0' >b4 ovTLv N S H Flood plain elevation, if applicable Na - A . ft S = Suitable for system CONVDITIONAL I MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable for stem ®S O U � S O U J@ S ❑ U IR 0 U [IS O U EIS O U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD /ft Boring # Horizon in. Munsell pu_ Sz. Cont Color Texture Gr. Sz. Sh. Roots Bed Tiench D -Zy l0`12 Z •6 Z Z (4 -9 Z ko1-iR- 3)y - sit Z,'�3 C.LV • S • Ground 3 uz -SO Z.Sti2 Sly - S 1 g k wlv •U • S elev. Cl S.O fL y So -86 's `iR Y/( S • b Depth to limiting factor � Remarks: Boring # o_ 1 t 1�zm R z L z Z wf vn 1 v S k z Z It -_LL/ totic;�_ 31 s� 1 Z 'F s�k w, � �w . s • � 3 4v- p ly _ s 1 �s bk �1 v`�t- eS ► - 5 Ground elev. L f V y -9 0 - S Lf V- V1 L - '�s o S'3 S 6 9 -5 ft. Depth to limiting factor > 90 Remarks: T Name.— Please Print Phone: Arthur L. We erer 715- 425 -0165 egerer Soil Testing & Design Service -P.O. Box 74 River Falls,WT 54022 Signature: l Date: CST Number C `� _2 9 � - 7- Z \Z -3 —� 7 M00576 • PLOT PLAN Page 3 of 3 SCALE 1 "= Flo ' �gtl -l1. 103.6' ni- SM-L'L Re+ce- ?oar. e ' LrLvoo.o' w 6" MGw 31y bi A pvC P1Per. �tq1° ? O I � 3 �►�.� � nom,., erg � . 6 ° o � Il to O a• 0 ' g-3 t*ti.tOp 3 ON I ro J1 o� to 6 e -S 0 o 8•Z 2 kA-�3 flouro L^JC L 'X 10.0' SQUO OF - MEKJ Cl+eS-- - - ---- ati 715 ) 425 -0165 14 00576 CST Signature Date Signed Telephone No. CST # • ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer A( 6kZIA -1 Mailing Address 17 Property Address /43 Zy, (91 ,O ,e&l (Verification required from Planning Department for new construction) City /State Parcel Identification Number d `7y - 11--0 Z O LEGAL DESCRIPTION Property Location Alai ' /4, A ' /4, Sec. aZ 7 , T -R Town of Tio Subdivision rU 9 Lot # Certified Survey Map # , Volume , Page # Warranty Deed # 3 q9 O 3 / Volume ? 0 3 , Page # S Spec house ❑ yes JZ no Lot lines identifiable M 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. Uwe, 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 days of the three year expiration date. d�i SidNATUkE bf APP CANT 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 pro erty described bove, by virtue of a warranty deed recorded in Register of Deeds Office. t �, SI ATURE OF ANT 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 � � ��. n.. . �, � r�, � ,� ,< t .'•z � wF y � i iP'!E^� x � d i ^ VA TX BAs OF WH©OMM YOU i... im "No" r" I"Wip"I 3 ,`" 't, «», - • t .........•- f .. ... ued fth .... R.�.. p 114.4 ............ .............. dap of = D. 9 .» - --- -- - --- - - - -- ................ ... ............ ........ ........ C 8:30 � So following dncrl M reel estate in ............. A t._..Cr.Qix_ .......... 47onIft &04 of Whwonwa: The Northwest Quarter of the Northeast Quarter (NW'} of NEk) of Section 27, i Township' 28 North, Range 19 West, Tax Parcel No: ._...-- ...._... ._..., subject to an easement for a non - exclusive access road 66 feet wide across that part of said forty as is necessary to provide access to the NEk of NWT from the North -South town road crossing said NWk of NEk. Subject to existing town roads and utility easements. FM 0 E 1. ' i ii ii I` I i This i8 nO-- -___ homestead property. (is) (is not) is Dated this 8 -- --- ---- day of ... ...................... Jan l .... , I u --- --- ----- ----•------ -- (SEAL) ......... -- (SEAL) I Ruth Lewinski i --------------------------------------------------- ........... (SEAL) ....................................... (SEAL) • �� ii AUTHENTICATION is ACHNOWLED(iMBNT SiSnsture(a) -- ---_R11tti._L�F1 II -1; ............... STATE OF WISCONSIN ................................................... _ .......................... ss. 'c ` 8th a en - County. y� day of._.___: Jars 1 9 85 Personally came before me this ---- _ ----------- day of �� 19-••--._ the above named .......... C. L. Ga ord TITLE: MEMBER STATE BAR OF WISCONSIN .. . .. ......... • - -- •-.... •..- ---•- ...... •............ _..................--•------ (If not, -----------•------------ •--- -- -- -• ... ................. authorized by § 706.06, Wis. Stats.) ......... . . . . .• ' to me known to be the person ............ who executed the Foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY