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HomeMy WebLinkAbout040-1163-50-000 ` ST. CROIX COUNTY ZONING DEPARTMENT .1`' AS BUILT SANITARY REPORT " ' �" � / j f Owner N pjPm ! Address - ar7.? L. €�y. -vl rPo :a sr .C,R01, i City /State G.l s Syv2.� �, ,� CIO urtlFy ZC?NINGUFFiCf= Legal Description: Lot Block Subdivision/CSM # Y4 ' /4 ` Sec. 1 , T /9 N -R W, Town of - ;�o PIN # - S o -cob SEPTIC TANK --DOSE CHAMBER — HOLDING TANK INFORMATION.- Tank manufacturer e�;x - s7 6 Size ST/PC / Setback from: House 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: Er r.� cmcd Width 5 Length / o Number of Trenches -e Setback from: house ys' Well g_ p2 So Vent to fresh air intake '0 ELEVATIONS Description of benchmark �o.e/c Q�r� l sl„�E,trT L+� S c E�s� SAc' o r levation O o, oo ' Description of alternate benchmark Elevation Building Sewer ST/HT Inlet ST Outlet 9f2?' PC Inlet PC Bottom Header/Manifold t ,? — 2' Top of ST/PC Manhole Cover Distribution Lines (A) 9 V, / b 6 Bottom of System (A __ ,' (B) 93i ( ) Final Grade W -22- (6) - 2. Date of installation fl-.3 IW Per it number 3 a 1) State plan number Pl umbers sigg nature/ ' License number kIDP X95 Date SS I 17 Inspector nit Z 1 o 97 s7 complete plot plan or 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. PLAN VIEW Aio,PrtF PIP° 7-11..nit GUEST ' r ,0' D.I. ' 0' IP /1 1 le fitST 4S' f/o' it) ZA.14... Dz.c,< . t \_L i �•-' DQ.' w ,0,v.-er-De — cw CjFp(zjd-i- xi,NE _---- -i ,' Ex I STmi L SfOT/c TitAX i LAS/S-ri.J6 C STinl s5iOt.�cc' L, 82Ae wviARK - g tSLm..:Arr -),.Jp o..., Si« zay. .. /oo.vo- OR, E,)AY SokTH PQaOERrY 4/Ali 6,/,c.kl ✓`1 onJT PO INDICATE NORTH ARROW Visconsin,Department of Commerce Count r PRIVATE SEWAGE SYSTEM Safety and Buildings Division INSPECTION REPORT 5 -. G'c tx GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 3077/)G, Permit Holder's Name: ❑ City ❑ Village 09- -Town of: State Plan ID No.: wnav► IMa�-w ro --- CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 00 oo' &- w-W1 W t vidow Si 1 0q 1 0-t1(,3 -5b -0 o 0 TANK INFORMATION ELEVATION DATA M a0vto cf TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic �5 +i Benchma :57 (V& /OSG,$ too Dosing a' ulyR� Aeration fir 1 �•S q�- Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Air l to ntake ROAD Dt Inlet Air I Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System 12• co 93•� PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Num er GPM TDH Lift Friction System TDH Ft Forcemain Length Dia. Fi Dist. To Well SOIL ABSORPTION SYSTEM BED Width Length GO , No. Of Trenches PIT No. Of Pits nside Dia. Liquid Depth DIMENSION DIMENSION SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHIN Manufacture . SETBACK CHAMBER INFORMATION Type O r Model Number: Syste SO �S 70 OR UNIT DISTRIBUTION SYSTEM Header / Manifold Distribution Pipes) x Hole Size x Hole Spacing Vent To Air Intake Length 12 Dia_ r Length 5 4 1 1 Dia. Spacing _( Se-µ 2'72 } 5ls SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over It Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center o� Z Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) &7,2 Cg 1evtrnon4 Q� 3 5 reev+ -GO&M d0, 1 v G +a hicad e r S - 6 ,j e- Cc44 - 6 r- 4w$nfe aocI{ 4 ep4i ojew AIS IQirJe. �2,tnprl�s 3) E44N S q4t,_ k, � cods, St4c. >< S-(u arJ Plan revision required? ❑ Yes No Use other side for additional information. .st SBD -6710 (R.3/97) Date Inspector' ignature Cert. N Safety and Buildings Division �/� SANITARY PERMIT APPLICATION 201 E. Washington Ave. Vi sconsin In accord with ILHR 83.05 Wis. Adm. Code P.O. Box 7969 Department of Commerce Madison, WI 53707 -7969 • 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. 4' (qtr O • See reverse side for instructions for completing this application State sanitary Permit Number '�>C>77/ l(o The information you provide may be used by other government agency programs ❑ 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 © / e-� 1/4 5 1/4, S , � T ' , N, R �O E (or Property Owner's Mailing Address Lot Number Block Number 4;LEniM0 -.n /V/J Cit , State Zip Code Phone Number Subdivision Name or CSM Number tlioli h4 II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ V It il (age Nearest Road �iUl�lOitJt �o Public jg 1 or 2 Family Dwelling ❑ - No. of bedrooms � Town OF / �[ o v III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 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. ❑ New 2."Replacement 3. E] Replacementof 4. ❑ Reconnection of 5. E] Repair of an System Y_�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 R1 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. /inch) Elevation 4:510 1 scw • S (p00 * .� �3• t�� Feet 99�2S Feet Capacit VII. TANK in Ca allons Total # of Prefab. Site Fiber- Exper. INFORMATION New Existing Gallons Tanks Manufacturers Name Concrete strutted Steel glass Plastic App Tanks Tanks Septic Tank or Holding Tank /c900 ! S ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ I ❑ 1 ❑ 1 ❑ 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) PIUMOPT s gnature: o St s) MP /MPRSW No.: • Business Phone Number: >o4 /�10Ds � . G Plumber's Address (Street, City, State, Zi Code): _ 1 /S N, �cFvl� IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agent Signature (No Stamps) ®Approved []Owner Given Initial f� / ® � Surcharge Fee) Adverse Determination l Yj / X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD4m tR t 1Aq DISTRIBUTION: Original to County, One copy To: Safety 8 Buildings Division, Owner, Pkmd et Q3 PLOT & CROSS SECTION PLANS /j 7 °i ,� ZAPPA BROS. EXCAVATING INC PLUMBING UNIT .. . (i o PROJECT GJ LST �__ �— • — _ — AkD l-I 8► A l14w T��ti cHEs — 4 04M OAiT D R V rA t c g 41 SY0,- i A 15TiN` 0 ?Y f_LLS Fx5 /S'fiNG. �'� fi �xlSrir.1� S�PTic Tibu�( B EwK Nivt�NPK �- f,Jrc S£.r1L,vT Gv..u/J«..l r �Ql J�wrt`( �oLF�I rYlo.vr IPp s SCALE FRESH AIR INLET AND OBSERVATION PIPE APPROVED VENT CAP MAXIMUM 14` ABOVE FINAL GRADE MAXIMUM OF 42' ABOVE 4' CAST IRON VENT PIPE PIPE TO FINAL GRADE MARSH MAY OR SYNTHETIC COVERING SIGNED: LICENSE: MINIMUM 4' AGGREGATE OVER PIPE DATE: DISTRIBUTION PIPE - -� TEE • • • SOIL STING BY: ELEVATION BED 6' AGGREGATE • C �7 `3�l $' BOTTOM PER SOIL BENEATH PIPE PERFORATED PIPE BELOW TEST 18 • COUPLING TERMINATING �' FT ' AT BOTTOM OF SYSTEM Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page r of 3 tabor and44uman Relations — division of Safety 8 Buildings in accord with ILHR 83.05, Wis. Adm. Code` � COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size Plan m , ust ind4deyput S 7 Cat not limited to vertical and horizontal reference point (BM), direction andr�l4. of`slope, o -il f RCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. r APPLICANT INFORMATION— PLEASE PRINT ALL INFORMA�14N d rf 1 ;7 RE BY DATE PROPERTY OWNER: PROPER ION r' °. V�tQ91N IC/4 .,S Z� Tq N,R ZQ E (or) W PROPERTY OWNER':S MAILING DDRESS LOTff' .BLOCKA- $UBp NAME OR CSM # 27Z C STAT t ' ZIP CODE PHONE NUMBER ❑CI OWN NEAREST ROAD f �ti2kALL W ( ) 4 Nb&Yr Rb [ ] New Construction Use Residential / Number of bedrooms [ ] Addition to existing building P6 Replacement (] Public or commercial describe Code derived daily flow q50 gpd Recommended design loading rate O.7 bed, gpd /ft d.'Z trench, gpd/ft Absorption area required 6 M bed, ft trench, ft Maximum design loading rate 6-7 bed, gpd /ft 6 .g trench, gpd/ft Recommended infiltration surface elevation( q 37K ft (as referred to site plan benchmark) Additional design / site considerations Parent material - %'1 s - t9 x C Flood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL OUND IN- GROUND PRESSURE AT -GRADE S TEM IN FILL HOLDING ANK U= Unsuitable fors stem S❑ U S❑ U S❑ U [10 S❑ U ® S ❑ U El S U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bandary Roots GPBlht in. Munsell Clu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench z i 1/k 3 Z L 1 ,ter GZ' I S Ground �2. Jb 3 elev. '� ft. Depth to limiting ? f tor_ � DO Remarks: Boring # ' 4 d _ J 1. 1► 4 lak G W �Z g 3 � f 1 �►, rho e Z ,72 0 3 -- Ground ele . B 'yre 3 MS SG, ft. Depth to limiting factor ? 7.75 Remarks: CST Name : — Please Print N a�j Phone: -���� ddress: ry UAW Aj Signature: 1 � Date: > CST Number:�OA PROPERTY OWNER SOIL DESCRIPTION REPORT Page Z of 3 PARCEL I.D.S Mottles G P D/ft2 Boring# Horizon Depth Dominant Color. Texture Structure Consistence Boundary Roots in. Munsell au.Sz.Cont Color Gr. Sz. Sh. Bed Trench pop 1601 Ground elev. ft. Depth to limiting factor Remarks: Boring# A fl 4.) /6 yeRp... L i i C OA ts.s' 11 3 11 6, /oN/ 4/4- s .5 )14 frcr c 4;2, 39-111 ioY4_0 sei s A,/ — .7 Ground cON it. Depth to limiting jctor Remarks: Boring# gipaaaNi Ground elev. ft. Depth to limiting factor Remarks: Boring# MEMO Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(R.05/92) IV • , t Z v SID A i k I 1 A w m ❑ 1(A H ' j C f 3 -D � � Z r c � Ou L rm D , LA o rn A ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer A/0 D r 11-1 a 17,1 / i e� Mailing Address 6-1- Property Address 0 2 ) 191 ,;>„1 (Verification required from Planning Department for new construction) City /State 21/4 b't lt Parcel Identification Number LEGAL DESCRIPTION Property Location NE '' /4, E '/,,Sec. ` , T -R >o W, Town of / le 0;4, Subdivision , Lot # Certified Survey Map # , Volume , Page # Warranty Deed # Volume JXV , Page # Spec house ❑ 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. 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. SIGNATURE 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 the property described 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 NOTE NO I D FOR RECORDING DATA THIS SPACE RESERVE 1 I ASSIGNMENT OF MORTGAGE, II STATE OF WISCONSIN —FORM •I (j 7 am 854 PAGE 64 For value received - -.._._ j�1lrand:..Etwderal.._S&vjn REGISTER'S OFFICE I s ..and .................. II ---------------- ------------------------- - - - --- Loan. Assora i. atim-------- g___------------------ - - - - -- S . OIX CO., WI CR CR for Record a Corporation duly organized and existing under and by virtue of the laws of Ii the State of Wisconsin, located at ............. 1? L :rm d-------------------------- Wisconsin, OtCT 1 6 1989 I hereby assigns to ._...Federal _National .Mor� . tgage _Association ____ at 1.00 P M i 3900 Wisconsin Ave. N.W. Washin ton D.C. 20016 • .. --•----------------- ------------ -----.. -_. _._........ ..-- _._....• - -- --- _..... _... _ _ _______________ -xDtx __________ __ f3�eY+�4ik4 , a certain mortgage executed to Register of Deeds Fed$ra,]...riaw_�.Durands: Federal:_, S .avings.._ancl_.Ls��am..�,ssogj a ion b d and wife RF_TURN TO y .....]�IQxm �_ an_... :.._. .._...----•--•----------• ............................................... ............ •----- •- .._.. - - - • -- - 12 th -- • - - - -•- (I of ..... St.__Croix__ - _ ... County, Wisconsin, the___________________ _ - - - day o f ........... November A. D., 19_.71., and recorded in the office - - -- - - of the Register of Deeds of ... St. Cr•OiX ------------- _ ______________ I County, Wisconsin, in Volume ------- of Mortgages, on page ..--- ....46Z ....... .............. Document No. ..... 07870 ._...----- •--- •..- •-- - -• - -- � 071000 2225 I� i �I it l i i i I k I together with the ... ....... I .. ............ ,.. and indebtedness therein mentioned. i II In Witness Whereof, the said ....... D[ k._ FM.E�I. t_. SASIIMS__ AND._ MAbl._ ASSUCIATIDN ___..• ............... has caused these presents to be signed by ........................... Nmi.- F_._-- Holimbeck ... ..................... its President, and countersigned by ................ Smy a._J.... Hamm ............................ its Secretar t ...... =alu1 . ... ........ Wisconsin, # ltl� _._... ARX.1,lA. D., 19.89•.. and its corporate seal to be hereunto affixed, th ........... 10th... ......... day o ......... } SIGNED AND SEALED IN PRESENCE of ..... Mp.L�_AStSWIAT �GS* Corporate Name V ..- ...._... BY. •------ •----- - - - - -- .. - •� " o- . y % President ., JAI _________________ Noel F. olinbeck - c ; •- c COUNTERSI ED: try �.----------- - ----------------------------------------- ............. ........ _ ..w � onya J. n STATE OF WISCONSIN 1