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Home My WebLink About032-2018-90-200St. Croix County Planning and Zoning Wednesday, September /9, 2007at 1:26:55 PM Detail Sanitary Information Page 1 of I Computer q: 032-2018-90-200 Sub/Plat: NA Section: 5 Parcel #: 05.30.19.558E Lot: 3 TN/RNG: T30N R19W Municipality: Somerset, Town of CSM: Vol. 10 Pg. 2866 114114: NE 1/4 NW 1/4 Owner: Koeller, Tim 501 18M Avenue Somerset, WI 54025 State Permit: 228356 Issued: 0410511995 POWTS Dispersal: Non -Pressurized In -ground Permit: New County Permit: 0 Installed: 09/07/1995 POWTS Detail: Bed- Seepage Bedrooms: 3 WI Fund: POWTS Pretreatment: NA Notes Issuer/Inspector As Built Plumber Other Requirements Additional Notes Money Owed Mary Jenkins Yes O'Connell, Kim 0.5-rated soils - 12' x 75' bed $0.00 Jim Thompson Signed Off: Yes Maintenance Scheduled Pump Date Pumped 1st Notification 2nd Notification 3rd Notification 9/7/1998 10/19/2004 10/19/2007 ------------------------------------------------------------ 9 IEL .k , N cb ("ZCNING 1995 STC - 104 .!; ASBUILT SANITARY SYSTEM REP4FFIC.E OWNERl ADDRESS SUBDIVISION / CSM$�� LOT SECTION Lr T_y/S' N-RZ_?W, Town of ST_ C`AnTY nnttumv ...r.....,..--.- Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: ALTERNATE BM • SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: f��%S Liquid Capacity:f1 Setback from: Well House_ Other Pump: Manufacturer Float seperation Alarm Location Model# Size Gallons/cycle: SOIL ABSORPTION SYSTEM Width: Length �_ g ys Number of trenches 1rt/ 71 / Distance & Direction to nearest prop. line: Setback from: well: House _2_ Other ELEVATIONS Building Sewer _ ST Inlet. 9Z�a ST outlet 24, M PC inlet PC bot Pump Off Header/Manifold & 9L Bottom of system 9:E9,f Existing Grade Final grade DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR:� 3/93:]t Wisconsin Department of Industry, Labor and Human Relations Safety and Buildings Division GENERAL INFORMATION PRIVATE SEWAGE SYSTEM INSPECTION REPORT (ATTACH TO PERMIT) Pjb2j2ftANaViM 0 City Vill age Town of: Somerset CST BM Elev.: Insp. BM Elev.: BM Description: /CO, (z /X. CD iz__�aas- TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic Dosing Aeration Holdin TANK SETBACK INFORMATION TANKTO P/L WELL BLDG. ventto Air Intake ROAD Septic » Q S' NA Dosing NA Aeration NA Holdin -PGMP / SIPHON INFORMATION Demand Model Number TDH I Lift ranI �stem�DH Ft Forcenyirf"j Length I Dia. I Dist. To well -SDIL ABSORPTION SYSTEM ELEVATION DATA ounty$T. CROIX Sanitary Permit No.: 228356 State Plan ID No.: Parce Tax No.: A9500050 STATION BS HI FS ELEV. Benchmark 17(0 / ' Bldg. Sewer 7,0V 1 1 %? Stiftrnlet F,c/ep St Y4 Outlet Dt Inlet IL Dt Bottom Header,F Amp, Dist. Pipe L ' 96, f5� Bot. System �3 5, 9jl Final Grade -P s6 be 7 .S' /dU, Co/' o[6e-CY BED/TRENCH Width Length i No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS :2 5 SETBACK SYSTEM TO P/L I BLDG I WELL LAKE/STREAM L IN uacturer: INFORMATION r: Type tw System: �ortd; " ^ 3�/J , UNIT DISTRIBUTION SYSTEM Header/Manifold ,i Distribution Pipes Y x Ho a Size x Ho a Spacing Vent To Air Intake I/ Length �/Dia. Length v Dia.-L Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grad�n_I� 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: SomeQrset.5..y3�0.19W, NE, NW, Lot 3, 180th Avenue �i a&z4,) O.Y f�Q Z� �-J�r"Oe -It" Plan revision required ❑ Yes 11Hfi6 / Use other side for additional information. 7 ,sr SBD-6710(R 05/91) Date Inspe or'ssignat re Cert.No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: SANITARY PFRMIT APPI 1[_ATIAN t. it L�ii% In accord with ILHR 83.05, Wis. Adm. Code �f COUNTY -Attach complete plans (to the county copy only) for the system, on paper not less than STATE NIrq(�v�ES MIT p �/'/, Ian 8 4 x 11 inches in size. NIT ❑ Check If revision to previous application —See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER I. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION PROPERTY OWN R'S MAILIN ADDRESS LOT # BLOCK # F�lIeor / CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER II. TYPE OF BUILDING: (Check one) State Owned Ej CITY NEAREST ROAD ❑ !] VILLAGE ' ❑ Public ®1 Fam. Dwelling bedrooms-� or -#of PAR L ( ) 111. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo 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 in line A. Check line B if applicable) A) 1. V New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit # 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 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: TE 6. SYSTEM ELEV. 7. FINAL GRADE 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERZih REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min) ELEVATION - a Feet Feet VII. TANK CAPACITYin allons Total # °f Prefab. Site Fiber- Exper. INFORMATION Gallons TanksConcretestructed Manufacturer's Name Con- Steel glass Plastic App. New Istin Tanks Tanks Septic Tank or Holding Tank Lift Pump Tank/Siphon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for install 'on of the onsite sewage system shown on the attached plans. Plumbs s Ne (Prjnt): Plum i s S' nat e: No 6 s) MP/MPRSW No.: Business Phone Number: i lumber's Address Street, C , Slat Zip e . IX. COUNTY/DEPARTMENT USE ONLY Approved ❑ Disapproved ❑ Owner Given Initial Sanitary Permil Fee (Includes Groundwater Surcharge Fee) Date Issued Iss ing Agent Signature (No Stamps) Adverse Determination gL X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398(R.08/93) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete ## of bedrooms if 1 or 2 Family Dwelling. III Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. Vill. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system it required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11188) —/06& Fy ------- -------- PAGE __ OF 1 Cro5S Sec�lun pk A 16e0 JyJecn Fresh Air Inlets And Observation Pipe am--- Approvrd Vaal Cap Mlnimawr 12'Abovo TIrI 20- 42. Above Pipe _ e' Carl Iron To Final Greg• Venl Pipe Mash Nor Or 5pthetk Cawing min 2' 4aarepal• Over Plea Olatribvtion Pipe o 0 o e — Too - V Aaaraoals BAMHe Pipe Perforated Pipe Bets. o Capllne Twminaline At Bottom Of Sralem Pr,pa5eD j'tne.l 9rr.c1< 51ItJ•-T'tor� SOIL FILL DISTRIBUT101.1 PIPE APPRDVEO $yQITNETIC COVE0. 2m O+F AGGREGATE —' . �'OR MARSH "A,'j ATE41- OR OF STRAW •Fee to OF �r2 -Zi/Z AGGREGATE .•P �% DISTR19iJTI0A1 PIPE TO BE AT LE1k5T IAICHES BELOW ORIGIUAL GRADE AIJI) AT LEASTLO IAICNES BUT 1,10 MORE THAI,I 42 IAICHES BELOW FIMAL GRADE !'1AlcIMuM Mrvi OF EXOIWAT100 FROM ORi&rdAL 63KADF- WILL BE INCHES MKIMUM 9Ef OF EXCAvApom FROM. 01�146IWAL ORAQE WILL BE INCHES -�8 SIGIJED: �� LICEAISE UUUMBBEER: L_ DAT E : _L ` Z,2,�— Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Labor and Human Relations Diva omof Safety 6 Buildings i� A41, n uo 002 nc iu:.. A...., rl-A- Page - of 3 Iu 1 -Attach complete site plan on paper not less than ir�i e n must include, but not limited to vertical and horizontal reference i dir on am pe, scale or COUNTY PARCEL I.D. # dimensioned, north arrow, and location and di to n j REVIEWED BY DATE APPLICANT INFORMATION -PLEASE T ALL ITO AT10N _. 1 _i PROPERTY OWNER: = —APlUrtKTY LOCATION y— LOT 1/4 1/4,S T 516 N,R Vlore PROPERTY ER':S MAJ�ING ADDRE y ^,,� ` �,�.:,,:. i .7 BL K ff S BD. AME OR CSM 0 .. CITY ATE 71PCODE 1 'E1CVeIL1AGE.,VOWN NEAREST ROAD 1yd` J New Construction Use bQ Residential / Number of bedrooms (J Addition to existing building ([ Replacement [ ] Public or commercial describe Code derived dairy flow . Q_ gpd Recommended design baling rate bed, 9P ��trench, gPd/ft2 Absorption area required 9ap— bed, ft2 >-'<2*) trench, ft2 Maximum design loading rate _.,5r bed, gpd/ft2_,_j/,__trench, gpd/ft2 Recommended infiltration surface elevabon(s) �9,5; Q ft (as referred to site plan benchmark) Additional design / site considerations " Parent material Flood plain elevation, if applicable vlf It S e Suitable for System U- Unsuitable forsystem CONVENTIONAL ®S ❑U MOUND [as ❑U IN -GROUND PRESSURE ®S ❑U AT -GRADE ®S ❑U SYSTEM IN FILL ❑S OU HOLDING TANK ❑S MU Ground elev. AL ft. Depth to limiting factor 941 SOIL DESCRIPTION REPORT Rolm '• M = MMMIME No : �MW NORM OMMMWAR == Remarks: Boring # 13 Ground elev. .ICY. ft Depth to limiting factor nar nar". T Name: —Please Print Phone: ZZ Address: Signature: Date, CST Number: PROPERTY OWNER ., 7Ca��/�P SOIL DESCRIPTION REPORT Pve,,2—of ! PARCEL I.D. # Boring # u Ground elev. ,Iit Depth to limiting factor 1>>58 STC-105 SEPTIC TANK MAINTENANCE AGREEMENT SL Croix County OWNER/BUYER//%I D T� Pr kDEL L "ie MAILING ADDRESS ST # 3 Sp/llt7,C SE PROPERTY ADDRESS (location of septic system) Please obtain from the Planning Dept. CITY/STATE PROPERTY LOCATION WF 1/4, IV W 1/4, Section S T 3 0 N-R/_W TOWN OF So inEQ 56 7- , ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER 3 CERTIFIED SURVEY MAP �B VOLUME /0 , PAGE a 9441 LOT NUMBER�f 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 agree 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. L'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.betn maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the thi SIGNED St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 S T C; - 100 This application form is to be completed in full and signed by the 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 LGZ Location of property N 1/4-&W 1/4, Section ,T 30 N-R / Township SQ/%IM5e T Mailingaddress 1-/3f REfIJ S% #�3 SQlll e-:kSC / I Addressof site n - - -- Subdivision name Lot no. other homes on property? n Yes NO Previous owner of property Total size of property 3 S Total size of parcel 3 Date parcel was created Are all corners and lot lines identifiable? _Yes No Is this property being developed for (spec house)? Yes k_No Volume 0 and Page Numbero2 U 6 as recorded with the Register of Deeds. ------------------------------------------------------------------- INCLUDE WITIi THIS APPLICATION THE FOLLOWING: A 14ARRANTY 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 (Iced recorded in the offic(, of the County Register of Deeds as Document No. , and that I (wc) 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 Register of Deeds a!: Document No. 5.igr:�t rr of P,1.). T ant Co-Ahpl i c:ant sic nat.ur