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HomeMy WebLinkAbout038-1085-50-000 (2) ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT yy` Owner Co L -e / e _ 0 v Property A dress CHOIX \, COUNTY ` City /State o - >, ZONING OFF- E Legal Description: g P 3 Lot �_ Block Subdivision/CSM # 12 2� 6t/ %aS' /4, Sec. , T 3/ N -Rf, Town of a� PIN # C>38- /oP�- 3� ?4. 3/.1 S. 35513 SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION Tank manufacturer Size ST/PC 1 / boo Setback from: House [ Well &5 P/L /•S Pump manufacturer Model 9g 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 - Z_ Length Number of Trenches Setback from: House o ?7 Well X70' P/L mss' Vent to fresh air intake R.? r ELEVATIONS Description of benchmark /o t Q Elevation ,'00 Description of alternate benchmark/ Elevation Building Sewer y ' /HT Inlet 9S: S ST Outlet PC Inlet PC Bottom ( )V 92 Header/Manifold S7, Top of ST/PC Manhole Cover S S Distribution Lines Bottom of System ( ) 7G r Final Grade () �� S ( ) ( ) Date of installation // 11g /9$ Permit number 3 Z o 2 °7 �/ State plan number Plumber's sig at re ��Z.�a� / License number ZZ // 7/ Date l/ h'S / S Insp Complete plot plan ...__ Clt r1p.fo� P, 7 HEAL) 6PAY CURVI i— t 'i� I I�. -••' MOOEL "98" j I f I j1� h 4 1/16 v o al.ec>w!S to ao _ so .... w � �a IUl sr / ?s� rfS ...._.. .. 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Arr l ., . • .. i I �� 1/ C .t�NhMU) iM�A t�f NL• ":iE� i�,r t )C'IPfCME,!- a DE'AGI For unusual cor'.a.tlucm %n rvacrt ;"' S:f." a: is id hro tale c in cit &.'el'y LOet;vr ov-no. .— ...,.w_.. ._._. .. 444_4. ._.. ... 4_4_44.._ .. ,44_44.._. .. _ _ 4444.. _.._ ...........�...�_.._....._...._ t.AINII11l'' ` *MM Mi ltlaAtlhl ltrr"t of , . 11/18/H WED 16:43 FAX 715 386 4686 ST CRX CO ZONING 2002 PUM P \ P U , �•.�, ? CHAO AEER CROSS SCCTi01J ANC SPCCIFICl-A'fOkj`) RECEIVED I r - , r — VE W T CAP ` NOV �1 I`I u C n,T P1 P E ` 1998 r ru WEATHERPROOF _ AP Vf :O L (at t'lj )( � JUIJCI'IOW BOX M A 1: C O` /oftNTy FROM DOOR, �%Vltd�aC?FFIC�E �o WII ;)'+J OR FRESH 12�MIU. � �' Alf OTAKE I r' 'T cOUDUIT ` — — - PROW DE MULCT I - - - -- �- T AIRTIGHT SEAL * f A I i ' I II ALARM f3 I I {. I I *APPROVED t oIa G JOINTS WITH EL FT. APPROVED PIPE __� 3' ONTO PUMP pFF D SOLID SOIL_ COUCRfTE HLOCK RIS ER EXIT PLRMI7rED OAlLy IF TAWK MAIJUFACTURI~R HAS SUCH APPROVAL_ PTIC SPECIFICATIOA.IS ,IQKS MAMUFACYURER: WUM6ER OF DOSES: PER DAS TAWK SIZE' (I A GALLOWS 0052 VOLUME _1kIkA MAIJUF - ACT URER: L IMLLUDIMG EACKFLOW: `�a 6Att ON MODEL AIUMDEIR; ��y CAPACITIES: A= o�7 IUCAESOR 3 23 GALLOIJ SWITCH TYPE: IMCHES OR O ?V GALLON Il�P MAMUFACTURER1 G = —/ L.. INC. HCS OR 0AI-LOW MODEL MUMDER; 'W DII AD— . INCHES OK ZO G ALLOK SWITCH TYPE: 7 MOTE' PUMP AND ALARM ARE TO DE MINIMUM DISCHARGE RA E `S GPM INSTALLED ON 5EPARATE CIRCUITS KTICA.L DIFFEREWCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE.. FEET MIMItALIM METWORK SUPPLY PRESSUR / _ , , . , _ , _ 2 FE.CT 3 3 FEET OF FORCE MAIN X F /opFr.FRICTI0U 1FACTOR -.� / FEET I = TOTAL D`IUhMIL HEAD = �?.l FEET '1 DIMEA.ISlOIJ4 Of TAUK: LEN(sTH Z,s• � ;WIbTF4 �.�.. ;LIQUID pCP7Fi LICEWSE WUMBER; ?ZZ!K7 DATE: / / - /Y9 a� A s 731Kj La r Z.. -. 0 . STc���: 1NYY -4z js 4& T., - sv,, t, be i 1 , 46.1 kd ait (euaf' t,,(Q//' —► -- , - LG T � , .�o �� .moo .>7 y 3,:,� 47 gy s • 3 " 2 Wisconsin Department of Commerce Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count INSPECTION REPORT ST, CR01 C 'GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar Permit No.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)], 32x29 q Permit Holder's Name: ❑ City ❑ Village ❑Town of: State Plan ID No.: nor LETE4 STA 'PRkTRTt CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 7D �6� P op L„ �LVC ® 3 g - logs. o _ D TANK INFORMATION ELEVATION DATA 14g,:iii 0C18 7 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic 0FFE L- too Bench m� J, I 3s �� goo Dosing coM f3rN,r�'ITOr1 (p Aeration "" Bldg. Sewer -�.�( `35 Holding '` St /Flit Inlet 7•�S qs TANK SETBACK INFORMATION St/ Ht Outlet r TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake StRILC, + f 5 5 11 N Dt Bottom f1,�3 C) Do It P. NA Header/ Man. Aeration NA Dist. Pipe Holding ;�7T_ -- Bot. System - 7. 1 9 G • 2 PUMP/ SIPHON INFORMATION -71 9 1 ) "1 u Final Grade Manufacturer O Demand 3 C?C . Model Number 8 3C>GPM k_, A1+. to TDH Lift �3 Friction . --t System,^ TDH5 Ft Forcemain Length 3� Di H Z f Dist. To Well SOIL ABSORPTION SYSTEM ED TRENCH Width t Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth EN I N 12— DIMENSION SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type Of A CHAMBER Model Number: Syste W Nv 90 OR UNIT DISTRIBUTION SYSTEM Header/Manifold �/ Distribution Pipe(s)� '' LL x Hole Size x Hole Spacing Vent To Air Intake Length & Dia. y Length 1!5 Dia. T Spacing � � SG H' /4 ; T, Z 3 57 1 SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over f 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.) �.OGA- 'T �TARp(lA112tG Sv;9rc�ZO.3(,(g 207,4 CTV RD G Gar' ? 355f3 10 P i' Pvs~ P 2 - C 12>ivtti;�� R- E" r PUMP 7PrP_)' ANt) c�.p t Q' Plan revision required? Yes ❑ No Use other side for additiorSal information. Ll 1 (2 R SBD -6710 (R.3/97) Date Insp ctor's Signature C No. tJl� Safety and Buildings Division ri�� � • r` SANITARY PERMIT APPLICATION Bureau of Building Water System �'■R 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 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. S . • See reverse side for instructions for completing this application State Sanitary Permit Number 3Zo7%rq- The information you provide may be used by other government agency programs E] Check if revision to previo s application (Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION N INFORMATION -PLEASE PRINT ALL INFORMATION `-- Pronertv Owner Nam Propert Lo -tlon O r $�✓1/4 yC 1/4, Sa T,31 , N, R gyp E (or) Property O er's Mailing Aqress Lot Number Block Number ;t Z ArV C c,7"1 / ity, StateQ / Zip Code Phone Number Subdivision Name CSM Number w It, 1 Z �fi,r ow - r* rr ).ZYG -- 27 P� 11. TYPE OF BUILDING: (check one) ❑ State Owned ity Nearest Road [] VII age Public a 1 or 2 Family Dwelling - No. of bedrooms Town OF r III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment / 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: spec IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1 New 2. ❑ Replacement 3. ❑ Replacement of 4. E] Reconnection of 5. ❑ Repair of an - _____System ________ System___________ _ =ar'dr_=6=F_11_y__ ____________ ExlstingSystem ________ Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number J Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution -Pres ur►zed Distribution Experimental Other 11 f jSeepage 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. /inch) Elevation /Iln) 3 (s Z3 5G. 3 Feet", 3 Feet VII. TANK Capacity Site in gallons Total # of Prefab. Fiber- plastic Expec INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass App - New Existing structed Tanks Tanks Septic Tan or Holding Tank /QQ i f mCJC� Z— El 1:1 El El Lift Pump Tank /Siphon Chamber E1 ❑ El VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans_ Plumber's Name: (Print) P o Stamps) MP PRS o.: Business Phone Number: Plumber's Address (Stree City, State, Zi Code): 7 Z Yo s i 4." -#.. Gv 6 IX. COUNTY/ DEPARTMENT US ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issuin Agent Signature (No Stamps) Surcharge Fee) ft] Approved ❑Owner Given Initial � C/A 0�� Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD -6398 (R. 05/94) DISTRIBUTION: Original to county, One copy To: Safety & Buildings Division, Owner, Plumber q-,1 "� D S2,6 Zo % -7- e IN cl to be i vtS-W leol' c4 leuaf y i ol 4 4o' 4�7 r�. PAGE OF C,, bep S y S ten - � Fresh Air Inlels And Observation Pipe n Approved Vent Cap Minimum 12' Above Final a l Grade 20- 42' Above Pipe _ 4" Cost Iron To Final Grade Vent Pipe Mareb Noy Or syntMtk Cowrinq - wIn, 2' Aggregate Over Plps . Distribution — Tea Pipe i 6' Aggr6ga14 o Perforated Pipe Below 13406.111 Pipe - Co Terminoling At Bottom Or System ��cJr;l• Ion �`\.��\\ SOIL. FILL D1STRI5UT101'J PIPE APPROVED SIMIETIC COVER OR 9' OF STRAW 2" OF AGGREGM —��. /� OR MARS" HAy (e OF 12 -Z / AGGREGAT E LEV. QF --'L e� b E � P T_� �--- ---I DISTRI9'JTI0AI PIPE TO BE AT LEAST INCHES BELOW ORIGIMAL GRADE A►JV AT LEASTLO IUC14ES BUT LIO MORE THAN 4Z KICKS BELOW FIAIAL GRADE MAXIMUM PEQTH OF EYMAVATiaij FRoM ORI &WAL f KAtm WILL BE - I MC14ES rdfamum gq OF EXCAVATION f pOM c*tGI 694 WILL BE INCHES A Q/ 'ilk 6'� LICENSE IJUMBER: - 2 2 /7 , / DATE: Wisconsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page of Bureau of Int @grated Services in accordance with s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must Countyty ^� include, but not limited to: vertical and horizontal reference point (BM), direction and � i, l: percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # -Za k5 -,Sb APPLICANT INFORMATION- Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). k . W I / 0 Property Property Location / /" Govt. Lot !�w 1/4.3 1/4,S 20 T . / ,N,R /7 E (or)ff Property Owner's Mailing Address Lot # I Block# Subd. Name or CSM# ,/ zg�s_(" 0 A a (�_ -7— C 3 Irl City State( Zip Code Phone Number ❑ City ❑ V' lage . Town Neare t Road 4E New Construction Use: 91 Residential /Number of bedrooms '3 Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow O gpd _ Recommended design loading rate I bed, gpd/ft e p trench, gpd/f1 Absorption area required !3 bed, ft -s trench, p Maximum design loading rate • bed, gpd/ft2 je trench, gpd/ft Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design /site con iderations Parent material Flood plain elevation, if applicable tt S = Suitable for system Conventional Mound In- Ground Pressure I AT -Grade System in Fill Holding Tank U = Unsuitable for system I as ❑ u BS ❑ u -E�S ❑ U ❑ S H U ❑ S au ❑ S © U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure GPD/ft Consistence Boundary Roots 0 in. Munsell Gr. Sz. Sh. Bed Qu. Sz. Cont. Color 'Trench / 7�s iP2/ — t. e) .4 7SX Ground elev. Depth to limiting factor 7_Lin. Remarks: Boring # a. 6 — S� l/G � �1!/`� C!?Al Ground elev. Depth to limiting factor 7_2!Lin. Remarks: CST Name (Please Print) ignature Telephone No. A— r - _AY Address f7 — Date CST Number 4, . S' za L4J / 3 �t 2 79 7 j ! w- -e �--\ � 1 �3q,3y y� g' ST CROM COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Ownerlsuyer e D r' Z6 Mailing Address C ,5 Property Address X1en/ � (Verification re d Planning Department for new construction) City /Stab /� �y=� Parcel Identification Number 63 8' ✓0 8 ZS— S0 LEGAL DESCREMON Property Location 5A� ' /4,. y., Sec. oly , T,'ULN -RAW, Town of .5fa ie. l o r Subdivision Lot # Cerd0ed Survey Map # J �O d �o . Volume . Page # Warranty Deed # o �02 _ Volume Page # Spec house ❑ yes ❑ no Lot lines identifiable 0. yes ❑ no SYSTEM MARU NA'NCE Improper use and maintenance of your septic system could result in its prxmature failure to handle wastes. proper ma&wnance . 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 masterplumber, jowrneymau plumber, mtrictedplumber 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 115 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 exp' 'on date. -� X0,3,98' SIONATE OF APPLICANT DATE 4WNER CER�ATYON I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(&) of the property described above, by virtue of a wam mty deed recorded in Register of Deeds Office. SIGNATURE OF APPLICANT DATE * * * * ** Any infomation 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 trap if reference is. made is the wataaaty deed 588224 VOL 1362PW099 DOCUMENT NO. State Bar of Wisconsin Form 2 -1982 WARRANTY DEED REGISTER'S OFFICE ST. CROIX CO., WI Ree'hd for Record OCT 01 1998 Earl W. Cloutier and Kathleen B. Cloutier, husband and wife, a : &'n P. convey and warrant to Cory Leier, a single person, the following "5re9.' D"e described real estate in St. Croix County, Wisconsin: R. teter of Deeds TRANSFER a� Y a� C r Y $ FED Parcel ID Nos. 038.1994 40 109 038- 1085 -50 Lot 1 of the Certified Survey Map filed June 11, 1997, in Volume 12, page 3278, being part of the Southwest Quarter of the Southeast Quarter (SW 1 /4 of SE 1 / 4) and Southeast Quarter of the Southwest Quarter (SE 1 /4 of SW 1 /4) of Section Twenty (20), Township Thirty-One (3 1) North, Range Eighteen (18) West, TOGETHER WITH a non - exclusive easement for ingress and egress by vehicular and pedestrian traffic and for public utilities across Outlot 1 and Outlot 2 of CSM recorded in Volume 12 at page 3278 as Document No. 560896. This is not homestead property. Exception to warranties: municipal and zoning ordinances, easements and restrictions of record. Dated this 1st day of October , 1998. Earl W. Cloutier athleen B. Cloutier ACKNOWLEDGMENT ACKNOWLEDGMENT STATE OF WISCONSIN) SNkTE OF WISCONSIN ) ss. ) ss. ST. CROD� COUNTY ) ST. CR0 COUNTY ) Personally came before me this 3d'�` day of September, Personally cam before me s 30 ` � day of 1998, the above -named Kathleen B. Cloutier to me sebk� - r� her, 199 , e abo -named Earl W. Cloutier known to be the person who executed the foregoing to me known to be the per who executed the foregoing instrument and acknowledge the same. instrument and acknow ge same. U 0 7 d .pc SH 56 �8� 6' s I S THIS INSTRUMENT DRAFTED BY ED FLANUM JOB NO. 9 - ~ • O O ® ='C o BEARINGS ARE. REFERENCED TO THE No y NORTH - SOUTH 1/4 LINE OF SECTION k ,� �j 20, ASSUMED TO BEAR N01'04'52 "E N wx °z� r° �Q) y, �m ° O �• Z z Z �N Kz �J � m , ��- t ' z� D I I� �m� I Q �O�Ar C7 m �Z OC W0 C o om OOrr 0 O D!V.r v C z C z� oZ �o v 2.74' I y r7'' Oc� Z mm Z ° m° Xm m o cy rn IN ( t z A�� z 0 �� �N ° I� ` NORTH SOUTH pL� ��9�' �O 2.67 •� - 0 o N01 '04'52"E �gti �� y � � � 1/4 LINE X 52.14' � po . ��, �, � SS�p'J iN -1 x • Co N 01'04'52" E 3950.68' 0 z g 01'04'52" W m- C)� 2.63' N N OS \� A \ 0 z ° I 4clb�N ;u \ ;o a � � c'B ° C C rI - N � z O I j i V) n m - ►i Q y y W. cl v Cl , m ° cn I� rI N ��' �b� c ° ° + �CAD � 13 t� U . 3 t � �