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HomeMy WebLinkAbout030-2057-90-000 (2)ST, CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT Owner f�ffa�A Property Address i3!2yS `.- ,:.; City/State Legal Description: Lot Y Block Subdivision/CSM '/4 1/4, Sec. T�`�'�'� _10 N-R2( LW, Town of 5 rzo PIN 9 6-70—�,Zg2S:7-Y49 Z SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer Size ST/PC/,04o/ Setback from: House Well1d ZP/L Pump manufacturer Model Alar-m location CUOLDE"iG TANKS ONLY) Setbacks: eirvic Meter location Alami--W���� ip SOIL ABSORPTION SYSTEM* .t to fresh a*' ater Line Type of system: _Width 3 Length - '2 -5"' Number of Trenches .�'... Setback from: House Well. Z62 t. P/L Vent to fresh air intake ELEVATIONS: Description of benchmark _Z01-9 6S�L) Z,6� Elevation Description of alternate o74 'T rnate benchmark 75,eg &4LI-o7- -fL4r46E- Building Sewer ST/HT Inlet ST Outlet PC Inlet AA — PC Bottom Header/Manifold ? Top of ST/PC Manhole Cover Z04-, Y3 Distribution Lines o2 ( ) Bottom of System ( ) �f.�, S 5 ( ) 9'S � .5�5r ( ) Final Grade ( ) f 4 ( ) �' % � ) Date of installation / S,-' Permit number 32,0 -3e State plan number �(A Plumber's signature eft License number. Dated /;F 1" /00" II Inspector 06( 6C6 Complete plot plaD 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 QUELL S/1!4/IFO UJ I T ff D UJNY7IL ��G„f i 8�� 3r-7 3 BOO �1 v A-3)(75' T/1,�I�OcH,�S Apo G.C. SrT, SW zaT STAFF ic/`f- / 1 0�0. INDICATE NORTH ARROW Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count �'T'CROIX Safety and Buildings Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) San"!Y � Yj � 660 Personal information you provice may be used for secondary purposes [Privacy s. 15.04 (1)(m)]. Permit Holder's Name: Ity Town of: 9fe Rd9 State Plan ID No.-. ERLITZ, KEVIN & ANN CST BIVIElev.: Insp. BMElev.-. BM Description: Parcel6ajbcL'2057-90-000 I - TANK INFORMATION ELEVATION DATA A9800488 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Bencbmjr�.,?,C, Iff le Dosing Aeration Bldg. Sewer Holding Inlet I et 6 TANK SETBACK INFORMATION Ka� +t Ou tl et TANK TO P L ELL BLDG. Air Intake ROAD Dt Inlet Septic NA Dt Bottom Rosin g ------- NA Header / Man. q7.64 Aeration NA Dist. Pipe Holding Bot. System "Y 3 PUMP SIPHON INFORMATION Final Grade Lle eO Z7 2 Manufacturer Demand I 5L Model Number GPM Ictlam TDH LossFt Loss Ffead! T H--- —[6W �Nv Forcemain �w SOIL ABSORPTION SYSTEM BED, k ENC Width e n I QM Length No. Of Trenches f-� IlDIMENSIONS PIT No. Of 10SAE! Dia. Liquid Depth DIPAE I __ SYSTEM TO P/L BLDG WELL LAKE STREAM LEACHING Manufac SETBACK INFORMATION I T y p3pil ro ;7 1 CHAMBER OR UNIT —Model Number: Sy L44% DISTRIBUTION SYSTEM Header / Manifold Distribution Pipe(s) tl Iiia. Spacing &�L_ x Hole Size x Hole Spac Intake Vent To Air Int Length Da LenLength 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 0 Yes E] No © Yes Q No COMMENTS: (Include code discrepancies, persons present, etc.) 36 LOCATION: ST. JOSEPH 27.30.20.558,NWINE 1390 HAGGERTY STREET o k"� A Top 51d,�q pl)ollf� pw 10 - 1 2> Plan revision required? [:]Yes 9-ooNo AIV Use other side for additional information. � �" Date inspector's Anature SBD-6710 (R.3/97) dww� Nfiri SANITARY PERMIT APPLICATION Safety and Buildings Division sconsi 201 E. Washington Ave. on In accord with ILHR 83.05, Wis. Adm_ Code P.O. Box 7969 Department of Commerce Madison, WI 53707-7969 Is Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x 11 inches in size. S'J'. C,.-, 7,1, 0 See reverse side for instructions for completing this application State Sanitary Permit Number 00 The information you provide may be used by other government agency programs 't rev' application [Privacy Law, s- 15.04 (1) (m)]. F] Check ision to previous app i ion 's 0XV71-6 State Plain I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Prope owner Name Property Location rtv 1/4 1/4, S Ig T 30 N, R zp o E (orb' / �U/ A/ <74 AAI& Ee4�Lllz _Z - ; Owner's �sMa­I Address Adress Property w 7-Lot Number Block Number J-371V I-1AC,6:6r1?;ry 5, 1 a 1 07 City, State dip Code Phone Number Subdivision Name pj SM Nu I mber 11. TYPE OF BUILD (check one) ❑ State Owned El Cit Nearest Road E] Village 0.6=4 1:1 Public 1 or 2 Family Dwelling - No. of bedrooms XTown OF 5Z e r7 111. BUILDING USE: (if building type is public, check all that apply) Parcel Tax Number(s) Su L .*I 7)Y01 Pa 4Q 710 0 0, 1 F1 Apartment/ Condo 0 0 — aq 05- ZZF.0 — 000 2 E] Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 0 Outdoor Recreational Facility 3 E] Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/ Bar/ Dining 4 E] 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. X New 2. E] Replacement 3. [] Replacement of 4. E] Reconnection of 5. E:] Repair of an _-_-__System 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 DQ Seepage Trench 22 In -Ground Pressure -7 42 Pit Privy [-] 13 Seepage Pit 43 ❑Vault Privy 14 14 E] System -In -Fill M 14, lbk-Ay CA9.�em VI. ABSORPTION SYSTEM INFORMATION. �q__ .00 T. 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.) (MinAnch) Elevation 7-To 1 4?�570 Feet j 91�f,0 Feet 711. TANK Capacity in gallons Total # of Prefab. site Fiber- Exer- INFORMATION New E x istin Gallons Tanks Manufacturer's Name Concrete Con- Steel lPlastic p App. strutted glass Tanksl Tanks - J 000 1:1 El 1:1 1:1 Lift Pump Tank _Siphon Chamber ❑ ❑ ❑ ❑ Vill. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) P1 b is S Signature: (No Stam s) Mt!LP RSW N�- Business Phone Number. A/ -5 7_7 E Plumber's Am"r— Address (Street, City, State, 7iprr,,A0)- -AMWO— IX. COUNTY / DEPARTMENT USE ONLY 1:1 Disapproved Sanitary Permit Fee (includes Groundwater Surcharge fee) MApproved Ej Owner Given Initial Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: W-924701 vane Issued Issuing nt Signature (No Stamps} aTe to �" L 5BD-6398 (R - 11/96) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber L I - I - I I I - . — - - . 16 Fr e AST 3 fAk65' Wisco.nsin Department of Commerce Divisioh"Vf Safety and Buildings SOIL AND SITE EVALUATION Page of Obureau of Integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code d-L Attach complete site plan on paper not less than 8 112 x 11 inches in size. Plan must County' include, but not limited to: vertical and horizontal reference point (13M), direction and -5 �.. percent slope, scale or dimensions, north arrow, and location distance to nearest road. Parcel 1. D. # APPLICANT INFORMATION - Pleas info a a Date N.'. Reviewed by Personal information you provide may be used for se purpo -Law. S. .'11�1504 (m)). (2 2 '1-, Property Owner (.0 o erty Location County Parcel 10/1 Or7- n Lot N 1/4 /VL/ 1/4, So? T3o N,R 0?0 W Property Owners Mailing Address S T CROIX Block# Subd. Name or CSM#City 99 uOUNry P/ 1 State Zip Code P ne Num City LJ Village PRr Town Nearest Road iw i-k I Pet r, .,P", S 1. LY New Construction Use: EgResidential / Number of bedrooms Addition to existing building El Replacement EJ Public or commercial - Describe: Code derived daily flow 0 gpd Absorption area required bed, ft2 trench, ft 2 Recommended design loading rate bed, gpd/fF (0 trench, gpd/ft2 S70_0 bed, gpd/ft2 Maximum design loading rate trench, 9 pd/ft2 Recommended infiltration surface elevation(s) 9< —ft as referred to site plan benchmark) Additional design/site considerations Parent material Flood plain elevation, if applicable ft S Suitable for system Conventional Mound In -Ground Pressure AT -Grade System in Fill Holding Tank u= Unsuitable for system, N S El U EWS 0 U NS Ou RS 0 U El S WU F] S 9u SOIL DESCRIPTION REPORT Boring # Ground elev. eft. Depth to limiting factor fin. Boring Ground elev. ? -Aft. Horizon Depth Dominant Color Mottles Texture in. Munsell Chu. Sz. Cont. Color je -34? e V& _32-22 7�ve 5/ Q r s Remarks: Structure Sr. Sz. Sh. Consistence I Boundary Roots GPD/ft2 Bed , Trench tl jkv7S�4 A� k 0, a. n_L7 T_ Pr -3r- Depth to — ------------ limiting factor + Zj�in. Remarks: CST Name (Please Print) Signature Telephone No. 01.1 Address 2 Z-44 /X_ 41 Jez Date CST Number oerc 13;�2 2 �;�O? q r' t � �•� SOIL DESCRIPTION REPORT PROPERTY OWNER � Page _ 0t _ PARCEL l.D.# 0-3 S7— Yo 1, Boring # Ground 7,� cs pelev. ! - t2yf Depth to limiting factor i n. Baring # ................. Remarks: love '34 Ground �`�ft• Depth to limiting facto r �in. Bering # Remarks: 0 Oye— AV'? I Ac� P2 C ci ........ ...... .. ... .. ... 3 v-se fn-5�k Ground7-1 A? rn 1)b ?K:" elev.Depth to limiting factor �-� n. Boring # Remarks: C� qrt.S Ground Iv "f. Depth to limiting factor-fA in.. Remarks: SBD-8330 (R. 07196) Horizon Depth in. Dominant Color Munsell Mottles G]�u. Sz. Cont. Color Texture Structure Gr. 5z. Sh. Consistence Bounda � � 9�s o c� ,e s�/.� y /-90 Ds Horizon Depth in. Dominant Color Munspll Mottles Chu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPQIft� Bed ,Trench A .0 -PROPEFITY OWNER L L //,SOIL DESCRIPTION REPORT PARCEL I.D.# �� -��-- 90 Boring # 1111 )116 11 1 kelev. I, it ' Z r - Depth to limiting facto -f-I n. Boring # Ground elev. �- �-- j t Depth to limiting factor -fjFY i n . Boring Ground elev. Depth to limiting factor in. Boring # Ground elev. ft Page -J - of -�/ Horizon Depth in. Dominant Color Munsell Mottles Chu. Sz. Cont. Color Structure Gr. Sz. Sh. Consistence Boundary Rootsu. QE Bed Trench Z- /0 KIR- 79 Remarks: 212 C tj 6- Remarks: Horizon Depth in. Dominant Color Munsell Mottles Chu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPDA�— Bed Trench Remarks: Depth to limiting factor Remarks: SBD-8330 (R. 07/96) 4''% 7 F F I r I A/ �17 4J-7; S A lcS e/pj? /V 7-?r)A/ P � 3 ly ra t5y 'lh6-"a5 -�)Llll�lllr a��v��9 ���/� cs/r�,/ ok �7is�s'�s -6 6s/ ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer C Aft �wLL7z' Mailing Address #04of L 7 0 -Ar 0.9 900f2 Property Addre EI?-y 7- 9LO ve 77 (Verification required from Planning Eq_4r TC t=_nt or new construction) City/State 7-,n 't Parcel Identification Number -0,70 -,�Q5,7 -10-6W LEGAL DESCRIPTION Property Location G V41 '/4, Sec. T,__7_0N-R10 W, Town of r If Subdivision . Lot # Certified Survey Map # Volume , Page # Warranty Deed LC -, Volume //D Z_ ,Page # - / Z& Spec house El yes W no SYSTEM MAINTENANCE Lot lines identifiable N yes 0 no 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. I/we, 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 y septic system has been maintained must be completed and returned to the St. Croix County Zoning Off -ice within 30 days of, ee xpiration date. Qe2 "--§IGNATURE OF DATE OWNER CERTIFICATION I (we) ertify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the prope escri ove, by virtue of a warranty deed recorded in Register of Deeds Off -ice. 4�IGNATURE OFA ,OH15A'INT 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 off -ice a copy of the certified survey map if reference is made in the warranty deed L L) PRE-�xZn1U6 OUT 6�ILDING a PRZ:U1571N6 OUP BaOl tAG Xa'- 4ql 1 PROPOSED ul E51 DENTI AL DWE LLI NG VIVIN4 A"h ER�ITZ \5RO tAAQAtWTY 5T, HOUL70N WI, 9408a SITE PLAN N SCALE