HomeMy WebLinkAbout032-1061-80-000( 1 4
JZOIX ("OUNIT ZONING EEA
DPAR'"I'M'Y
0 -j
AS RUILT SANIrl'ARY R14"J"OlZry
j
Owner
Address
City/State
Legal Description:
Lot Block Subdivislon/Csm ii
-� / -
Sec., T, N 2 Z f 7
-R W, Town of 7,J
PIN fl
SEPTIC TANK - DOSW CHAMBER - HOLDING TANK INFORMATION:
Tank manufacturer
Pump manufacturer Size ST/PC,/4gL/ Setback from: Douse Well
P/L
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: Width Length
Setback from: House Well P/L Number of Trenches
Vent to fresh air intake
ELEVATIONS:
Description of benchmark 4,
Elevation z��
Description of alternate bendmark � �.�; � .� .
Elevation ZLev�,-72
Building Sewer 1� 'r
SUHT Inlet
--z �- ST Outlet- PC Inlet
PC Bottom Head er/Mani fold --91,11-zl Top of ST/PC Manhole Cover
Distribution Lines O — 9 5122,--_ ( )
Bottom of System ( ) �Qr � �
Final Grade ( ) � ( )
Date of installation IZI-122RY Permit number ` _
State plan number
Plumber's signature License number
Inspector/ ,c>
Date
Complctc P10( plan 8-Ir
s 1
NOTICE: Plcasc 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.
Wisconsin Dopartm'a..nr of Commerce
Safety and Buildings Division PRIVATE SEWAGE SYSTEM
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT)
Personal information you provice may be used for secondary purposes [Privacy Law, s. 15.04
e', %7 (1)(m)]
r.
gft'�E CitkER Villa n Town of:
I 1�0 SEF
CST BM Elev.:. Insp- BM Elev-.-
BM Description:
/00,00
TANK INFORMATION
TYPE MANUFACTURER
CAPACITY
Septic
Dosi ng
Aeration
Holding
TANK SETBACK INFORMATION
TANK TO P L WELL BLDG.
Vent to ROAD
Air Intake
Septic
NA
Dosing
NA
Aeration
NA
Holding
PUMP/ SIPHON INFORMATION
County.-
ST, CROIX
Sanitary Permit No_,
315960
State Plan ID No-:
Parcel Tax No.,
034-1001-60-000
'ELEVATION DATA
A9800349
STATION BS
HI FS ELEV.
Benchmark
Bldg. Sewer
St/tA Inlet
St /Kt Outlet
Dt Inlet
Dt Bottom
Header/Man.
o.
Dist. Pipe
0 cz a
Bot. System
Final Grade
SOIL ABSORPTION SYSTEM
BED/TRENCH
Width
Length
No. Of Trenches
DIMEN51ON5
SETBACK
SYSTEM TO
P L
BLDG
WELL
INFORMATION
Type Ofi
System....,
PIT
No- Of Pits
Inside Dia. Liquid Depth
DIMENSIONS
LADE / STREAM �
LEACHING
Manufacturer:
CHAMBER
OR UNIT
Model Number:
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length Dia- Spacing
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 [j Yes F] No F] Yes [] No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: SOMERSET 23-31,19,313Arsw,SW 2015 60TH STREET
/3
Plan revision required? Ej Yes [nN o
Use other side for additional information.
SBD-6710 (R.3/97) Date Inspector's Signature Cert No
Safety and B
Nvisconsin SANITARY PERMIT APPLICATION 201 E. Washinuildingsgton AveDivision.
Department of Commerce In accord ILH R 83.05, Wis. Adm. Code P.O. Box 7969
Madison, WI 53707-7%9
0 Attach complete plans (to the county copy only) for the system, on paper not less County d
than 8 112 x 11 inches in size. /L2,
0 See reverse side for instructions for completing this application State Sanitary Permit Number
The Information you provide may be used by other government agency programs Check it revi3sion lto5previouspapp Pication
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
I. APPLICATION INFORMATION - PL SE PRINT ALL INFORMATION i
Property vv n e r N a nriee;) Property Location
1/4, S� T, N I R �(or�.
Property Owner's Mailing Ad rpss Lot Number Block Number
-J(,g z L
Cl to Zip Code Phone Number SubdiV,0 Name or CSM Number
ut A/111 - Yl,
11. TYPIF OF 1311 JILDING: (check one) ❑ State Owned El Cit Nearest Road
El Village
0 Public 1 or:! Fami o. of bedrooms Eg Town OF
Dwelling - N I ge
111. BUILDING USE: 'If building type is public, check all that apply)
Parcel Tax Number(s)
1 E] Apartment/ Condo 013-31. 1q. 313A 11 1.��
2 [:] Assembly Hall 6 [] Medical Facility/ Nursing Home 10 El Outdoor Recreational Facility
3 E] Campground 7 ] Merchandise: Sales/ Repairs 11 ❑ Restaurant/ Bar/ Dining
4 0 Church / School 8 F1 Mobile Home Park 12 r-1 Service Station Car Wash
5 [] Hotel / Motel 9 [] office / Factory 13 E] Other: specify
IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B. if applicable)
A) 1. ® New 2. E] Replacement 3. [:] Replacement of 4. [:] Reconnection of 5. E] Repair of an
----__System _------_System ------------- Tank Only__--- ---------- Existing System Existing System
B) E] A Sanitary Permit was previously issued- Permit NumberDate Issued
SYSTEM. I -
V. TYPE OF : (Check only one)
Non -Pressurized Distribution Pressurized Distribution Experimental Other
11 (S Seepage Bed 21 ❑ Mound 30 [:] Specify Type 41 ❑ Holding Tank
12 E] Seepage Trench 22 ❑ In -Ground Pressure 42 Pit Privy
13 E] Seepage Pit 43 F1 Vault Privy
14 E] System -In -Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area I Absorp. Area 4. Loading Rate 5. Pert. Rate 6. Syst lev. 7. Final Grade
I , , t�_ "
Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (M i njnch) Elevation
Feet Feet
VII. TANK.Capacity�
INFORMATION in gallons Total # Of Manufacturer's Name Prefab- Site Fiber- Plastic Exper-
New Existin Gallons Tanks Concrete Con- Steel glass App.
I structed
Tanks Tanksl
Septic Tank 1 11111toldlil, 9 ftlik
Aza 1:1 0 1:1 EI 1:1
Lift Pump Tank /Siphon Chamber ❑ El 1:1 El 1:1 El
Vill. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for instofation oft t�p onsite sewage system shown on the attached plans,
14 1 — —
Plumber' Nam a( 0- Plumbe Si atur S s) MP/SW No.: Business Phone Number:
162
Plumber's Address �P City, 5 p Code)
Pe�?Ci ta
IX. COUNTY/ DEPARTMENT USE ONLY
0 Disapproved Sanitary Permit Fee (Includes Groundwater at Iss ed Issu n nit SO4,PZaure (No Stamps)
Approved I [] Owner Given Initial Surcharge Fee) Ic Mal
Adverse Determination
� l � X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SE3 D-6398 (R. 11/96) DISTRIBUMN - Original to County. One copy To: safety & Fluildings Division, Owner, Plumber
Asa
Wisconsin Departmenrt of Industry, SOIL AND SITE EVALUATION REPORT
LabCir and Human Relations
Division of Safety & Buildings in acco; ILHR 83.05, Wis. Adm. Code
A
Attach complete site plan on paper not less t x 11 inc e*-s'Jn-_si- -, Plan must include,
but
not limited to vertical and horizontal refere t (113M), diroction a nO 0 11 slope, scale or
dimensioned, north arrow, and location a nce
near"d. li�
APPLICANT INFO RIVIATION—PLEA INF TIC
Page of
COUNTY
_5`� � r
O?�
PARCEL I.D. #
REVIEWED BY DATE
PROPERTY OWNER: OPERTY LOCATION
OVT. LOT -ILli 1/4 N R
_12A -1� i 5 1/4 S T (ord�
4e
PROPERTY OWNIER':S MAILIZNGDDIRESS T BLOC" # SUBD. NAM'OR GSM #
;7 (4
CITY STATE ZIP CODE OCITY LAGE _DOWN NEAR ROAD
r�,
i5
New Construction Use Residential / Number of bedrooms Addition to existing building
Replacement Public or commercial describe
Code derived daily flow gpd Recommended design loading rate Z bed, g pd/ft2 trench, gpd/ft2
I
Absorption area required bed, ft2 trench, ft2 Maximum design loading rate Z _bed, gpd/ft2_trench, gpd/ft2
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material .'.L' Z_2 Flood plain elevation, if applicable ZVZ ft
S = Suitable for system CONVENTIONAL MOUND IN -GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable for system 0 S El U 21 S 0 U Z S El U FKI S El U EIS OU El S Z U
SOIL DESCRIPTION REPORT
Horizon
Depth
in.
Dominant Color
Munsell
Motes
Qu. Sz. Cont. Color
Texture
Structure
Gr. Sz. Sh.
Consistence
Boundary
Roots
G P D/ft2
Bed 7rendh
Remarks:
Boring #
.................
...............
Ground
elev.
ft.
Depth to
limiting
factor
-7-el
Remarks: I
DST Name --Please Print
Address:
Signature:
4.23
Z
Aho
F
Phone-
/7J.
x�
Date: CST Number:
e-�
�PROPERTY OWNER SOIL DESCRIPTION REPORT
.%:: �%'�c��`f
PARCEL I.D.
' Page of
J
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
- 9--?- - --
Boring #
:S S .1•.5.•.
.......::ti{ti.....
Ground
elev.
ft.
Depth to
limiting
factor i,
Boring #
L:ti{
Ground
elev.
ft.
Depth to
limiting
factor
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
M'OMM
ax
Remarks:
Remarks:
1,4
Samoa oe2z ZO-7
� r
S -efez
NP MOO
Remarks:
Remarks:
5BD-8330(R.05192)
��.rlor
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
� �
k"
Owner/Buyer
Nlallliig Address V e—, 0'4�-"/
'5__ e
-ON cc 7-L,
Property Address I '�? _(r � . IS � �� �� � � �-,
(Verification required from Planning Department for new construction)
-itification Number
City/State le 1/1-%. 11__4�::LParcel Idej
LEGAL DESCRIPTION
Property Location SW V,, SL'Al, Sec. T N-R /'j W, Town of
.56�*l4,k,5eT
Subdivision P/ca.-f 0 .- 'C;. A Lot # ?---
Certified Survey Map # 5 3 C)q /(/0 ,Volume
. Page #
Warranty Deed volume 0 Page # 2- Z C
Spec house El yes U-1ro 1--ot lines identifiable 0-yes 0 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
rnaster 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/Wel 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.
SIGNATUREvOF 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.
ZY
SIGNATURE F APPLICANT DATE
* * * * * * Any information that Is mis-represented may result in flie 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
i •
a 11;
EKmftE � Y 530340
LOCATED IN PART OF THE S WIA OF THE SWIA AND PART OF THE NW 1/4 OF THE SW 1.4
OF SECTCN 23, T31 N, R I9W, TOWN OF SOMERSET, ST. CROIX C OUNTY, WiSCONS ,
' =TLITY EASE S
Each parcel shown on this sup (plat) is wo pole or buried cables are to be
subject to State, County and Township placed such that the installation could
laws, rule■ an3 e ' _.tans f 4 .e. , disturb any s,irvey ■t&ko, or oaottruct.
ratlandr, minimum ot�sixe, access to vision along any lot line or street
parcel, etc.). se[ore purchasing or line.
developing any parcel contact the It. The disturbance of a survrf stake by
Croix County Zoning Office and LQT 1 anyone is a violation of section 236.31
appropriate Tres►* Ord for advice. of Wisconsin Statutes. utility
. .h� sasements as
herein set forth are for
the
publicuse
utilttieschbaovdingsthe r ghtate
to
serve the area.
S88'53'18"E '409.41'
wL-14 CC1M4ER C1F
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LEGEND
_ � � . � ALWI�LM gp�IMT'r AR7t/�fT IOX7
rn � � r rows+ net �a.w
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LOT � .- x W " P". &." t.es
MIN LP"Poor,
LOT 3 5.00 ACRES .............. AQUWW wradix k4m I way I
�,.5-ht. 217,802 So. FT. ••-12' WON WFILOrr CAs[MLwT
n A- Phi r - FAKEL 1GI @ :` woe rii►t rouwo
A
v_OL.7621 PG231
S 88' 53' 181 433.0 t'
33.01' 400.00' Mgr �cxanoa�
Eppp e
+8 i TO" OF S T CMERSET
Fi 53 I W 400•00
,,rr��
I i e r q cfi • wrr v4
sr ls' I
n
LOT 3 _
7.61 ACRES
..:+3s?3,416 SQ. FT.
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noM
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f ... �` •' : ^� 4 esy�� 1�� j Y. F , 7' i 1 " 1 .' ram.;" ' xw ' ." i CCM�tieirL ilI t ' ', _ ' CO. Ift
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• try �' tie r+�L►r'l`;,•..�..'Yi'• ,+�'•,, {.i. ' ,� %' S :'i .4,' '�iY.� ''-' ►
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_ :.��_.. �•. LOT.
22.43 ACRES S88058'AmE 4922V
959.793 So. FT.16
2,49 329.
C, a e' ! • •�. � -.. � ...�}jam '. s•
. � t .. _. ram. • - _.
- _ -
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m.00' 33e 17' r7l �l 0.
l Sago13,16`E 4W52' a4 it7
LOT `3 n
J
bl 14?'
N8'9"1316"N 469.67'LOT 1,
S 8 C.
0
LOT z 4.18 ACRES
c� 182,046 so. FT
23
t•
14-3
- 334, r9' ,
DEOICATEO TO THE PUBLIC L4wse'sa'serw
Sow CORNM OF7. — + _ _ _ .w _
SfCT+CN Z'i W. + N6 49% sa+T,. L,wr or n,c Swi.,%, SCCY m ss,ssr.+e` sue+ taR
as C T%Om
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ore= r iN FFFT I`• coo UNPLATTED LANDS