HomeMy WebLinkAbout020-1335-80-000 (3)""'a S CIZOIX C40UNTY ZONING I)EI'ARTMENT
AS 13U(�,T SANITARY IZI-'
Owner f
Address "?4n C7
City/State
Legal Description:
Lot 22— Block ,
S,bdI-'s' 4
i ion/CSM A I
#
'/4 y W Secln�fi
. �zv T��N—R 1<� 1
Town of
PIN #
SEPTIC TANK OSE CIJAMBEJR __ HOLD
FORMATION:
Tank manufacturer W E I �.. Size Svpc/e*_M�_/,
PUMP manufacturer Setback from: ljousei
Model map=-. Wei I 6-t— PILL3 0
Alarm location
(HOLDING TANKS ONLY
Setbacks: Service road Vent to fresh intake Meter location air e Water Line
Alarm location
SOIL A113SORPTION SYSTEM:
Type Ofsystem: _J, 1'!C1 AToaWidth w"
gth$?�
of Trenches
Setback from: HoLenNumber
use L!O�Well Vent to fresh air intake 7, -------------
ELEVATIONS:
Description
of benchmark t.1 P.6
Description of alternate bencElevat oomL tIonf 90
Elevat'on
Building Sewer
PC Bottom ST/HT Inlet ST Outlet, -PC Inlet
He
Top Of ST/PC Manhole Cover
03
ow� 07, of
Distribution Lines
Bottom of System dW' 7 - 9 1. 7�0
Final Grade
( } ?
, ` ��
( }
Date Of installation/_�Pcritiit number (Sli P DState plan "umber
Plumber's signature�,�,� �/�
� ` • � License ntimberA#k 5 400 1 e;OD C) DatDaterluspector /�' / 1
C0,11pictc plot plan av
t i
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 covcr.
• Show alternate benchmark, if applicable.
Ij
( Cp f` # 0-- � tj M- C-) M -
Wisconsin Department of Commerce
Saf6ty and Bbildings Division PRIVATE SEWAGE SYSTEM
GENERAL INFORMATION INSPECTION REPORT
(ATTACH TO PERMIT)
Personal information you provice may be used for secondary purposes [P rivacy Law,
�t��erfs W S - 15.04 (1)
of:
E] C EJ Village Tawn HNSON
CST 13M Elev-:. n s p - BM Elev.: B—MDescription:
11 . .JL
TANK INFORMATION
TANK SETBACK INFORMATION
TANKTO P Ventto L WELL BLDG. Air Intake
_NMMMMEE�
Septic //57
Dosi ng
Aeration
Holding
PUMP/ SIPHON INFORMATION
Manufacturer
Model Number
:TD:H] Lift Frith stem
L Mead
ForcemAin Len
ROAD
m�w NA.
NA
NA
Demand
GPM
TDH Ft
g U11 a. Dist- To Well
SOIL ABSORP ION SYSTEM
BED / TRENCH_ Width Length No. Of Trenches
DIMEN2QNS
C;1/1
020-1335-80—000
tLEVATION DATA
STAI-ION BS HI
"FS'
ELEV_
Benchmark
' -4�
211
-7
Bldg. Sewer
St/5 Inlet
St/M Outlet
Dt Inlet
Dt Bottom
Header
Dist. Pipe
1.-0 41
Bot. System
Final Grade
Y
J
PIT No- Of Pits Inside Dia, Liquid Depth
DIMENSI_ONS
SYSTEM TO P/ L IManufacturer:
SETBACK P / L BLDG WELL LAKE LEACHING
INFORMATION Type
M
CHAMBER
S y s t e M 7�_Lf 4,4,_,64o,4r t�-7 /,Z//) Model Number. -
OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold I Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length Dia_
Spacing
SOIL COVER
Depth Over x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over
xx Depth Of Seeded
Bed / Trench Center p xx Seeded J Sodded xx Mulched
Bed /Trench Edges D Yi
I 3� I Topsoil ❑ Yes E] No EJ Y e s D No
COMMENTS: (include code discrepancies, persons present, etc-)
LOCATION: HUDSON 27-29.1g,sw
INW 769 WILFRED RD—BADLANDS PRAIRIE LOT 38
Plan revision required? E] Yes No
Use other side for additional information.
./ : , I "
J
SBD-6710 (R-3/97) Date
�
�nspcsttor�s Signature Cert- No.
SANITARY PERMIT APPLICATION Safety and Buildings Division
N*isc nsin 201 W.Avenuel Washington
Department of Commerce In accord with JLHR 83.05, Wis. Adm. Code P 0 Box 7302
Madison, W1 53707-7302
• 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;;+ -Cco
• See reverse side for instructions for completing this application State Sanitary Permit Number
Personal Information you provide may be used for secondary purpo -31 (FSES [Privacy Law, s- 15-04 (1) (m)]. "EE7&9 Wl"Irr C/ Ad. 0 Check it revision to prevDiou application
L AP INFORMATION PLEASE PRINT ALL INFORMATION State Plan I.D. Number
Property Owner Name
6f
Property Location
ILI" ion —
L ropert)(Owner's Mailing Address :5 to 14 �/ Q_,Y/41 s;? 7T 2- N, R 0� E (or$�W)
Lot Number
Block Number
City, State Zip Code Phone Number Subdivi-sionNa eorCSMNu
L) 5 Z
BMW DING
11. TYPE OF r
EJ Public (check one E] -State Owned El Cit Nearest Road
ic I or 2 Family Dwelli 0 village
ing - No. of bedrooms own F0 L) Q.�o F 7N
FA AW BUILDING USE: (if building type is public, check all that apply) Parcel Tax Number(s)
1 El Apartment/ Condo 14 A 7.
2 El Assembly Hall 6 ❑El Medical Facility / Nursing Home
3 El Campground 7 Ej Merchandise: Sales/ Repairs 10 El Outdoor Recreational Facility
4 Ej Church / School 8 El Mobile Home Park 11 [] Restaurant/ Bar/ Dining
5 [_1 NO Hotel / Motel 9 El Office/Factory 12 El Service Station / Car Wash
13 El Other: specify
IV'. TYPE OF PERMIT: (Check -only-one box on line A. Check box on line B. if applicable)
I e)
A) 1. New 2. Ej Replacement
System 3. R Replacement of 4. E] Reconnection of
- - - - - - - - - - - - - - - - - - - - System ------------- Tank Only 1 5. [] Repa i r of an
--------------- Existinq System Existing System
B) Ej A Sanitary Permit was previously issued. Permit Number _ _-
Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non -Pressurized Distribution Pressurized Distribution Experimental Other
Seepage Bed 21 ❑ Mound
12)Q Seepage Trench ..]DE W/Mi3f k22 In -Ground Pressure 30 ❑ Specify Type 410 Holding Tank
v
1 YE� Seepage Pit IV 42 E] Pit Pri y
1
14 El System -In -Fill 43 [:] Vault Privy
ABS0RPTI_ON SYSTEM INPORMATION:
1- Gallons Per Day 2- Absorp. Area j 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) I I
"*% &_► I Elevatictp
f -Z a 47.5# Feet t7
V11. TANK Capacity -Feet
INFORMATION in gallons Total # of Prefab. Site 7—
New Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel Fiber- Plastic Exper-
04 7 Tanks Tanks structed glass App.
Lift Pump Tank /Siphon Chamber F _F_J1 11 El El El
11. RESPONSIBILITY STATEMENT MEN _0 12—MMU 11 1 ME
the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print)
Plumber's Signature. (No Stam ps) MP/MPRSW No.,Business Phone Number: P
k
MA ^10i
L F 07
_j_t A - L�_
Plumber's Address (Street, City, State, Zip Code).-
N7t_ /L, & 0
IX. COUNTY/ DEPARTMENT USE ONLY
IE] Disapproved Sanitary Permit Fee (Includes Groundwater Date issued Issul, g nt S, cure (No
surcharge Fee)
,4Approved [:1 Owner Given Initial Qrl� F /1 �i5 !9W (tamps}
I Adverse Determination OU I /
Lf—C
IM — ;i i =5 I
X. C ITIONS OF—APPRO fk�
VAL/ REASONS FOR DISAPPROVAL: (I —
SBD- 6398 (R.11/97) DISTRIBUTION: Original to County, One cupy To: Safety & Buildings Division, Owner, Plumber
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5 7c7�
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OIIT
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m
THE
SIDEWIND-ER°
Chamber
High Capacity Model
-z:--
16
Chamber End View
200 I <
34"
SYSTEMS INC
Leading the way in septic and stormwater chamber systems
4 Business ParK road lo P.O. Box 768* Old Saybrook, CT 06475
800-221-4436 * 860-388-6639 * Fax: 860-388-68 10
�HIY� h41�1�,� jj AOCHNUS
� �q u�i� r-2t� Q�. 7Au� 0 2v -1335- 'b�
�-T/tEN�F��S 07 SIDE W(h) r"-4 5 X4C,N T0T141_ 14$
Chamber Side View
S�ySTEOR Ef, � �S•ao
75 >
Closed End Plate
0
Open End Plate
Product Information
Chamber Specifications
Size (W x L x H) 3411 x 75 11 x 16'1
Invert* 11U
Storage 122 gal/i 6.3 ft--"
Weight 31 lb
* 4' SCAR 35 pipe
Product Benefits
• Lightweight units offer easy assembly
and installation.
• Fully -louvered sidewall provides maxi-
mum infiltration.
• Open chamber bottom allows addi-
tional infiltrative area.
• High -density PolyTuff" polyethylene
construction guarantees strength and
durability.
U.S- Patents: 4.759.661 5.017.041- 5,156,488 ' 5.336.017: 5,401.116. 5.401.469. 5,511.3M. 5.588,778; 1.815.925: 1.974,93B- 1.729-381 4A8.333 C-wmd-an Patents:1-129.959: 2.004,564 CLhef U.S_ Cartadan, and fore4gn patents per<ng_
Infiftraux. Equahzef. P�;Ac.N and SoeWrlaer are registwea tradwnarks am rw 10tiawmg are traagrruuM of IWftrawr Systems Inc.- BVFoo(, Cor"im. ()istr,buuv. L4aXvrKzef. MaxWlr, L4jCMLAaCrWV. p T FIM
oty uP SnapLock- Ljm 01997 infiltrator Sysieffm Inc. PMV00 in U-S A. C 1_57HP
Wisconsin Department of Industry,
I
",aC�, and Human Relations SOIL AND SITE EVALUATION
Division of Safety and Buildings in accordance with S. ILHR 83Page
.09, Wis. Adm. Code
Attach complete site plan on paper not less than 8 112 x 11 inches in size. Plan must
include, but not limited to: vertical and horizontal reference point (13M), direction and
percent slope, scale or dimensions, north arrow, and location and distance to nearest road.
County
St. Croix
t`arce! i.L). #
APPLICANT INFORMATION - Please print rmati6m- eview 7()
It- Date
Personal inforn-tation YOu provide may be used for secondarY Ourposes (Privacy Law, s. 15-04-� 1) (m)).
Property owner
Property Location
n
Richard Stout V
6p\ of
I— ---- I -a. SW 1/4 NW 1/4, S 2 7 T 2 9 N,Rl 9
Property owner's mailing Address W
Lod` 4
0- 0 Blo�7k# Subd. Name or csm#
353 Awatukee Trail 1) kol I
8, Badlands Prairie
,,7
:�Pv Lo "' 'ot 7,1
)n
8,
Code
4 0 16 j ty
u
city
State Zip Code
one u m tfs eo
n
-Hudson WI_ 1 5401 6 4X�*� evO tY Village Town Nearest Road
)5 731 H'uds n
IState Hwy 12
A
New Construction Use-, 5flResidential
Ll Replacement U m� 60-160� -3---A— Addition to existing building
Public or commercial - Describe:
ICade derived daily flow 600 gpd
Absorption aroa required 2 Recommended design loading rate -- 7 bed, gpd/fF • 8___trench, gpd/ft2
8-5-8-----bed, ft --7-5-D—trench, ft2 Maximum design loading rate -7 bed Recommended infiltration surface elevation(s) ___, gpd/t� 8 trench, gpd/ft2
dj—ft as referred to site plan benchmark)
Additional design/site considerations
Parent material Glacial _�__ ___ _`__ __��_ __
0 S i� t
Flood plain elevation, if applicable
Conventional
Suitable for system Mound -6--Ground Pressure AT -grade System in Fill Holding Tank
U Unsuitable for system
I -RS U L, -� S U F-1
Boring #
Ground
elev.- 9 9 4G—ft,
Depth to
limiting
factor
9-8 1 n.
Boring #
2
Ground
elev.
9 8
mft�l I -- L) LAJ Z:) L-1 U Us M Li S U
SOIL DESCRIPTION REPORT L R1
"Ilwft�
Remarks:
I D-2
- - none IL
2ma2 20-0 I Oyrjbk--.mf r cs 2m
S2mbk mvf r S
I f .5 86
3 4 0 - 9 1 Oyr4/1
none MS osg
M1 cs .7 .8
Depth to
limiting
factor
Remarks:
(`QT KI-N.—
Signature Telephone No,
oi
ddress
Date
CST Number
.A) P
- :1ROPERTY OWNER Richard Stout
."ARCEL I.D.#
Boring #
3,round
2 V.
99
.)epth to
imiting
actor
9D-in.
3;oring #
4
:iround
?Iev.
9 9--,-"t.
lepth to
actor
9-6--in.
Boring #
5
Ground
elev.
0 0 1. 0 5ft.
Depth to
limiting
factor
_q2_ .... irl.
B I oring #
Ground
elev.
- -ft.
Depth to
limiting
factor
in
Remarks.-
Remarks:
SOIL DESCRIPTION REPORT
Page _ 2 of 3
Horizon Depth
in.
in.
0 12.7-5)Yr2.5Z1
2 12-42
3 42-92
Dominant Color
munsell
10yr3/4
10yr4/6
Q-u. SZ. Cont. Color
none --L
none
none
Texture Structure
Gr. Sz, Sh,
2mabk
sz.
2mbk
MS osg
Consistence Boundary Roots
mfr cs 2m
mvfr cs
--'l f -.5
M1 CS
GPD/ft 2
--Bed Trench
.5 .6
.6
* 7 -8
Remarks:
Remarks:
SBDVV-8330 (R. 08/95)
M �
r
/�y dlt:- I
1 " r-3 q
�dT3a
IAV
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer f� 4/1 —A / 14.,.,..,_
Mailing Address _-a0y Zy/ �z
Property Address U) I L FYQ, aka y`3 )c,�'
(Verification required from Planning Department for new construction)
e_j
City/State ��7SN Parcel Identification Number 0 0" 1 =3 ml� :r:mw c4F 0
LEGAL DESCRIPTION
r
Property Location-SUJ 1/4,&U) 1/4, Sec.cD 1 T." N-R Town of ON
Subdivision 17 P t C*4
f f, , Lot # ,:D
Certified Survey Map #406 10 f <0 - Volume --V-- . Page # 4? /
-
Warranty Deed 4<� � ►:� , volume I S1� Page #
Spec house yes EJ no
SYSTEM MAINTENANCE
Lot lines identifiable Vyes 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.
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 th three year expiration date.
AM P 4
NATURE OF three
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 Off -ice.
AITURE, Or 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