HomeMy WebLinkAbout042-1075-60-000 (2)ST. CROIX COUNTY ZONING DEPART EN'
AS BUILT SANITARY REP 0RTX�'\'1#I---'
Owner
Property Address
City/State 22&ate q 0 )---A* ST
COUNTY
O
Legal Description: ZONINGr-;:ICE
1
Lot
Block Subdivis*on/CSM #
1/4 1/4, Sec.J, TdaN -R f 8 W, Town of 9:::�^ PIN #
r-60
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION:
0
j000/ I 00d of
Tank manufacturer ,?-D,,.�� A4. Size ST/PC Setback from: House Well P/L
Pump manufacturer Model
Alarm location
(HOLDING TANKS ONLY)
Setbacks: Service roa
Meter location
Alarm location
SOIL ABSORPTION SYSTEM:
h air intake
4r
Type of system: . ij� Width"� Length Number of Tenches
Setback from: House 5o"- Well 3 -50' P/11, .5 -or Vent to fresh air intake Ls) o
ELEVATIONS:
Description of benchmark
Description of alternate be:
Building Sewer ST/HT Inlet ST Outlet PC Inlet
PC Bottom Header/Manifold YY. F Top of ST/PC Manhole Cov/rw,,,e7.
Distribution Lines � Zr ( ) y� a ( )
Bottom of System 7 / O �� � ( )
Final Grade V. cir d � ( )
Elevation J 0 0-
Elevation /00.
Date of installatioq/d&/j',Vre m.4. numb-er,, ./S-347d� State plan number
Plumber's signature License number Datev
Inspector 0 k
kL Complete plot plan gir
K
r
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.
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INDICATE NORTH ARROW
Wiscdnsin Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and Buildings Division INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT)
Personal information you provice may be used for secondary purposes [Privacy Law, s. 15.04 (1)(m)].
Permit Holder's Name- E City El Village N Town of:
Jaselman. D vid Town of Warren
CST BM Elev- Insp. BM Elev.- BM Description,
I CS 0 1
-------------- 4�iy 4(
TANK INFORMATION EAVATION DATA
TYPE
MANUFACTURER
CAPACITY
Septic
Dosing
Aeration
Holding
TANK SETBACK INFORMATION
TANK TO
P / L
WELL
BLDG.
Vent to
Air Intake
ROAD
Septic
NA
%;W& 3
> 159
L
O'A
NA
Aeration�
Holding
PUMP/ SIPHON INFORMATION
�4<u f actu rer
M&Iel Nu
TDH Lift f r i ric stem
L.
_-S�Ls I
Forcemi ength ]::D :ia
SOIL ABSORPTION SYSTEM
Demand
GPM
TDH Ft
County.
St. Croix
Sanitary Permit No.:
353132
State Plan ID No
Parcel Tax No
042--1075-60-000
STATION
BS
HI
FS
ELEV_
Benchmark
-0, 04:'
10-D " 0
Alt. BM
Bldg. Sewer
St/ Ht Inlet
St / Ht Outlet
. ....... I
gt Inlet
ga ss
:5t Z
- *3 Z,
CtZ (01
Header Man.
ti.
Dist. Pipe
H 19 .7-3
g-+ - 99
Bot. System
t3 - 34
3
RG .5-9
Final Grade
0
Z!ZZ-0 ,
St cover
Dist. To Well �� I
L A Uj.,� )
Width
Leng&,.,
No Of nches
PIT
No Of Pits
inside Dia.
Liquid Depth
DIME I '0W
DIMENSIONS
SETBACK
SYSTEM TO
P L
BLDG
WELL
LAKE / STREAM
LEACHING
Mari uf actu�er:
_
INFORMATION
CHAMBER
Typeof
model Number:
System:
I ci
I
> LCO
-1
1 OR UNIT
DISTRIBUTION SYSTEM V
Header /Y anifold
Distribution Pipe(s)
x Hole Size
X Hole Spacing
Vent To Air Intake
length Dia it
1 7'Spicing '
F_ I
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Zf—
r_ 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.) Inspection # 1: 10 / 147/ 9j Inspection #2:
Location: 742 130th Street, Roberts, WI (NEI/4, SEI/4, Section 27 T29N-R18W) - 27.29.18-427B
3
'T
I�
A 41n
At La (4--
Plan revision required? Yes No
Use other side for additional information. [` �, f �°
SBD-6710 (R.3/97) Date Inspector's Signature Cert No
' .
r Safety and Buildings Division
SANITARY PERMIT APPLICATION 201 W. Washington Avenue
Nvisconsin P 0 Box 7302
Department of Commerce In accord with ILHR 83.05, Wis. A e Madison, WI 53707-7302
0 Attach complete plans (to the county copy only) for the system, on paper not less
County
than 8 112 x 11 inches in size.
0 See reverse side for instructions for completing this application
State 5a itary Permit Numb
353
Personal information you provide may be used for secondary purposes
t] Check revision to previous application
lPrivacy Law, s, 15.04(1)(m)].
State PI n I.D. Number
I. APPLICATIONINFORMATION - FLEAE PRINT ALL INFORFANT1.1
Property Owner Nam C
Propert L ca ion
To N', R E
Zj (or
Property OAner's Mailing Addre S
Lot'bar
Block Number
City,
Z
,aCode
, V 0,2 3
2
Phone Number
Subdiv sion Name or CSIVI Numbe
s
11. TYPE OF BUILDING: (check one) ❑ State Owned f-1 C 1. t Nearest Road
[�3 Village
Publlc2ll or 2 Family Dwelling - No. of bedrooms E];,,Town OF
Ill. BUILDING USE: (if building type is public, check all that apply) Pa el Tax Number(s) cQ '07 - 1A T q21 6
1 ❑ Apartment/ Condo
2 F] Assembly Hall 6 El Medical Facility/ Nursing Home 10 F] Outdoor Recreational Facility
3 E] Campground 7 E] Merchandise: Sales/ Repairs 11 E] Restaurant/ Bar/ Dining
4 Ej Church / School 8 F1 Mobile Home Park 12 E] Service Station / Car Wash
5 0 Hotel/ Motel 9 El 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. [:] New 2. Replacement 3. E:] Replacement of 4. E] Reconnection of S. E] Repair of an
------System ystem ------------- Tank Only --------------- Existing System --------- Existing System
B) F1 A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF STEM: (Check only one)
Non -Pressurized Distribution Pressurized Distribution Experimental Other
11 E] Seepage Bed 21 ❑ Mound 30 E] Specify Type 41 [] Holding Tank
ij��eepage Trench 22 ❑ In -Ground essure 42 Pit Privy
—
&0-
13 [:] Seepage Pit 43 Vault Privy
14 ® System-In-F" I 7 "-,r_ , �;
VI. ABSORPTIOtICYSTEM 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.) Pro used q. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation
5— 5' Feet
VII. TANK
INFORMATION
Capacity
in gallons
Total
Gallons
# of
Tanks
Manufacturer's Name
Prefab.
Concrete
site
Con-
steel
Fiber-
glass
Plastic
Exper,
App-
New
Existin
structed
Tanks
Tanks
Septic Tank or Holding Tank
��o
t-1) e2z
An-
El
El
El
1:1
1:1
_
Lift Pump Tank /Siphon Chamber
I
El
El
i El
El
El
El
Vill. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for installn of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print)
Plumber's Si r No Stamp
MP/MPRSW No.
Business Phone Number:
do
Plumber's Address (Street, City, Stat Zip Cod Z;C Z2 2=4
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sapitary Permit Fee (includes Groundwater Date Issued Issuing Agent Signature (No Stamps)
53Approved Ej Owner Given Initial ip, Surcharge Fee)
Adverse Determination
X. C =NDIIIONS OF PPROVAL REASONS FOR aIS PPROVAL:
WOMEW4.
SBD- 6398 (R. 11/97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
r
r
PLOT PLAN
PROJECT David Haselman ADDRESS 742 130th St. Roberts W i 54023
NE 1/4 SE 1 /4 S 27 /T 29 /R 18 ' TOWN Warren COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 9/30/99 BEDROOM 3
CONVENTIONAL )C)OC IN-GRO D PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 Gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .5 ABSORPTION AREA 954 # of chambers 30
IL BENCHMARK V.R.P. Base of Siding ASSUME ELEVATION 100'
DBOREHOLE WELL *
H.R.P. Sam Benchmark a as hmrk e c a
SYSTEM ELEVATION ,
Alto BM 9remn ^f A;,- n.,ra;+ir.r,ar 1 (In n 9 r�Vent
Existing 3 > 12" Sidewinder High
ell g Capacity Leaching
Bedroom of Cover p
200' House Chamber with 31.8
rLongft^2 per chamber
16"
Alt. Grade at System Elevation
ls,�-M- B.M. 34„
ppl-
+..; Old Tank to be pumped and buried
&n T Baffles were not found m existing tank
0 30' Vent
en
Ponding Water found at
T ground surface,
system has failed
100'
' B-1 40'
kh-
FF-
75'
0'
Vents
50'
125'
6%
Slope
Property Line
Vents
2- 3' X 98' Trenches with 6' Spacing
Wisconsin department of Commerce
SOIL AND SITE EVALUATION
Division -of Safetyq and Buildings
Bureau of Integrated 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 inchesin Size. Plan must
County
include, but not limited to: vertical and horizontal reference point (BM), direction aryd
percent slope, scale or dimensions, north arrow, and location and distance to nearest roo&? Parcel 1. D. #
APPLICANT INFORMATION - Please print all information.'--,` E , ?, , -R 1.iewed by
�9
Personal information you provide may be used for secondary purposes (Privacy
Prop` 01A Property Owner P POY Lo
0vt 'Lot 1 /4 1 4, S
4r do
Property Owner's Ma ling Address k k# Subd. Name or CSM#
mom
/ I mow
city State Zip Code Phone Number❑City ❑ Village 4Q Town
10
40-23
Page of
S-- by
Date
T ***? 9 , N, R / � E (or
Nearest Roa
/ :77 ,, ;: I,<;
k New Construction Use: residential / Number of bedrooms 3 Addition to existing building
New
E]Public or commercial - Describe:
<0
Code derived daily flow Y_S�_o gpd Recommended design loading rate bed, gpd/ft� 9trench, gpd/ft2
2 ?0I
Absorption area required S' bed, ft2 4�/�7 C70 ft trench, Maximum design loading rate bed, gpd/ft _ trench, gpd/ft2
6�1 o
Recommended infiltration surface elevation(s) E7 4rc ft (as referred to site plan benchmark)
Additional design/site considerations
Parent material �e�: 0100-0, Flood plain elevation, if applicable ft
Conventional Mound In -Ground Pressure AT -Grade System in Fill Holding Tank
4
S Suitable fors ystem Je
U Unsuitable for system S ❑ U S Ei U S0 U S[:] U [:] S e U ❑ S 3<U
Ground
lev..t.
J;_
-1� e th to
-IV*,,
limiting
factor
/�in.
SOIL DESCRIPTION REPORT
Horizon
Depth
in.
Dominant Color
Munsell
Mottles
Qu. Sz. Cont. Color
Texture
Structure
Gr. Sz. Sh.
Consistence
Boundary
Roots
GPD/ft2
Bed Trench
09_tt1-__
.01
-ID
001,
10
vul 1..z-
k, IN4 OY.
N7
I IV
J
Remarks:
=PAO,
mma
=or,
FA4 ®r
Remarks:
' OIL DESCRIPTION REPORT
PROPERTY OWNER
PARCEL I.D.#
1 ,
Page" o� .
1
Boring #
Ground
e v.
D ft.
Depth to
limiting
fact r
.
e-1>126J I
901,
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in.
Boring #
blev.
ft.
Depth to
limiting
factor
in.
Boring #
Ground
elev.
ft.
Horizonm'
Dominant Color
Munsell
Mottles
Qu. Sz. Cont. Color
Structure
Gr. Sz. Sh.
Consistence
Bed Trench
O�II�''rr�l�l!l1�Iil
F'-0'a�!1T.�l
m
pwd '
0►�l��ilf1�.lAl��►�J�;'lr�Ji�IL'�J�
Remarks:
Remarks:
Horizon
Depth
in.
Dominant Color
Munsell
Mottles
Qu. Sz. Cont. Color
Texture
Structure
Gr. Sz. Sh.
Consistence
Boundary
Roots
GPD/ft2
Bed , Trench
ILI
Y
t
Depth to
limiting
factor
in. Remarks:
Remarks:
- �XK
SBD-8330 (R. 07/96)
rSoil TPlot Plan
Project Name David Haselman Shauns
!
Address 742 130th St.
Roberts Wi 54023
CSTM'#226900
Lot ---- SubdivisionDate 8/30/99
NE 1/4 SE 1/4S 27 T 29 N/1318 W Township - Warren
❑ Boring Q Well PL Property Line County ST. CROIX
kBMorVRp Assume Elevation 100 ft. Base of Siding
System Elevation 86.5 *H R P
Alt, BM Tap of Air Conditioner @ 100.0'
M
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
This is to certif that I have inspected the septic tank presently
A
serving the residence located at:
jf %, , ,. =s , Section T N R W, Town of
Upon inspection, I certify that I have found
the tank and baffles to be in good condition, and it appears to be
functioning properly.
Last time serviced: ��` % ��
Did flow back occur f m absorption system?
Yes No (If no, skip next line)
Approximate volume or length of time: gallons minutes
Capacity:
(.-j e Other
Construction: Prefab ConcreteA, st-
Manufacturer: (If known):
Age of Tank (If known).:
(Signature)
(Title)
Date
T)til 0& '5 /0'1/0"Oj�po k
(Wai'rie) Please print
(Li(.---ense Number)
Form to be completed by licensed plumber (s.145-06, Wisconsin
Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative
Code)
Plumber (applying for sanitary permit) Certification*
In accepting the above statement regarding existing septic tank.
condition, I certify that the tank to t�,ke best of my knowledge will
conform to the requirements of ILHR 83, WisAdm. Code (except for
inspection opening over outlet baffle).
Name,,, signaturf, MP/MPR3.
SYSTEM ELEVATION AND SIZING CALCULATIONS
Below Grade Chamber Soil Absorption Systems
Permit Number 10/4/99 jDate
X WXW Gravity Distribution
only 1 Pressure Distribution
3 ft Suitable Soil 1 Note 1: Bury depth as per manufacturer
18 in Chamber Height 2
8 ft Maximum Bury Depth 3
ff450 gpd
0 gpd/ft2
0
86.50 ft
Estimated Daily Peak Flow
Wastewater Infiltration Rate
Down Sizing Credit
Proposed SAS Elevation
900.0 ft2 Code SAS Size
360.0 ftReduction (-)
540.0 Ift2Min. SAS Size
Soil
Boring
Number
Surface
Grade
Elevation (ft)
Limitation
Depth (in)
SAS Elevation (ft)
Acceptable
System
Elevation?
Finished Grade EL 4 (ft)
Minimum
Maximum
Lowest
Highest
89.50
96.00
1
92.50
T70
84.67
90.33
Yes
2
90.00
110
83.83
87.83
Yes
3
91.00
110
84.83
88.83
Yes
1. Depth of suitable soil required below the infiltrative surface for treatment.
2. Total height of chamber in inches.
3. Maximum bury depth as per manufacturer's recommendations.
4. Based on chosen system elevation, and chamber height. Top of chamber is
equivalent to top of aggregate. The addition of fill for cover or the reduction of
finished grade may be required to meet minimum or maximum code standards.
SBD-10553-E (R.05/98)
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
iRSHIPCERTIFICATION FORM �� � / � � � -� b
I
l ,
Owner/Buyer
Mailing Address2falz_
Property Address
(Verification required from Planning Department for new construction)
:11 7
City/State �4
Parcel Identification Number
LEGAL DESCRIPTION
Property Location /)/2!� '/4 V4, SeQ2Z
0
��N-R Town of
Subdivision ..,Lot#
Certified Survey Map # Volume Page # aq t b
Warranty Deed # 6Volume Page# 7 Z
Spec house 0 ye no
Lot lines identifiable 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
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 yseptic system has been maintained must be completed and returned to the St. Croix County Zoning office within 30
days of th, ee yearf.expi tion dat
SIGNATURE 0F'"kPPL DATE
OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the best of my (our) knowledge.
the prope escribed a ove, by e of a warranty deed recorded in Register of Deeds Office.
ATURE:-bf APPLICANT
I (we) am (are) the owner(s) Of
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