HomeMy WebLinkAboutSAN-2024-130 038-1075-90-100County Sanitary Permit Application
ST. CROI%COUNTY WISCONSIN
In accord with Chapter 12 St. Croix County Sanitary Ordinance
COMMUNITY DEVELOPMENT DEPARTMENT
ST CF; sonal information you provide may be used for secondary purposes
ST. CROIX COUNTY GOVERNMENT CENTER
[Privacy Law. S. 15.04(t)(m))
1101 Carmichael Road.
Hudson, WI 54016-7710
(715)386-4680 Fax(715)245-4250
A ach complete plans for the system on paper not less than 8.112 x 11 inches in size.
Coat y
ry Permit # ❑
Check if revision to previous application
StCto4
SAN-2024-130
-2ta q - J0
I. Application Information - Please Print all intormation
Location:
Property Owner Name11
Ii1 ' 1!4 114, 5eC _
r
T _� N, R E (or6
2 Z�?L
Property Owner's Mailing Address
Lot Number
Block Number
City, State
Zip Code
Phone Number
Subdivision Name or CSM Number
it T pe of Building: (check one)
[]City ❑ Village ZTown of
1 or 2 Family Dwelling - No. of Bedrooms:
❑ PubliclCommercial (describe use): Zone X
Nearest Road /]
�f r
❑ State-owned
N. Type of Permit: (Check only one box online A. Check box online B if applicable)
Parce Tay, Number(s)
1� Repair 2.M Reconnection 34]Non-plumbing 4.[]Rejuvenation
A)
_
Sanitation
Permit Numbgr
Date Issued
e)
❑ State Sanitary Permit was previously issued S�
`� — f
IV. Type of POWT System: (Check all that apply)
W Iilimiii pFessinik--a 1p ,....,.pa t] Mound > 24 in. sulsable sail ❑ Mound s 24 in. suitable sosl ❑ Mound A+0
❑ Sand Filter ❑ Constructed Wetland ❑ Float Filter ❑ Drip Line
❑ Pressurized In -ground ❑ Holding Tank ❑ Single Pass ❑ Other
E] At -grade Q Aerobic Treatment Unit ❑ Recirculating
V. DispersalfTreatment Area Information:
1. Design Flow (gpd)
2. Dispersal Area
3, Dispersal Area
4. Soil Application Rate
5. Percolation Rate
5. System Elevation
7, Final Grade
Required
Proposed
(Gals. /daylsq.ft.)
(Min./inch)
Elevation
VI. Tank Information
Capacity in Gallons
Total
# of
Manufacturer
Prefab
Site Con
steel
Fiber-
Plastic
Gallons
Tanks
Concrete
structed
glass
New
Existing
Tanks
Tanks
<y
❑
❑
❑
❑
❑
❑
❑
❑
❑
VII. Responsibility Statement
I, the undersigned, assume responsibility for repairrreconnection%rejuvenation/installation of non -plumbing for the POWTS shown on the attached plans. A
license is not required for terralift repair or the installation ❑ non -plumb n anitatia system.
Plumb s Nam Mpt)v
Plumber's t rq ❑ p
MP/MPRS No.
Business Phone Number
Plumber's dress (S-trget, 9� y, State, ode)
c� 1 4 ,
Vill. County Use Only
Sanitary Permit Fee
Date issued
Issuing Agent Signature (No stamps)
Approved
�roved
Give dverse
$ Z 1S,
513%
30 / �O Zf
Determination
IX. Conditions prov al:
SYSTEM OWNER: 3) Existing septic tank, dose tank, and mound system must be certified by
1. Septic tank, effluent plumber.
an flter and dispersal cell
t 4) Plumber to contact staff after reconnection is completed, to update the
must serviced maintained as per
POWTS files for this property.
management plan provided by plumber.
5) All required setbacks to/from well must be maintained.
2. All setback requirements must be maintained
as per applicable code 1 ordinances
Rev: T21
SAN-2024-1�
7�
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MMi401*1
SAN-2024-130
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j w/opener wlopener
j 10' x 10' 12' x 12' 7100
Ins Overhead Door Ins Overhead Door I
I
3' 3' 6' 6'
_________ ______I I I
-- _.--_------_ .—_ __—_---24" Boxed Soffit & Fascia Overhangs on 4 Sides j ----- — -----
30'x4'x4` Concrete Apron I I I
{ � I
I t01 I
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8' 8' 8'
John Holt
40' x 60' x 13"4" Ceiling
$55 220th Ave
Somerset WI 54025
6' o.c, eave pasts
6' o.c. Trusses
a'
40'x60'x4" Concrete Floor on 2" Foam + Neat Tubing
1 OWOW' wrap around porch wlsteel ceiling
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and Building Division
INSPECTION REPORT
GENERAL INFORMATION (ATTACU TO 9.�RMIT)
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)).
Permit Holder's Name:
City Village X Township
Holt, John
Star Prairie Townshi
CST BM Elev:
Insp. BM Elev:
BM Des ptior /
TANK INFORMATION
TYPE
MANUFACTURER
CAPACITY
Septic
%�
i- �
/ Z v o
Dosing
r �_ _ 1 b
Aeration
Holding
TANK SETBACK INFORMATION
mpg
wanow
PUMP/SIPHON INFORMATION V aCy
Manufacturer T -14 n n Dbii and I I
mociel NumDer BI v � 0 Y 40
TDH Lift . (` rictio�Lo�s 1 � System ,1A, N T a,+, D i t
II o q0imain� 1L� to IUla isluisr, to vven N �� r j I
ON SYSTEM
oll
ELEVATION DATA
County: St. Croix
Sanitery Permit No:
453396 0
State Plan 10 No:
Parcel Tax No:
SecHon/rown/Range/Map No:
18.31.18.
STATION
BS
HI
FS
ELEV.
Benchmark��
Alt. BM
, �
g
96•
Bldg. §ewer
yv
St/Ht Inlet
Ckt C110
SUHt Outlet
Dt Inlet
Dt Bottom
Hea7e—rMW.•��
Dist. Pipe
3.
Iv_ S
Bot. System` D o.
Final Grade
2-1
co3.
T Cover
r 6i Is: r
rSQ i/s
-tom
1
-%-
�• Zi
`J
S, (o
V � jy►� � y, t
� t-o oS
BED/TRENCH
DIMENSIONS
Width
Length
r
No. Of Trencchheess`/
PIT DIMENSIONS
No. Of Pits
Inside Die.
Llquld Depth
SETBACK
INFORMATION
SYSTEM TO
Type Qf System: /
P/L
UL)�/
BLDG
IWELL
LAKE/STREAM
EACHIN
CH
UNIT
Manufacturer.
Model Number.
DISTRIBUTION SYSTEM Va,& . ,21/,_
1Header/t t ngold-""
Distribution /
/�
Length
x Hole Siz
Ix Hole Spacing
~
V/eMto-Air Intake
1-ength_ Dia 2
' r Dia Spacing _
7i
2
; /
SOIL COVER x Pressure Svstems Only xx Mound Or At -Grade Svstems Only V N a c f AaAi2?
Depth Over
Depth Over
xx Depth of
xx Seeded/Sodded
xx Mulched
Bed/Trench Center LSa
Bedlrrench Edges
Topsoil
[] Yes No
[ Yes l J No
S
an
COMMENTS: (Include code d'screpencles, persons present, etc.) Inspe ttiion�#1:`` }� / Inspection #2: /� 7 /dy
/
Location: 855 220TH Ay.Q Unkno n (NW 1/4 NE 1/4 18 T31N R18W) NA Lot 1 ` vv "L e Parcel No: 18.31.18 .
1.) Alt BM Description = U
2.) Bldg sewer length = Lff�i' i l ` T►cv•
- amount of cover+= !!� vo , n - Wv- G
3.) Contour = Ctgwr� 1-4/
Plan revision Required? Yes ,.. No
Use other side for additional information. --
Date Insepctor's SI ure Cart. No.
Safety and Buildings Division
7162
County J -i - - --- - - -
1 h
vis
N(608)
201 W. Washington Ave., P.D. Box
� ,
Madison. Wl 33707 - rl162
Sanitary Permit N=*ex (to be fid in try Co.)
2.66-3151
S 3 3q�o
Department of Commerce
Sanitary Permit Application AID
Mate PYui I_D. Number
Dl
in accord with Comm 83.21. WiL Adrm. Code, peraenal infomution your prtivi
may be used for secoodaty purposes Pmacy Law, 6I5-KI xtn)
project Addr= (if different that[ maitiug *Micss)
I. Application Indorm flon - Please Print All Iaformtio
grope ty otvt es Name L
I U L 1 'J f J I-1
parr el Block tx
/7
Pro perty Qwrrx's Mailing Arldrrss
Locatxan
City stam Zip Code
1220 crC/
Phone Number
Ttk N.TT"
W
or Building (dmecl{ that apply) °�' �' '''"
csM
prmillr Dwe]ling - Numtxx o' ms
r
(v 1 �' �+ `{{� ` � 2-2
PabIk0Coam tl -- Describe U— e K �S
`n ' = °
city- V-a4r; "''Wp r�
State awned - Use
In Type t'crudt; (c ede only one box on Iim A. Compt� ling B if ■Pptkark)
A.
Sn m
Repl-cmeta Systarn
TreatmantMoking Tdc Rrplaaematrt Only
Other modificadoo to Exbduf Syzk=
List Prsvious Permit Number and Dam LmW
B.
permit Renewal
permit Revision
ChaW of
rcrit Trensfar to New
Before Expiration
plumber
G�
peof poWTS 5 Cinch all that apply)
YV.
Nan la rourui � 24 in. of suiuble soil Maud c 24 it of suitable soft
At-Cirade singie Pass sand Filter
construaW Wedand pressurized lo-Cround Holding Tank Peat Fi1wr Aerobic Tit Unite Ronrwi np�5aod =f
1J7
s Me&aFruter Chambet Dsi Line Gravel-ka Pi Other
r�Arra Proposed (s)
V. N ttmnt Area Informalwm
Desigp now (Spd) D*p soliFaw
ystem
LJO
f / C
�'
. rI
VI. Tank Infot7'
Gallons
prefab
sloe
Coasbucsed
steel
Fiber
GlrssNorw
Piasttc
Eatw°a
ran"
Tadcr
Sepbc or itoUft Tack
y
Aaa6ic irutnioae Uait
Vu Rrspondbtllty
plitml s Nam (Print)
��
the bill for rngtanatlan of the rOW S dwamn an the attaeied
pl-
plumber' MP/i►iPRB Nurrberr Bttrti¢ress Pbov
vII� [. co t Use onI m JUVW
sanitary permit Fee [itmciudcat Grottadwasa
Appmved Surctwgc Fee] t Tin
3 r
Giwta Reas«r
I7C. C md1dow of Approval/Rewoas for disttpprorsi
SYSTEM OWNER;
1 Septic tank• effluent filter and
dispersal cell must all be serviced / maintained
as per management plan provided by [slumber.
2. All setback requirements must be maintained
as per applicable code/ordir<i11,:t'::
Ana& pleas (to the C—aq �) I" the s� as Paper cot le. arcs iUZ z tl inches is atae
PA Siaadree ( v shMPS3
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CERTIFIED SURVEY MAP
LOCATED IN PART OF THE NW1/4 OF THE NE1/4 OF SECTION 18, T31 N, R18W,
TOWN OF STAR PRAIRIE, ST. CROIX COUNTY. WISCONSIN, INCLUDING LOT 41 LOT
3. AND PART OF LOT 2 OF A CERTIFIED SURVEY MAP RECORDED IN VOLUME 1,
PAGE 197, AT THE ST. CROIX COUNTY REGISTER OF DEEDS OFFICE.
SURVEYOR:
DOUGLAS J. ZAHLER - —
S & N LAND SURVEYING, INC.
2920 ENLOE STREET
HUDSON. WI 5401E 220th-A_ v_._
N1/4 COR.-
SEC. 18 o. 331.4T -09
PL�G1vv(21D
S88`39'08"E 2633.53'
NORTH LINE OF THE NE1/4-
(EAST)
88°39'08"E 857.83'
OT 1
5.038 S
( 56 SO. FT.)
4.787 ACRES
i
(208,51a SO. FT.)
C. R/W
LOT 4 icy
6.00E ACRES
(281,606 SO. FT.)
INC. R/W
5.980 ACRES
(260.617 SO. FT.)
EXC. R/W
48
858.07' 3f
t -33.00' 361.58' 99.02't
..... I46O.60'
. •.�EXISTINC±... • ...c
50 ' DRIVEWAY
/ EXISTING
HOUSE
e-WELL
WELL ? �.
�i SEPTIC_ G
•m VENT ''+b EXISTING
:�l LOT 2 GARAGE
33' 6.978 ACRES
(303,946 SO. FT.)
INC. R/W
6.629 ACRES
(288,750 SO. FT.)
EXC. R/W
-� 66.0a
S89°17'32"E
�
2So
m
y
LOT 3
8.109 ACRES
(353,242 SO. FT.)
g
INC. R/W
75'
8.084 ACRES
Z
SETBACK
(362.153 SO. FT.)
EXC. R/W
I N88'42'42"W : — \
SOUTH LINE OF THE NW114 OF THE NE114
— T —
APPROVED
ST. CROIX COUNTY
pWwft ZZrk4 Hy Ppk, COMMI ME
MAY 1 2 2004 O
If not nWOrdad vAthin 30 days of
al data aappppm�o&v shall be
SCALE IN 1rYtr�a
Fm No
200 0 200
THIS INSTRUMENT DRAFTED BY: WILLIAM KANE
JOB NO. 6351-01 DATE: 10/28/2003 REVISED: 05/11/04
867.26'
'?62iF—�86
VOL 18 pA(3E 4746
KATALfiEfi H.WALSH
REGISTER OF DEEDS
ST. CROIX CO. MI
RECEIVED FOR �tECORD
05/12/2004 09s25AM
CERTIFIED SURVEY MAP
REC FEE s 13.00
COPY FEES 3.00
PAGES; 2
PREPARED FOR:
BRIAN VOGEL
1705 VICTORIA RD. SO.
MENDOTA HEIGHTS, MN 55118
NE COR.
SEC
___ 18
17Y — . 7s.7a
1 1' IRON PIPE FOUND
S13'02'68"W 3.3&
FROM SET 1' IRON PIPE
OWNER:
KEITH VOGEL
861 220TH AVE,
SOMERSET. WI 54025
z
Nm2
a
AOW
oz m
iR
Imo'"
�^A�
r
40
I
0
z T
40
I Q
1�
Z
DOUGLAS J. Z
ZAHLER
5-2145
LEGEND "
FOUND ALUMINUM COUNTY SECTION
CORNER MONUMENT
FOUND 1" OUTSIDE DIAMETER IRON PIPE
SET 1' OUTSIDE DIAMETER BY 18' LONG IRON
PIPE, WEIGHING 1.13 LBS. PER LINEAR FOOT
BUILDING SETBACK LINE (AS SHOWN)
RECORDED BEARING AND/OR DISTANCE
68' WIDE JOINT DRIVEWAY EASEMENT
FOR LOTS 3 AND 4
EXISTING FENCE
® SOIL BORING
SHEET 1 OF 2 SHEETS
Vol 18 Page 4746
PLOT PLAN
CT John Holt ADDRESS 6421 134th St. W. ADDle Vallev Mn 55124
1/4 NE t /4S 18 /T 31 N/R 18 W TOWN Star Prairie COUNTY ST. CROIX
MPRS Shaun Bird 2269M DATE6/30/04 BEDROOM 4
CONVENTIONAL AT -GRADE CONVENTIONAL LIFT HOLDING TANK
MOUND XXX SEPTIC TANK SIZE 1255 gallons LIFT TANK SIZE DOSE TANK SIZE 765
HOLDING TANK SIZE J OAD RATE 1.0 ABSORPTION AREA 600 # of chambers none
® BENCHMARK V.R.P. Top of 2" pipe ASSUME ELEVATION too' Filter Zabel A-100
❑ BOREHOLE O WELL sH.R.P. SameasBenchmark
SYSTEM ELEVATION 100.2' 1.1' Sand Ilft
220th Ave
630'
Property
Line
Scale = 1 /4" = 10'
Tank is to be properly
bedded and provided with
B.M. 1 * B -1 lockdown covers with
CJ Grading is to be approved warning l E
B.M. #2 to divert run-off B - 2
Top of 2" pvc away from system �cS�
pipe @ 100-Y
n
B-3
Area 15' below i' 3%
system is to remain Slope
undisturbed
Please note: contours
were field verified
before design
Pro 4
Bedroom
House
/ Huffcutt Combo Tank
99.1'
ml
Well is to meet all
setbacks found in
Comm. 83
331' Property Line
S T, CROIX COUNTY-No. STC -:5AN -zozy-/so
SANITARYPERMpT
OWNER
r
PLUMBER K��„� ���,u LIC. # Z.2LZ�3
TOWN OF !jI_AfL kA(P[15 LOCATED
AluaL %y_ SEC �_ T 31 N;R�
AND/OR LOT
CS) MA ( /g-4i96
c
THIS PERMIT EXPIRES
TWO YEARS
POST
BLOCK
SUBDIVISION
REPAIR ❑
FREdbNNEC'TION I _ I
NON -PLUMBING ❑
SANITATION
REJUVENATION ❑
(a) The purpose of the sanitary permit Is to allow repair, reconnection,
rejuvenation, or installation of non-piumbing sanitation as described in the
application for permit.
(b) The approval of the santlary permit Is based on regulations In force on
the date of issue.
(o) The sanitary permit Is valid for 2 years from original date of issuance and
may be renewed for similar periods thereafter. Application for renewal shall be
made through the county and shall comply with regulations In effect at the
time.
(d) Changed regulations will not impair the validity of a sanitary permit until
the time of renewal.
(e) Renewal of the sanitary permit will be based on regulations in force at
the time renewal Is sought. Changed regulations may Impede renewal.
(f) The sanitary permit Is transferable. A sanitary permit transfer shall be
obtained from the St. Croix County Zoning Department.
If you wish to renew the permit, or transfer ownership of the permit,
please contact the St. Croix County Zoning Department.
AUTHORIZED ISSUING OFFICER- DATE
P'Z Z.DZ& UNLESS RENEWED BEFORE THAT DATE
R M ORIGli AL DATE OF ISSUANCE
..IN P-LAIN VIEW
VISIBLE FROM THE ROAD FRONTING THE LOT
DURING CONSTRUCTION