HomeMy WebLinkAbout012-1041-40-000
STC - 104
AS BUIL SANITARY SYSTEM REPORT
OWNER J
a ADDRESS
I/(,) P 5-4,1 7
SUBDIVISION / CS M# LOT #
SECTION__,~5_Tj_N-RW , Town of ST. CROIX COUNTY, WISCONSIN
33
PLAN VIEW
sSHOW EVERYTHING WITHIN 100 EET O SY TEM
1/Q
' 1,2
yOsct z ds:
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK: pa f ) y'
ALTERNATE BM:,~
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Liquid Capacity:
Setback from: Well House S`Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: Lc - Length LS-X Number of trenches
Distance & Direction to nearest prop. line: Z
Setback from: well House~~e other
ELEVATIONS
Building Sewer ST Inlet: ST outlet:
PC inlet PC bottom Pump Off
Header/Manifold _ZSa Bottom of system
Existing Grade Final grade DATE OF INSTALLATION: 7
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR:
3/93:jt
Wisconsin Dgpartmentof Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations
INSPECTION REPORT ST. CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sa n ita ry Perm it No.:
GENERAL INFORMATION 289353
Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.:
KIMLINGER, GERArLD ERIN PRAIRIE
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
012-1041-49-000
TANK INFORMATION ELEVATION DATA A9700370 3197
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic )~5 may' s> Benchmark 3 ~D /olJ. G~
Dosing
Aeration Bldg. Sewer 38'
Holding St/Inlet
TANK SETBACK INFORMATION St/W Outlet
TANK TO P/ L WELL BLDG. Ae Intto ntake ROAD Dt Inlet
Septic NA Dt Bottom
Dosing NA Header,hbba:
Aeration NA Dist. Pipe
Holding Bot. System 935 , y~S
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
Loss
Forcemain Length Dia. mead
Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Liquid Depth
DIMENSIONS DIMENSIONS
SYSTEM TO P/ L BLDG WELL LAKE / STREAM LEACHING Manufacturer:
SETBACK CHAMBER
INFORMATION Type O Moe Number:
System: OR UNIT
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 ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: ERIN PRAIRIE 18.30.17.270B,NW,NE 1559 160TH AVENUE LOT 1
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
Vsc'onsin Safety and Buildings Division
SANITARY PERMIT APPLICATION 22001 E. ~~hinngtonAve.
Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 1/2 x 11 inches in size.
• See reverse side for instructions for completing this application State/Saannitary Permit Number
The information you provide may be used b other government agency F99
y y by programs ❑ Check if revision to previous application
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION
Prop" Owner Name Pyoperty Location
_ , v >lt/4 1/4,5 T , N, R(or
Property Ow er's Mailing Addles Lot Number Block N ber
~
City, tate zip Code Phone Number Subdivision N me o CS umber
Ill. TYPE BUILDING: (check one) ❑ State Owned City Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms 3 o To wan OF I /
III. BUILDING USE: (If building type is public, check allthatapply) Parcel Tax Nuumbber(s) /
1 ❑ Apartment/ Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ 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. 0 New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ 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 IN Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM 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.) Propose (sq. ft.) (Gals/day/sq. ft.) (Min.%fnch) E[e ation
-7 .9
Feet Feet TANK Capacity
VII.
INFORMATION in gallonTotal # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
New Existing Gallons Tanks concrete structed glass App.
Tanks Tanks
Septic Tank or Holding Tank - ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the ndersigned, assume responsibility t pr inst atio 0 onsite sewage system shown on the attached plans.
Plum r' !7a:(( P t) Plum S Si u to s) MP/MPRSW No.: Business Phone Number.
1 I
Plu ber's Ac dre sit, C , State, Code):
s(
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate slue Issuing Agent Signature (No Stamps)
Approved ❑ Surcharge Fee)
Owner Given Initial
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
M-8398 (8.11/96) DISTRIBUTION: Original to County. One copy To: Safety 8 Buildings Division, Owner, Plumber
F
INSTRUCTIONS '
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/ Renewal Form (SBD-6399) to be submitted to the
county prior to installation
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever
necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of
Wisconsin, Safety and Buildings Division, 608-266-3151.
To be complete and accurate this sanitary permit application must include:
1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to be installed.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is public, check all appropriate boxes that apply.
IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested for numbers 1 through 7.
VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and
manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and
holding tanks for this system. Check experimental approval only if tanks received experimental product approval from
DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.),
address and phone number. Plumber must sign application form.
IX. County/ Department Use Only.
X. County / Department Use Only.
Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must
include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic
tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon
tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served;
B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume;
elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section
of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information.
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
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Wisconsin Department of Commerce SOIL-AND SITE EVALUATION
Division of Safety and Buildings Page of
Bureau•of Integrated Services , in accordatLCe. S. ILHR 83.09, Wis. Adm. Code
Attach complete site plan on paper not less an,8 1/2
MAY size: Pla must County
include, but not limited to: vertical and ho ' dal refere~ldire0'tion nil ~~C'✓~~
percent slope, scale or dimensions, north , and location and distance tq ne rest road. Parcel I.D. #
III MAY 0 8 199?
APPLICANT INFORMATION - PI rint atWi ationl Reviewed by Date
Personal information you provide may be used for c pm;i Aw is (1) (m)).
Props Owner Property Location
9 5 Govt. Lot 1/4 1/4,S/ff T N,R (or
Property Ow ;Ws Mailing Addres Lot # Blockij' Subd. Name or CSM#
City State1 Zip Code Phone Number ❑ City ❑ Village ® Town Nearest Road
I 1 )Q
New Construction Use: Residential / Number of bedrooms ~ Addition to existing building
Replacement ❑ Public or commercial - Describe:
Code derived daily flow g_Pd Recommended design loading rate ~ bed, gpde _z2 trench, gpd~2
Absorption area required bed, ft 2_5-3 trench, ft2 Maximum design loading rate , / bed, gpd/ft2~ trench, gpd/ft2
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design/site considerations n I
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 ,Z S❑ U .0 S ❑ U ~@S ❑ U j3S ❑ U ❑ S au ❑ S 9U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Ground / S
elleev~~ 5
Depth to
limiting
factff~~ff
~ %~in.
Remarks:
Boring #
jy 41
of
=2 ;2L
Ground - - n ,1 22.
elev.
Depth to
limiting
~facUto~r
.resin. Rem rks:
CST Name ( le Print) Signature Telephone No.
n - _ fly-5-
Address Date CST Number
L ` -
SOIL DESCRIPTION REPORT
PROPERTY OWNER Z4~9L~ Page ~ of
PARCEL I.D.#
Boring # Horizon Depth Dominant Color Mottles Texture structure Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
I s
13 0-17 Z22L411'.
-
Ground
R
Depth to
limiting
factor
Remarks:
Boring #
i
z2 _S
D
13
3 o,
Ground S X, S ZIP,
cis -
elev.
Depth to
limiting
factor
min.
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots PD/112
in. Munsell Ou. Sz.
Ccx) t. Color Gr. Sz. Sh. Bed , Trench
Boring # `;e
- S"_
El i 'A
Ground
F
e~le.~v
Depth to
limiting
factor
?'n• Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
'n• Remarks:
SBD•8330 (R. 07/96)
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N00°16'18"W 89.79' Bearings are-referenced to the
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER lQ~z r) 4z
MAILING ADDRESS
PROPERTY ADDRESS ~S S~ kl, ~n• 2;
(location of septic system Please obtain from the Planning Dept.
CITY/STATE Ae'Gr/
PROPERTY LOCATION N"I 1/4, /V4_ 1/4, Section T N-R 7 W
TOWN OF ~cJ ,4 6- ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
, VOLUME _~L, PAGE .SyLOT NUMBER
CERTIFIED SURVEY MAPS
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 licensed septic tank pumper. What you put into the system can affect the function of the septic tank
as a treatment stage in the waste disposal system.
St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost
of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that owners of all new systems agree to
keep their system properly maintained.
The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner
and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1)
the on-site wastewater disposal system is in proper operating condition and (2) after inspection and
pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum.
I/We, the undersigned have read the above requirements and agree to maintain the private sewage
disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR.
Certification stating that your septic has been maintained must be completed and returned to the St. Croix
County Zoning Officer within 30 days of the three year expiration date.
w
SIGNED/
DATE: Ci Y `rf '7
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
This application form is to be completed in full and signed by the
owner(s) of the property being developed. Any inadequacies will
only result in delays of the permit issuance. Should this
development be intended for resale by owner/contractor, (spec
house), then a second form should be retained and completed when
the property is sold and submitted to this office with the
appropriate deed recording.
Owner of property o ~~L'~~ T9 x-2
Location of prope rty_&~/1/4 IVr 1/4, Section T .--V N-R~W
Township g~~,~,¢IQ~ Mailing address
/ ~vE
Address of site
Subdivision name _ Lot no.
other homes on property? Yes No
Previous owner of property S.4r1te
Total size of property
Total size of parcel
Date parcel was created -94 -97
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house) ? _Yes A No
Volume L and Page Number ---~1F-- as recorded with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUME'NT NUMDEIZ, VOLUME AND PAGE
NUMBER AND THE SEAI. OF THE REGISTER OF DEEDS. In addition, a
certified survey, if available, would be helpful so as to avoid
delays of the reviewing process. If the deed description
references to a Certified survey map, the Certified Survey Map
shall also be required.
PROPERTY OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the
best of my (our) knowledge that I (we) am (are) the owner(s) of the
property described in this information form, by virtue of a
warranty deed recorded in the office of the County Register of
Deeds as Document No. and that I (we) presently
own the proposed site for the sewage disposal system or I (we)
obtained an easement, to run the above described property, for the
construction of said system, and the same has been duly recorded in
the office of the County Register of Deed: a!; Document No.
i atu eo1 A icant Applicant:
Dcite of Signature Date of Signature
5 30210 Sate Bu of.Within Fa~► 2 -,1
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