HomeMy WebLinkAbout016-1018-50-100
ST. CROIX COUNTY ZONING DEPARTMENT
AS BUILT SANI'T'ARY REPORT
Owner f/LC''
Address
City/State
Legal Description: f
Lot Block 3/79 i ~~✓ti^~N o,~ g-T
_ T Subdivision/CSM # VP/ uo ~
Sec. N-R n of / o ..PIT 0 v J7 U
SEPTIC TANK DOSE CHAMBER HOLDING TANK INFO ION:
.01
Tank manufacture Size ST/PJ44-:~)4 Setback from: HouseZ/~ Well l~~/La2 ~7a
Pump manufacturer Model
Alarm location
(HOLDING TANKS ONL
Setbacks: Service road) Vent to ce Water Line
Meter location
Alarm location
SOIL ABSORPTION SYSTEM:
l/
Type of system: Width.3 Length ,'6,as- Number of Trepches
Setback from: House ,4L-:~ ^ Well~~ Vent to fresh air intake e5d
ELEVATIONS:
Description of benchmark G~ Elevation,/ d
Description of alternate benchmark
Elevation, , l
Building Sewer S- ST/HT Inle ST Outlet PC Inlet
PC Bottom Header/Manifok(~
Top of ST/PC Manhole Cover _
Distribution Lines ( ) ( ) ( )
Bottom of System ( ) O ( )
Final Grade ( ) ` Q ( ) ( )
Date of installationoz &/yPer number ~J State plan number
Plumber's signature License number Dave? zlyl i
Inspector
complete plot plan
NOTICE: Please provide the f6llowing:
• 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.
PLAN VIEW
?rig Fr&Jf4
6 3 k°arv,,
i J
INDICATE NORTH ARROW
Wisconsin Department of Commerce
Safety and Buildings Division PRIVATE INSPECTION SEWAGE REPORT SYSTEM County
ST . CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Ple9M
Personal information you provice may be used for secondary purposes [Privacy L , s.15.04 (1)(m)J.
~MiLL 'e'MMN & BARB r7..fitu_C_l.l/,6be ❑ Town of: State Plan ID No.:
CST BM Elev.
: Insp. BM Elev.: BM Description: Parcel bite-;1018-50-100
r t A", Pze: /t_ 1
TANK INFORMATION ELE ATION DATA A9800280
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark I a/ lpv. dC)
Dosing
Aeration Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/Ht Outlet 6•
Vent
TANK TO P/ L WELL BLDG. Airito ntake ROAD Dt Inlet
Septic NA Dt Bottom
Dosing NA Header / Man. 9 3a 9
Aeration NA Dist. Pipe
5G 4t.b5/'
Holding Bot. System 16,76• qo .
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand Giuc-'-) 5. q -08
Model Number GPM
TDH Lift Fri n System TDH Ft
Forcemai ength Dia. H Dist. To wen
SOIL ABSORPTION SYSTEM
BED / TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS ~J 'z S~ -7 DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type 0 /k2,_d CHAMBER Moe Number:
System: p Q 3 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 E] Yes E] No ❑ Yes E] No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: GLENWOOD 9.30.15,NE,NW 2947 170TH AVENUE LOT 1
u
tL jyt ¢~V / y~
C. ) Ino
Plan revision required? ❑ Yes ❑ No
Use other side for additional information. J3 8 6
SBD-6710 (R.3/97) Date Ins ect s Signature Cert No.
ADDITIONAL COMMENTS AND SKETCH Y T
SANITARY PERMIT NUMBER:
i
• Visconsin Safety and Buildings Division
SANITARY PERMIT APPLICATION 22001 E. WahihinngtonAve.
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 v2 x 11 inches in size.
S+-
• See reverse side for instructions for completing this application State Sanitary Permit Number
6891
The information you provide may be used by other government agency programs El 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 RMATI N
Property Owner Name 1 Property Location
D Qb 1/4 "o/4, 5 T 2D , N, R 5E (or)40
Property Owner's Mailing A ress Lot Number Block Number
{its, State [ZirTode IPhone Number Subdivision Name or C Number
] L10101 55 t
11. TYPE BUILD IN (check one) ❑ State Owned ❑ ~t~ dr- Nearest Road
❑ Vil age
Public -grl or 2 Family Dwelling - No. of bedrooms wn OF D 62
111. BUILDING USE: (If building type is public, check all that apply) Parcel TaxlNu/mber(s)) `,j, 1 -ts g
1 ❑ Apartment/Condo ! 0~ 00
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) 1New 2. Q Replacement 3. E] Replacement of 4. E] 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 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12'2nfSeepage Trench 22 ❑ In-Ground Pressure f 42 ❑ Pit Privy
13 ❑ Seepage Pit f XD 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMA ON:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
G,, Re 2fired (sq. ft.) Pro osed sq. ft.) (Galstday/sq. ft.) (Min./inch) EI vation
l r 9~
Feet ,D .()Feet
_~l -j
VII. TANK Ca
in galloacits Total # of Prefab. Site Fiber- Plastic Exper.
INFORMATION New Existing Gallons Tanks Manufacturer s Name Concrete Con- Steel glass App.
structed
Tanks Tanks .
e tic Tank 1660 21 - ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ~ 1:1 ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber's Si nature: (No Sta ps) MP/MPRSW No.: Business Phone Number:
S s-a - b
Plum er' Addrgss (Stregt,~. S te, Zip_ Code):
;
up S'A no
IX. COUNTY / DEPARTMENT USE ONLY j
❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing ~tSi natu re,(No Stamps)
%Approved F1 Owner Given Initial 1 p r^ O0 Surcharge Fee) -?16
116 Adverse Determination l vv [ ~~O ~ti-
X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL:
SBD-6398 (8.11/96) otsTeteurtan: o.tytnat to county, one can To: safety a e„rd:rgs Division, Owner, Pkam er
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.
r
PLOT PLAN
PROJECT Vauan and Barb Voltz ADDRESS 1885 Countv Road D Emerald Wi 54012
NE 1/4 NW 1/4S 9 /T 30 N/R 15 W TOWN Glenwood COUNTY ST. CROIX
MFRSBYRONBIRD JR.3318 DATE7/6/98 BEDROOM 3
CONVENTIONAL XXX IN-G ND PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 Gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .8 ABSORPTION AREA 572 # of chambers 18
BENCHMARK V.R.P. Top of Nail in Birch ASSUME ELEVATION 1001
❑ BOREHOLE O WELL *H.R.P. Same as Benchmark
SYSTEM ELEVATION 90.6
877' Property Line
Alternate Benchmark @ 100' is top of nail in Birch Tree
Vent
X12" Sidewinder High
of Cover Capacity Leaching
Chamber with 31.8 69"
ft^2 per chamber
6' Long 16"
Grade at System Elevation
34" B.M.
5' Vents 6' Spacing between trenches B-2 34" X 54' Trenches y
140 25 5' 8% Slope
B-2 B-5
Rep A
Pro 3 89
B
edroom 15'
House 0' ST 330' 15
10' B-1 60 B_60 B-4 100'
Driveway Revision to plan # 289403
r 45%
Slope
Existing Soil test to be used 4,
as a replacement area. Test
was done on 6-19-1997 by '
Byron Bird Jr.
r
841' Property Line
Wisconsin Department of Commerce SOIL AND SITE EVALUATION
Division of Safety and Buildings Page of
Bureau of Integrated Services in accordanC with s. ILHR 8 09, Wis. Adm. Code
Attach complete site plan on paper not less than 8 1/2 x 11 i hts in size~,Plaa rust County
include, but not limited to: vertical and horizontal reference 1
Qin1.(BM), dtli~tr a~rcly
percent
slope, scale or dimensions, north arrow, and locati F a'o` d distance to nearest road. Parcel I.D. #
QQ
ffd4 rsr' P O O-
-/0
APPLICANT INFORMATION -Please print al (PlOrmati(M.,, Re 'wed Date
Personal information you provide maybe used for secondary purpos jPacy Law,Yi) (m)). ~j~
Property Ownert Propertn , v
S 9 T3v N,R E (o W
V Q-(~ (l~/ u(~ / ,'_..out L114 O1/4,
Property Owner's Mailing dress Block# Subd. Name or CSM#
12 SSA
/2<85- Co P_J 2 Mr ~1621
Cam State Zip Code Phone Number El City El village Town Nea st Roa
1~- 0) ~~0)2 c~15) d~ 7J ;e, le', o orft /
25New Construction Use: residential / Number of bedrooms Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow 1 gpd Recommended design loading rate bed, gpd/ft2___-_Etrench, gpd/ft2
Absorption area required 4 7' 3 bed, ft2 trench, ft2 Maximum design loading rate 7 bed, gpd/ft2. ?-trench, gpd/ft2
Recommended infiltration surface elevation(s) T ft (as referred to site plan benchmark)
Additional design/site considerations
Parent material ct.i Flood plain elevation, if applicable Al ) } ft
S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank
U = Unsuitable for system 19,S El U El U ~ ❑ U S ❑ U ❑ S ❑ S U
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
I 0 3 O P:0 P.
Ground .3 i
v
11I ft. , YV) A ' -8
Depth to
limiting
nctpr
"~,b in.
3, Remarks:
Boring #
6= s I rte' r f 6
Ov'
.3 r) rn Yr
Ground
lev/
124, 6 ft. ,
Depth to
limiting
factoy
19 in. Remarks:
CST e (Please Print) Signature s 7 Telephone No.
f r 15
11 1
Addr s Date CST Number
PROPERTY OWNER QGG SOIL DESCRIPTION REPORT Page bf
PARCEL I.D.#
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
Q
AUL
Ground
elev.
-Depth to
limiting
factor
in.
7W,
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in.
Remarks:
Horizon Depth Dominant Color Mottles Structure GPD/ft2
Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
Boring #
Ground
elev.
ft. ,
Depth to
limiting
factor
in. Remarks:
SBD-8330 (R. 07/96)
4 t
Soil Test Plot Plan
Project Name Vaugn and Barb Voeltz Byro Bird Jr.
'Address 1885 Co. Rd. D
Emerald Wi 54012 C M #3479
Lot 1 Subdivision Date 7/6/98
NE 1/4NW 1/4S9 T30 N/R15 W Township Glenwood
M Boring ()Well PL Property Line County ST. CROIX
BM or VRP Assume Elevation 100 ft. Top of 1/4" Rod with Pop Can
System Elevation 90.6 * H R P Same as Benchmark
877' Property
Alternate Benchmark @ 100' is top of nail in Birch Tree
69"
B.M.
5' o
B-2 15'
15'
25' B-3 8% Slop&-
Pro 3 B-2 Re A B-5
Bedroom 8' p
F House -2 330' 15 15' ' M.
B-1 60' B_0' B-4 100'
~ Driveway
C~ 45%
CD' Slope
Existing Soil test to be used
as a replacement area. Test
was done on 6-19-1997 by
Byron Bird Jr. o
CAD
r
841' Property Line
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count
Safety apd Buildings Division §T. CROIX
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitac29nHo.:
Personal information you provice may be used for secondary purposes [Privacy w, s.15.04 (1)(m)].
Permit Holder's Name: f 1ICii1c_[]OVillAge Town o : State Plan ID N
OELTZ, VAUGHN & BARB G r;Nw OU
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel 22018-50-100
TANK INFORMATION ELEVATION DATA A9700218
TYPE MANUFACTURER CAPACITY STATION HI FS ELEV.
j4f
Septic Benchmark
Dosing
Aeration Bldg. Sewer
Holding St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
Vent
ir Itnto ake R et
TANK TO P/ L WELL BLDG. A
Air
Septic N Dt Bott
Dosing NA Header/ n.
Aeration NA Dist. Pipe
Holding A N em
PUMP / SIPHON INFORMATION Final Grade
Manufacturer Dem d
Model Number GP
TDH Lift I Friction tem TDH Ft
L
Length Dia. Dist.Towell
Forcemain
I I F_
SOIL ABSORPTIO SYSTEM
BED/TRENCH Width Leng o. Of Trenches PIT No. Of Pits Inside Liquid Depth
DIMENSIONS DIMENSIONS
LEACHING Manufacturer:
SETBACK SYST TO P B DG WELL LAKE /STREAM
INFORMATI N TypeO CHAMBER model Number:
System: OR UNIT
DISTRIBUTIO YSTEM
Header /Manifold Distrib n Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Leng Dia. Spacing
SOIL COVER x Pre Systems Only xx Mound Or At-Grade Systems Only
Depth Over 7 Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMEN (Include code discrepancies, persons present, etc.)
LOCAT OI' GLENWOOD 9.30.15,NE,NW 2947 170TH AVENUE LOT 1
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD-6710 (R.3/97) Date Inspector's Signature Cert. No
ADDITIONAL COMMENTS AND SKETCH r
SANITARY PERMIT NUMBER:
s
' •r ,.KM M f
^®;I;^ Safety and Buildings Division
v■`r■n SANITARY PERMIT APPLICATION 20Bureau of Building Washington Ave. Systems
.
In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
Madison, WI 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less County It
than 8 112 x 11 inches in size. 5+. C r ci o--
See reverse side for instructions for completing this application State Sanitary Permit Number
02ff
The information you provide may be used by other government agency 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 INFORMATION
Property Owner Name Property Location
/1 :L E1 /4 l /4, S T, N, R) S E (or G
Property Qwrier's Wilma ddress Lot Number Block Number
Ci , State r Zi Code Phone Nu ber Subdivision Name or 'M Number
1,2 [~31-71
V
II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ city Nearest Roa
❑ Village
Public 1 or 2 Family Dwelling - No. of bedrooms 2_ Town of V Lam'
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo \N
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 / Mote[ 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 -56ew 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
1 rir45eepage 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
1 113 Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation
Feet /13 Feet
VII. TANK Capacity gallonTotal # of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
New Existing strutted
Tanks Tanks
Septic Tank or Holding Tank r El El ❑ 1:1 1:1
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plum ignature: (No Stamps MP/MPRSW No.: Business Phone Number: /
Plu is Address Street, City, te~Zi od
IX. COUNTY/ DEPARTMENT USE Y_ 41ZI,
❑ Disapproved Sanitary Permit Fee ('nduciesuroundwacer ate Issue Issuing Agent Signature (No Stamps)
XApproved 41 surcharge Fee) ,
❑ Owner Given Initial
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SB[)-6398 (R. 05/94) DISTRIBUTION: Original to Counly, One copy To: Safety & Binh ii rigs Divoi on, Owner, Plumber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit maybe 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) + nusi 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, 608-266-3815.
To be complete and accurate this sanitary permit application imust include:
I. 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) fora 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.
r
r
PLOT PLAN
PROJECT Vaughn and Barb Voeltz ADDRESS 1885 Co. Rd. D Emerald Wi 54012
NE 1/4 NW 1/4S 9 /T 30 N/R 15 W TOWN Glenwood COUNTY ST. CROIX
6/19/97 BEDROOM 3
MPRS BYRON BIRD JR. 3318
4Z 1
DATE
CONVENTIONAL XXX IN-GR ND PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 Gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 648 BED SIZE 12'X54'
BENCHMARK V.R.P. Top of 1/4" Rod with Pop Can ASSUME ELEVATION 100'
❑ BOREHOLE (DWELL *H.R.P. Same as Benchmark
VENT SYSTEM ELEVATION 99.3
12" GRADE
TYPAR COVERING
12" 3' 6' ®3'
i SEWER R K
12'
170th Ave 469' Property
00'
Slopes and Site will be
00
altered to meet code
for slope requirements
and setbacks
0
b
c~
` 12' X 54' Bed
B-2 8% Slo~ B-5
03
Bedroom 300' 15 Rep A 15'
House 30' T - - ' M. 100'
B-1 60' B-3 60' B-4
Site Must Be Cut and Fill Must Vent 5%
Be Added to the Downslope of to 0
System In Order to Make the 20' p c~
SetBack from >20% Slope and
Make the Sight a Slope of <20%
c~
530' Property Line
wisconsisi Department of Commerce SOIL AND SITE EVALUATION
Division of Safety and Buildings Page of
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 inches in size. Plan must County
include, but not limited to: vertical and horizontal reference point (BM), direction and 5 _ Gr0
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
APPLICANT INFORMATION - Please print all information. Reviewed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner Property Location
- n Y~ eZ Govt. Lot/ 1/4~'I/4,S T N,R l E J?c
Property Owner's ailing Address Lot # Block# Subd. Name or CSM#
~s it )'o ~ -
Ci State Zip Code Phone Number Nearest Road
/ ❑ City ❑ Village Town 170
x/0-1(7
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 bed, gpd/fi2L trench, gpd/fl2
Absorption area required Z&- bed, ft2 trench, ft2 p
Maximum design loading rate n Vbed, gpd/ft2 0 trench, gpdfft2
Recommended infiltration surface elevation(s) . c~ O ft (as referred to sit pl bench ark)
11 0/
Additional design/sit~erclonsiderations ~o <o~d /d XL
Parent material / / ~0=4-k Flood plain ele lion, if applicable fi//4 ft
S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in ill Holding Ta k
U Unsuitable for system S❑ U ❑ S U S❑ U ❑ S U ❑ S U ❑ S U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
/ in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Ground
ALA
_f P to
limiting
fac or
7in.
Remarks:
Boring #
C
0 5 6 in X~'j Al 1,4- AZ)d
Ground
/oe v. ft ,
~ept to
limiting
factor
in. Remarks:
CST N (Please Print) re Telephone No.
r> ~ rs~~~'~Y-~ r~
Address Date - CST Number
i Jr- d b _ c~
SOIL DESCRIPTION REPORT
PROPERTY OWNER Page _of
PARCEL I.D.# CJ
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistarx;e Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
3 0- 10~ r -S, 0s t-n A
Ground
olv.
A/ )J -01t.
Depth to
limiting
factor
n
' Remarks:
Boring # - 13
lJ
Ground
Depth to
limiting
factor
in.
r J Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/(l2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Boring #
Ground
elev ;
Depth to
limiting
factor
in. Remarks:
Boring #
L
Ground
elev.
ft. ,
Depth to
limiting
factor
'n' Remarks:
SBD-8330 (R. 07/96)
a. ' R
Soil Test Plot Plan
Project Name Vaugn and Barb Voeltz Byro ird Jr.
Address 1885 Co. Rd. D
Emerald Wi 54012 CS & #3479
Lot 1 Subdivision Date 6/19/97
NE 1/4 NW 1/4S9 T 30 N/R15 W Township Glenwood
F1 Boring Q Well PL Property Line County ST. CROIX
BM or VRP Assume Elevation 100 ft. Top of 1/4" Rod with Pop Can
System Elevation 99.3/94.8 * H R p Same as Benchmark
170th Ave 469'
Property Line
00'
00
0
ITJ
B-2 8% Slop B-5
03
Bedroom
House 15' pri A I Rep A 15'
330' .M. 100'
1-0 B-1 60' B-3 60' B-4 00
Site Must Be Cut and Fill Must Be
Added to the Downslope of Slope 0
System In Order to Make the 20'
SetBack from >20% Slope and
Make the Sight a Slope of <20%
c~
IL
530' Property Line
1
~ F~~ED s
NOV 0 8 1996 i►
Z KAT ig NH. WALH
Register of peels 9
St Croix Co., WI
55.918 ti
CERT IF I ED SURVEY MAP
LOCATED IN THE NE 1/4 OF THE NW 1/4 OF SECTION 9, T30N, R15W, TOWN OF GLENWOOD,
ST. CR01 X CO., WI
PREPARED FOR: RON BONTE
UNPLATTED LANDS
NORTH LINE OF THE NW 114
N 90°00'00" W N 1i4 CORNER OF SECTION
2 19 7. 52' 17,0TH 9. (COUNTY MONUMENTFOUND)
S90000' 00" E 467.36' 33. 12' w S90° 00_00" E 469.72' -33. 00'
NORTHWEST CORNER OF
SECTION 9. (COUNTY
MONUMENT FOUND) HIGHWAY SETBACK LINE
6
NOTE: BEARINGS ARE
REFERENCED TO THE
NORTH LINE OF THE NW
O m 0 I co
r~ ~ 1,,4. (ASSUMED).
10.00 ACRES
n (435,600 SQ. FT. )
- 9.65 AC. EXC. R/W
00 (420,138 SQ. FT.) Z
J: - CY :Z a"i-, " u & %.0 S
Co 17 O -p
C
M QD n
LLJ:
a: a z
13T, CROC4 CntUN*T'
N z r mhg and
Parks Cmm.ittz--
if not recorded
vvi'ntn 30 days of
approves date
°'ro a-1' sha'.l be.
N900 00' 00" W 529. 84' s~=01 a
NA G 0 /VS
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
/
OWNERBUYER
MAILING ADDRESS
PROPERTY ADDRESS _02 ~ - j inti C r2P L_
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE x, Gy /
PROPERTY LOCATION 1/4, 7 O 1/4, Section W
TOWN OF ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
CERTIFIED SURVEYMAPSS/ Y/® VOLUME AGE ="'17OT NUMBER
7~
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 a piratio date,)
SIGNED: '
DATE: Q ~a q
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
C 1v u
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 ~L}
property / C1JZ
Location of pro earty V /4 LAA14, Section ,T~N-R W
Township Mailing address C-Oal'
j~ • ,SL
Address of site 9
Subdivision name Lot no.
Other homes on property? Yes No
Previous owner of property
Total size of property
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable.? Yes No
Is this property being developed for (spec house)? Yes V No
Volume -)44- and Page Number _ -7,as recorded with the Register
38g
of Deeds!,)//
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
NUMBER AND THE SEAL 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
prcperty described in this information form, by virtue of a
warranty deed recorded in he office of the County Register of
Deeds as Document No. sq 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 Deeds as Document No.
1 Signature o Applican Co-Applicant
Date of Signature Date of Signature
r >
STATE BAR OF WISCONSIN F )R%4 I - 19th
I!JTY
DOCUMENT NO. VOL ~ j 1 PACEEI 9 L
HEu!J I La J Gf r,~
This Deed, made between Ronald C. b Dine M. Bonte i ,T CRCIIX CO., FYI
f pKti to naoora
O EC 3 1996
and Vaughn & Barbara Voeltz _ 9:45 A.M
_ Re24ster et Deus
Gt~srrJ
Witnesseth, That the said Grantor, for a valuable cortsideration
conveys to Grantee the following described real estate in Saint Croix THIS SPACE RESERVF FDA RECORDING DATA
County, State of Wisconsin: NAME AND RETURN ADDRESS
Ronald C. Bonte
Located in the NE 14 of the NW k of Section 9, 1011 170th St.
Hammond, WI 54015
T30N, R1514, Town of Glenwood, St.CRoix County, Wisccwsin
Lot 1 of a Certified Survey Map in
Volume 11 page 3179.
PARCEL IDENTIFICATION NUMBER
FEE
This is not homestead property.
(is) (is not)
Together with all and singular the hereditaments and appurtenances tner►•=.:I, aeinnging,
And the grantor
warrants that the title is good, indefeasible in fee simple and free and clear of en.-mrnea-..xs except
and will warrant and defend the same.
Dated this 18th day of November ,19 96
(SEAL) (SEAL)
Ronald C. Bonte./~ Yjmrjan Voeltz
(SEAL) (SEAL)
• Dine M. Bonte tam ara Voeltz
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) Saame of Wisconsin,
ss.
St. Croix County
authenticated this day of '19- remumnly came before me this 18th day of
Tivrember , 19_2_6 , the above named
)bsald C. Bonte & Dine M. Bonte
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not, ,,...r....
authorized by §706.06, Wis. Stats.) to ME 1 mwwm who executed the foregoing
itt~tresacae
THIS INSTRUMENT WAS DRAFTED BY
Ronald C. 13onte
R . .
t:
Wj%consin Department of Industry, SOIL AND SITE EVALUATION
•!aboPanti Human Relations Page of
Division tf Safety and Buildings in accordance with s.{ I~tl3'@ Wis. Adm. Code
y
Attach complete site plan on paper not less than 8 1/2 x 11 inches in si ~p1rt must County
include, but not limited to vertical and horizontal reference point (BM},c, W*tion a "d Gj^p~
percent slope, scale or dimensions, north arrow, and location and di a_QQ to nearest road. Parcel ,D. #
APPLICANT INFORMATION - Please print all infor'.bn. ReYiVX d by Date
_
Personal information you provide may be used for secondary purposes (PrivacyV15.04 (1) (m)).
Property Owner Property,,~i6ea#ion , '
Lot #r4 1/41S T Q N,R I S-E (o
!2 < Property Owner's Mailing Addre B Subd. Name or CSM#
City State Zip Code Phone Number
/ f El City ❑ Village X T Nearest Road
o
l~~lerul
~ew Construction Use: residential / Number of bedrooms Addition to existing building
0 Replacement T public or commercial Describe:
Code derived daily flow gpd Recommended design loading rate 7 bed, gpd/fiz ~ trench, gpd/ftz
Absorption area required bed, ft2 trench, ft2 Maximum design loading rate 2 bed, gpd/ft2___L46_trench, gpd/ft2
Recommended infiltration surface elevation(s) It (as referred to site plan benchmark)
Additional design/site considerations
Parent material Flood lain elevation, if applicable, It
s
S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank
U = Unsuitable for system S0 U S U )4S ❑ U ❑ S (4 U ❑ S U ❑ S ;Z U
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
D
Ground
~ft.
Depth to
limiting
factor
in.
Remarks:
Boring # ,
Ground
elev.
/ ft_
Depth to
limiting
facto*
~in. Remarks:
CST Name (Plea Print) Signat Telephone No.
Address Date CST Number
SOIL DESCRIPTION REPORT
44
PROPERTY OWNER C P Page of 4
PARCEL I.D.#
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots G~pjft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
,
kx 5" -2 K
ZI!5;f 0W1 -Y-0
Ground
Depth to
limiting
factor
^6 Remarks:
Boring #
Cq/ o p~- G
t -Z
J l2
Ground
Depth to
limiting
factor
Remarks:
/ Horizon Depth Dominant Color Mottles Structure GPD/ft2
Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed '.Trench
Boring # - 0-1 A4 42Z
Ground
~eley.
auft.
Depth to
limiting
c r
Remarks:
Bo ifig #
Ground
elev.
ft.
Depth to
limiting
factor
in.
Remarks:
SBDW-8330 (R. 08/95)
r{ Soil ;Test Plot Plan
Project Name 2f~ Byron Bird Jr.
19
Address-
r...f G6i 3479
Lot I-Subdivisiorr GSj Date J
j~L1/4 1/4 S T UN/F W Township
0 Boring o Well PL, Property Line County
4..N.
BM or VRP Assume Elevation 100 ft.
System Elevation *HRP,
~le, 3
1 l VG `
71/- Zell,
a„
\ j
Scale 1/4" 10 Ft. When dimensions aren't stated