HomeMy WebLinkAbout032-2105-50-000
ST. CROIX COUNTY ZONING DEPARTMENT _ V
AS BUILT SANITARY REPORT r
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Owner
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Address - ~..N'e sT o
Nc0U AO1k ` ...Fr"
City/State Nrr
NGOFFjCE ~,4,
Legal Description:
Lot Block Subdivision/CSM # _ 101
'/4 i IL %4 --eo Sec.,,,?Q, TAN-R-W, Town of PIN # Ile,) SEPTIC TANK DOSE CHAMBER HOLDING TANK INFORMATION:
Tank manufacturer - Size ST/PC /,~2zn / Setback from: House - fL Well ZW/- P/L _S8-
Pump manufacturer' Model
Alarm location
(HOLDING TANKS ONLY)
Setbacks: Service road Vent to fresh air intake Water Line
Meter location
Alarm location
SOIL ABSORPTION SYSTEM:
Type of system: .o Widtl) Length _ Number of Trenches
Setback from: House _VS Well AlA. PAL ~,12 Vent to fresh air intake
ELEVATIONS:
Description of benchmark Elevation , Pe:
Description of alternate benchmark - Elevation , , . y~
Building Sewer ),&2 3R ST/HT Inlet '/r:,7, 5 l ST Outlet--- / s~ PC Inlet
PC Bottom Header/Manifold Top of ST/PC Manhole Cover
Distribution Lines ( ) ( ) ( )
Bottom of System ( ) 7~<~ ( ) ( )
Final Grade ( ) zz , 91~? ( ) ( )
Date of installation /b /7/ 97 P mit numb rt-~? x'90, f State plan number
Plumber's signature License number Date,p //7/97
Inspector
Complete plot plan Or
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.
PLAN VIEW
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INDICAT NORTH ARROW
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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County:
Safety and Buildings Division INSPECTION REPORT -5:1f. c✓v t ri
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. (~r~ D
Permit Holder's Nome- ❑ City [I Village Town of: State Plan ID No.:
I
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
ra~Kc✓ 03z_ zoos-so -oov
of0 ` 170' To ~ ~ 1,pLw y" m
TANK INFORMATION ELEVATION DATA ~17p04,0
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
eptlc y%/-G~ i(S 16D c7 Benchma l j•ajg (oZ /D ,(p ADO
Dosing Aft. M 4(0 I-Dqll-re
Aerat' n Bldg. Sewer 53 !103.37-
Holding _ $ lk inlet be0 /0Z-5w
TANK SETBACK INFORMATION (~SPlk Outlet (pr Z, 4J /07,3
TANKTO P/L WELL BLDG. Vomtake ROAD Dt Inlet 7
Air In
,.t
=Pt1c~ NA Dt Bottom p•7d 4'79
Dosing NA Header/Man. q$~ 1r.fr
Aeration NA Dist. Pipe g. Crt. -7
X0.7$` e17.3T
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade ~.7 0
Manufacturer Demand Way% Ito 17~ 603
Model Number GPM
TDH ft Friction TDH Ft
Loss
Forcemain Leng- Dia. Dist. To Weil
SOIL ABSORPTION SYSTEM
TRENCH Width Length LL i No. Of T s PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 2 .~`7 I DIMEN I N
LEACH urer:
SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM
INFORMATION Type Of C H A MRFR umber:
Gl p~ - OR UNIT
System
DISTRIBUTION SYSTEM
Header / Manifold L40 Distribution Pipe(ss) x Hole Size x Hole Spacing Vent To Air Intake
Length fog Dia. Length -W Dia. t Spacing D~ ~TA/I -&'L IZo I-
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed /Tr opsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) ~c~~ Iz• i'!'O~~
Plan revision required? ❑ Yes g J No 7
Use other side for additional information. 2t-
Date Inspector's S nature e
SBD-6710 (R.3/97)
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
Visconsin Safety and Buildings Division
SANITARY PERMIT APPLICATION 201 E. Washington Ave.
In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
Department of Commerce Madison, WI 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 81/2 x 11 inches in size.
• See reverse side for instructions for completing this application State sanitary Permit Nu ber
/70 q0 0 -7
0(7 0.1
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)]. Y3 o 199? V""'_ " S, State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INF - RMATION
Prope Owner ame Property Location
1/4 va, S T , N, R f(orW
Property Owner's Mailing Address Lot Number Block Number
Cit tate Zip Cod Phone Number Subdivisio5Name or CSM Number
y ( ) ~S
II. TYPE F BUILDING: (check one) ❑ State Owned ❑ !t Nearest Road
❑ Village
Public 1 or 2 Family Dwelling - No. of bedrooms Town o
111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
CZ,.3/ . / 990 0
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. El New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
_'---System --------System Tank Only______________ Existing System _____ExistingSystem
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 t4 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.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./' ch) Elevation
_ JC_o 7 Feet Feet
VII. TANK Capacity Total # of Prefab. Site Fiber- Exper.
INFORMATION gallons Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existin strutted
Tanks Tanks
Septic Tank or Holding Tank IZW I _ I 14 1 ❑ El El Lift Pump Tank /Siphon Chamber ❑ 1:1 El ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for in tallation of onsite sewage system shown on the attached plans.
VPluber" Name (P t Plum is S a r o S m ) MP/MPRSW No.: Business Phone Number:
u tier's c dress treg Cit , State, Z ode):
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps)
m
Approved E] Owner Given initial Surcharge Fee)
/
Adverse Determination 1 /0
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R.11/96) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
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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f Wisc'=4in Department of Industry, SOIL AND SITE EVALUATION REPORT Page-/ of
Labor and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less t 8x 11 it clue 'Ire ' e. Plan must include, but r
not limited to vertical and horizontal refere A (BM)4recti8h~nkof slope, scale or PA E D. #
dimensioned, north arrow, and location a i ance[qpr~ r road.,.-- ~ m - ?6"
APPLICANT INFORMATION-PLE RINT ALttI INF RMAi#t6. REVIEWED BY DATE
PROP OWNER: 1~ j; PROPERTY LOCATION
ST CROIX GOVT. LOT S 1/4~~~/ 1/4 g T N,R orJ~
PR RTY OW ER ':S MAILIN ADDRESS ZONINfiOFFIC6 LOT # BLOC # SUED. E OR CSM # ')d
CI STATE 1 ZIP CODE - ❑CITY VILLAGE MOWN NEAREST ROAD
] New Construction Use] Residential / Number of bedrooms [ ]Addition to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow ,~g--Z gpd Recommended design loading rate T~bed, gpd/ft21,f -trench, gpd/ft2
Absorption area required "s bed, ft2 trench, ft2 Maximum design loading rate _,-~bed, gpd/ft2-trench, gpd/ft2
Recommended infiltration surface elevation(s) 97.9 ft (as referre to site plan benchmark)
Additional design / site considerations µ
Parent material Flood plain elevation, if applicable ft
tS= tabl e for system CONVENTIONAL MOUND IN GROUND PRESSURE AT GRADE SYSTEM IN FILL HOLDING TANK
suitable fors stem SE U [ZS ❑ U RS ❑ U WS ❑ U ❑ S [XU [I S o u
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
Boring # Horizon in. Munsell Clu. Sz. Cont. Color Gr. Sz. Sh. Bed Trer>ch
Z::.:::•il:..4i?•i::~
Ground v s ' g
elev.
/WZ ft.
Depth to
limiting
factor
T-1
Remarks:
Boring #
r
Ground
elev.
/,O 1 ft.
Depth to
limiting
factor
Remarks:
CST Name:-Please P ' Phone:
Address:
Signature: / Date: CST Numbe
PROPERTY OWNER SOIL DESCRIP ION REPORT Page ";Zof
z
PARCEL I.D. # ~of7
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Co Color Gr. Sz. Sh. Bed Trench
ti~il:4: ii::v\•••::
Ground
elev.
j ft. ~s - -
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
42 - -
/ ft. Al
-,7 1
Depth to
limiting
factor
Remarks:
Boring #
l - r
Ground
el~
Depth to
limiting
factor
Remarks:
Boring #
{v4
Ix
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
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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 DMW / 5 A6Ld417e,r / ro - a e-,-k
Location of property 5,C 1/4SC1/4 , Section, T'}~_N-R / q W
Township So. t-srsef" Mailing address 3178 11alle-Y Uicw Tr.
Roylf~- U'ZZ o
Address of site ^t-o
Subdivision name „6ra-r-1'e- 61 s Lot no.
Other homes on property? Yes ___No
Previous owner of property jjQrh?zao lkm1-5 -4;1c.
Total size of property ac.
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 _ No
Volume la 53 and Page Number 12d-1 as recorded with the Register
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
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. 6-,6 ~ j/0 , 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.
Signature of Applicant Ao- - 7-197
te of. Signature Date of Signature
Da
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNEWBUYER
MAILING ADDRESS 31'S Lla Ile-U Llj gw 17 _ A v ~~ar► X ~.U~ S S/D
PROPERTY ADDRESS ~q/2 , rl 'rte. z" . 7~ /41/.
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE Symer-se f.,_ Mgr- 5y6,?S_
PROPERTY LOCATION S6' 1/4, • 5W 1/4, Section o; T-3-L-N-R 19 W
TOWN OF ~5orner SST ST. CROIX COUNTY, WI
SUBDIVISION Grot- _ e ~5-sfafes LOT NUMBER
CERTIFIED SURVEY MAP , VOLUME,-, PAGE , LOT NUMBER
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
acid by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (I)
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.
1/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.
SIGNED: DATE: 7- 7
St. Croix County Zoning Office
Government Center
1101 Carmichael Road 11/93
Hudson, WI 54016
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+ 'j01~ I STATE BAR OF %VISCONSiN 1`01M Z - 1982
S62 II WAIL ANgTYp~DEtiE.s~D
~5 fA4[~J:.. • AFG15ttlt"SGiFfV.F
DOCUMENT NO.
vft
St CFOXCTY.
Hartman Pomes Inc a Wisconsin
cor ora t ion
it 9:34 A. M
Dona Id_rL ~chacr ~r an[1 ~1~.~Fe,s.►-
conveys and warrants to
Tracy L. Emme_Ck.ho h ci ngl e pprcnns, rtopwd Do" ,
as joint tenants-
THIS SPACE RESERVED FOR RECORDING DATA
NAME AND RETURN ADORE
he following described real estate in _ qt. Croix _ County.
State of Wisconsin:
I
PARCEL IDENT6ICATg14 NUMBER
Lot 5, Gracie Estates in the Town of Somerset, St. Croix County,
Wisconsin.
This is not homestead property.
VAX (is no)
Exception to warranties: Easements, restrictions and rights-of-way of record,
if any.
Dated this.- -day of .A.D..19 9
Qn- `
s, c.
(SEAL) By- (SEAL)
Hartman X.HHaarrtman
tiie el .BEAU (SEAL)
_
AUTHENTICATION ACKNOWLEDGMENT
man State of Wisconsin,
$ignature(s) ^ j"1ChaE1__J •__H a r t
~l County.
authenticated this 0, day of 19 9 7 Personally came before me this dry of
19 .the above mrtte!
TITLE: MEMBER STATE BAR Of WISCONSIN I
(If not,
authorized by 3706.06. Wis. S(ats.) to me known to be the person who exccuted the foregoing
irv-4tument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY