HomeMy WebLinkAbout034-1002-60-100
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STC - 104
AS BUILT SANITARY SYSTEM REPORT
- OWNER J/z
ADDRESS_
SUBDIVISION / CSMJ ~LOT # -
SECTION .Z T~N-R /;a" W, Town . f S'f' / ~ 7`7Cox x
ST. CROIX COUNTY, i' WISCONSIN
PLAN VIER
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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INDICATE 14ORTH ARROW
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Provide setback and elevatio information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
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BENCHMARK: O d
ALTERNATE BM:
EPTIC TAN / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacture Capacity: Zec e (,rte
Setback fro Well Douse Other
Pump: Manuf$cturer Model# Size
Float seperation Gallons/cycle:
Alarm Loclat on
SOIL 'ABSORPTION SYSTEM
i
I Width: Length r Number of trenches
Distance & Direction to nearest prop. line:
Setback fpom: well House Other
I ELEVATIONS
Building Sewer "t3 ST Inlet. §T outlet
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PC inlet ~PC bottorii Pump Off
Header/Manifold Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION: K - 9x1
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR: /~~-7 SC1~
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
EaboranQlumanRelations INSPECTION REPORT ST. CROIX
safety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-:
Permit Holder's Nam : ❑ City ❑ Village Town of: State Plan w lo.:
CROSBY,BOB JR.
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing
Aeration Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
Vent
ir Ito ntake ROAD Dt Inlet
TANK TO P/ L WELL BLDG. A
Air
Septic NA Dt Bottom
Dosing NA Header/ Man.
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
Friction System TDH Ft
TDH Lift
I oss ead I - __T_
Forcemai n Length Dia. Fi Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMEN I N
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION TypeO CHAMBER Model 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: SPRINGFIELD.2.29.15W,NW,NW,RUSTIC ROAD 3
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
E7 - SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code CO
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than i:;) 946(g3
8% x 11 inches in size. ❑ Check if revision-to previous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPER OWNER PROP RTY LOC TION _
,Ay 4 ) u . %a /a, S - T N, R •.SE (or
PROPERTY OWNER'S (LING ADDRE LOT # BLOCK #
720 i`~ L
C FY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
11. TYPE OF BUILDI (Check one CITY NEAREST ROAD l2 Z
❑ State Owned VILLAGE :S 77
El Public1 Xor 2 Fam. Dwelling-#~ of bed ZOWW : s T
rooms PARCEL Ax NUMBER(S)
III. BUILDING USE: (If building type is public, check all that apply)
1 ❑ Apt/Condo r l
2 ❑ Assembly Hall 60 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 in line A. Check line B if applicable)
A) 1. ❑ New 2. ❑ Replacement 3. ❑ Replacement of 4.gReconnection of 5.0 Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit - Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 RMound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 In-Ground 42 ❑ Pit Privy
1130 Seepage Pit Pressure 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/7d (Min./inch) ELEVATION
IV 5~_v
3 -7 Z V52) a t Feet Feet
VII. TANK CAPACITY Site
INFORMATION in allons Total # of Prefab. Fiber- Exper.
New lExisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Se tic Tank or Holdin Tank ~k~11 PcLJ i~
Lift Pump Tank/Si hon Chambe -
Vlll. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
's Sign re: (No amps) P 94 P PRSW No.: Business Phone Number:
Plumber's Name (Print): [7--r,;
X23 L 5 CIJ
P
lum is Addres:=Ity, filtate, Zip C d
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IX. COUNTY/DEPARTM N USE ONLY
❑ Disapproved San ry Permit ee (includes Groundwater a e ssue Issuing Ag t signs a (No Sts
Approved El Owner Given Initial Surcharge Feel
SSSfff
Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R.11/88) 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 the 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 & Buildings Division, 608-266-3815.
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.
Ill. Building use. If building type is Public, check all appropriate boxes that apply.
IV. Type of permit. Check only one in 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 in ##1-7.
VII. Tank information. Fill in the capacity of every new and/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% 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) hcrizontal and vertical elevation reference points;.
C) complete specifications for pumps and controls; (Jose 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, ground-
water contamination investigations and establishment o1' standards.
SBD-6398 (R.11/88)
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
74-
OWNF.R/BIJYF.R c-'G"c
MAILING ADDRESS Pit i Z_IeA~ -1
PROPERTY ADDRESS. S
i _ (location of septic system) Please obtain from the Planning Dept. '
CITY/STATE
1
PROPERTY LOCATION A 4 1/4, Section T22N-R
TOWN OF G ST. CROIX COUNTY, WI
SUBD , .
IVISION LOT NUMBER ;
CERTIFIED SURVEY MAP VOLUME , PAGE , LO NUMBER +
i
proper, use and mai=tenanof your septic system could result in its p nature failure to handle
wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if ned
by licen septic tank pumper. What you put into the system can affect the function of the septa tank
as a treatinent stage in the waste disposal system.
It Croix County residents may be eligible to receive a grant 'for a maximum of 60%0 of the colt
of replacement of a failing system., +vhich 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
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keep their system properly maintained.
The property owner agrees to submit to St. Croix Zoning a certification foram, signed by the owner 1
and by a mater plumber, journeyman lumber, restricted plumber or a licensed pumper verifying that (1)
the on-site wastewater disposal system is in proper operating condition and (2) after inspedio ' anti
pumping (if necessary), the septic ta+ is less than 1/3 full of sludge and scum. I j
IlWe, 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 ust be completed and returned to the St. Croix
County Zoning Officer within 30 days of the three year xpiration date.
SIGNED:
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
t
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APPLICATION FOR SANITARY PERMIT
STC - 100
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.
.M
Owner of property
Location of property j" 1/9 U J 1/4, Section , T Z 9 N-RL,_W
Township S yt3/-~
Mailing address S 'r7 Address of site T7
Subdivision name
Lot number
Previous owner 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 resale (spec house)? Yes No
Volume and Page Number 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. ; and that I (We)
presently own the proposed slte.for the sewage disposal system (or I (we) have
obtained an easement, to run with the above described property, for the
const action of said system, and the same has been duly recorded in the Office
of t County Regi e f Deeds, as Document No.
- 0 fiu, /Ya~~ - I
S gnature o Owner Signature of Co-Owner (If Applicable)
199V
Date of ignature Date of Signature