HomeMy WebLinkAbout006-1041-10-000
AS BUILT SANITARY SYSTEM REPORT
J /
OWNER Lch'i Zan- c4z~0~- TOWNSHIP
.4~N-R_ W W ~g 10 fGt ✓ i VC
SECTION T--
ADDRESS 3a2 ST. CRO COUNTY, WISCONSIN
"4og e-r ~2 3f t-
SUBDIVISION lay ~I. q LOT LOT SIZE
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM In fc~ d
00 Qfl I
INDICATE NORTH ARROW
BENCHMARK: Elevation and description: jre~o 1255~-
11
Alternate benchmark 5x'~
SEPTIC TANK:Manufacturer: 1~ e /f5 Liquid Cap.
e
Rings used:~j t" Manhole cover elev:=Final grade elev:~~✓~
9 l
U Ta k inlet elev.: Z 4 5 ,7 Tank outlet elev.: 3 i
No. of feet from nearest road: Front , Side , Rear.-Ft. DD
From nearest prop. line:Front , Side , Rear')C Ft.
No. of feet from: Well Building:
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufact.: Pump Size
Elevation of inlet: Bottom of tank elevation
Pump on elev.: Pump off elev.: Gallons/cycle:
Alarm: Man.: Switch Type: Location
Distance from nearest prop. line: Front, Side, Rear_Ft.
Distance from: Well Building
SOIL ABSORPTION SYSTEM
Bed: Trench: Seepage Pit:
i
Width: 2 /Length 4;5~/ Number of Lines:_ 2 ,_-Area Built Exist. Grade Elev. ,02 -Proposed Final Grade Elev. 3
Fill depth to top of pipe:
No. feet from nearest ine:Front Side
prop. , , RearC Ft . 2d-,!57
No. feet from well: 4 ~-No. feet from building S
HOLDING TANK
Manufacturer: Capacity:
No. of rings used: Elevation of bottom tank:
Elevation of inlet:
No. feet from nearest prop. line:Front , Side , Rear Ft.
No. feet from: Well , building , nearest road
Alarm Manufacturer:
INSPECTOR:
DATE: PLUMBER ON JOB : c~T
LICENSE NUMBER:
6/90:cj
LQQNasT Ra tQaP ,dJsPy. 31.16.27 ~A1 E SEV1Ti069 SVif ENf HWY . 4 County:
Labor and Human Relations INSPECTION REPORT
Saf qty and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary- ermit o.:
Permit Holder's Name: ❑ City ❑ Village 9 Town of: State Plan ID o.:
mm X
ev.: -'-'_'_"]Y1nsp.BMEIev.: BM Description: Parcel Tax No.:
^ - - -
TANK INFORMATION ELEVATION DATA A9300015 t/t _
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark)
Dos' IT
6,63, d ,
Aeration Bldg. Sewer
Holding St/,W Inlet 5.061
TANK SETBACK INFORMATION St/ Ht"Outl 53~ y9q~~
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic 5a~ NA Dt Bottom
Dosin NA Header-/-Uan- 7 ~
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade p 9~J"S
Ma urer Demand
Model Number GPM
TDH Lift Friction S stem Ft
Loss Hea
Forcemain Length Dia. Dist. To well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width , Length No. Of Trenches PIT No. Inside Dia. Liquid Depth
DIMENSIONS G? CI DIM N I N
SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Man turer:
SETBACK CHAMBER
INFORMATION Type Of 0~,d i i i OR UNIT Mode Number.
System: i
DISTRIBUTION SYSTEM
Header "IFarrrfotd- Distribution Pipe(s) i , x Hole Size x Hole Spacing Vent To Air Intake
Length & Dia. Length _Z Dia. _A/_ Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over „ Depth Over „ y xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /4f-c h Center Bed /;F a Edges a1- 36 Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: CYLON 19.31.16.278,NE,NE, 210TH AVE. & HWY. 46
Plan revision required? ❑ Yes
Use other side for additional information. 3
[,q3l I M
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
7 DILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUNTY
Gyro J~K
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than ❑ Q-~
8% x 11 inches in size. c eck4f rev s on 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 PROPERTY ATION
x0 C/ & c, %a S T 7,1, E(o
PROP RTY OWNER'S MAIL NG AD LOT # BLOCK
O
CITY, STATE E PHONE NUMBER SUBDIVISION NAME 'OR C S N MBER
0 Lr i Oo2.5 / .SYo
II. TYPE OF BUILDING: Check one CITY NEAREST ROAD
( ) ❑ State Owned VILLAGE
4OWN OF
❑ Public ,91 or 2 Fam. Dwelling-~#of bedrooms ~ A
EL TAX NU BER() A', /Ov
III. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo
20 Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
30 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. fNew 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 - 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 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 ❑ 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/day/sq. ft.) (Min./inch) ELEVATION
O O s2 S G qj~-`~ Feet 'Z>/ Feet
CAPACITY
VII. TANK in gallons Total # of Prefab. Site Fiber- Exper.
INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
El r]
Septic Tank or Holdin Tank
,1__~xyey Z Z-,, _,Sr 1F711 11 Q f LL_ Ll
Lift Pump Tank/Si hon Chamber F-1 0 1 1:1 1-1
Vlll. 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 Signature: (No Stamps) MP/MPRSW No.: Business Phone Number:
Z~6p? ;1e,/ C 44.5a - 1 3
Plumb s Address (Stree , City, State, Zip Code):
IX. CO NTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued a1ssu1nLgem Si nature (No rn
Approved ❑ Owner Given Initial k Surcharge Fee) a/r 7 p
Adverse Determination
l
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety 8 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.
III. 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'f2 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, ground-
water contamination investigations and establishment of standards.
SBD-6398 (R.11/88)
STC-loo
,
This application form is to be completed in full
the oc~~ner and signed by
) 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
Location of property j,/4 !Z 1/4, Section
t T1LN-R W
Township
Nailing address / ~U ors -
Address of site
Subdivision name
Lot no.
Other homes on property?
yes- X/ No
Previous owner of property
Total size of parcel Q cr-~~
Date parcel was created
Are all corners and lot lines identifiable?
Y Yes No
Is this property being developed for (spec house)? Yes No
Volume~%y~'~jand Page Number `_r~ as recorded. with the Register
of Dee s .
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARIUVI.CY DEED which includes a DOCUMENT NUHDER, VOLUME AND PAGE.
NUMDER & THE SEAL OF THE. RLEGISTI;R OF DEEDS.
certified surve In addition, a
y, 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(Wc) certify that all statements on this form are true to the
best of my (our) knowledge that I (we) am
the property described in this information form b e owner(s) of
warranty deed recorded in the office of the Count y y Register of a
Deed:, as Document Tin. of
own the proposed site f e wage disposal and that I system
or presently
obtained an easement, to run the above described pro I ( for we)
the construction of said system, and the same has been duly
recorded in t e office of County Register of deeds as Document
No.
1 r
ignature of a licant
Co-appl cant
~ 11Z /9
Date of Signature
Date of Signature
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
ADDRESS: FIRE NO:
LOCATION.
1/41 1/4, SEC.,1f1`- _T N-R~W#
TOWN OF:_ hC/ d/7
ST. • CROIX COUNTY-,
SUBDIVISION: r_ LOT NO.
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 a 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 to
help with the cost of the 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 the St. Croix County
Zoning a certification form, signed by the owner and by a master
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. Certification from will be sent approximately
30 days prior to three year expiration.
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 form must be completed and returned to the St.
Croix County Zoning Officer within 30 days of the three year
expiration date.
SIGNED. /
a
DATE:__ / ? c/-3
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
bNDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX 769
N WI 53707
HUMAN RELATIONS
11 HR 83.0911) & Chapter 145)
LOCATION: SECTION: O NSH UNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME:
/T N111le- E (OF)
COUNT IMAILING ADDRESS:
U DATES OBSERVATIONS MADE p
NO. BEDRMS.: COMMERCIAL DESCRIPTION: R FI DESCRIPTIONS: PERCOLATIDNTESTS:~
Residence XNew ❑Replace / 5? _ '12 1
RATING: S= Site suitable for system U= Site unsuitable for system
r ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional)
S ❑U S ❑U S ❑U EIS ®U EIS ®U
If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the
under s. ILHR 83.09(5) (b), indicate: '6 Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN. ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBS RVED (SEE ABB V. ON PACK.)
/o ~r io -3a 5~
B- p 0 ~2
B- 5~~ o-n PG
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER 1+J AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 P R 1057- PER INCH
P- d G
P- G~ c
P- b
P-
P-
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION
\ )
T-1 _~F
I
r.
"Fin
4a~ I
I
(I
1 J3
I
2
i €
W- I'M j
r ;
3
01
~ F
I
7
!I `
11 0s
f... I
I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wi nsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME (print): TESTS WERE COMPLETED ON:
r~
ADDRESS: CERTIFICATIO N MBER: PHONE NUMBER (optional):
CS I URE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10/83) - OVER -
FLU I PLAN
PROJECT ADDRESS 213 1a J`! 57~ J`~~n~r zlE~^ S?E,a„Z
•G1~1/4/~~'- 1/4/S/f/T,71 N/ W TOWN _COUNTY
MPRS Byron Bird Jr. 3318 DATE
BEDROOM , CLASS PERC
_-;7- CONVENTIONAL .x IN-GROU RESSURE
CONVENTIONAL LIFT MOUND HOLDI TANK
SEPTIC TANK SIZE) IFT TANK SIZE
DOSE TANK SIZE HOLDING TANK SIZE
ABSORPTION AREA PERC RATE BED SIZE
Benchmark V.R.P. Assume Elevation 100'
Location of Benchmark
C7 Borehole (-Q Well Scale Feet
0 Perc Hole System Elevation ll''
Uent
12"
ode
TYPAR COVERING
2"
12" 3' 4 6, Q 3'
I 6' Sewer Rock r,
i 1.2'
fro
30 l~ ~ ~ 7 , , pro
117 r fora
U~ ~60
l~
REPT131 CYLON ST. CROIX COUNTY ZONING PAGE 1
04/21/93 13:26 REQUESTS FOR INSPECTION WORK SHEETS FOR: 4/23/93 AREA: JT
Activity: A9300015 4/23/93 Type: CONV93 Status: PENDING Constr:
Address: CYLON 19.31.16.278,NE,NE, 210TH AVE. & HWY. 46
Parcel: 006-1041-10-000 Occ: Use:
Description: 193355
Applicant: DAGGETT, DAVID Phone:
Owner: DAGGETT, DAVID Phone:
Contractor: BIRD, BYRON JR. Phone: 268-7616
Inspection Request Information.....
Requestor: BIRD, BYRON JR. Phone:
Req Time: 12:04 Comments: 1060 -
Items requested to be Inspected... Action Comments Time Exp
00012 FINAL INSPECTION
Inspection History.....
Item: 00012 FINAL INSPECTION