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HomeMy WebLinkAbout036-1081-60-050 4 0. n I °o I N I O O 9 x N U~ I o~ II', ~ z 'c w I U. c m w moo ~ o I v ~ Cl) I Z r Z w O v IL co M H Z C C7 O Z d' i c c N a) O co CY rn 0 O O N O 4) O • ~ d U) L U N (mil O O O CD Q 04 Z OD Z Z O N E o r- ` w Y r m - I 06 G. 'L] C ~N O ~N FfA O U f c 3: 3: 3: ni O O O O •F„~ m L a a a CL (V N 11~ 7 O N 3 O 6) N VJ J U o rn o~ ~ _ Z 24 -a I C) a) O NM p p O CL ~ 'd fA ~ e.» N O O _O ! N C rO o Q 3 -j aa)) N N CL:) 11 o C) CL CL - O OC) L co N O O N N O r U V T L L O O Y O N F- F- N O O ~ M N .R. O Q N U O ~ m U) z =5 U) V1 y G m at a ~ ~ O. 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CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE -Al, PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM I ~ ~r ~ b . ~d& Iff k"I~ o/INDICATE NORTH ARROW BENCHMARK:Elevation and description: fmT c~F ~~,J~.l Alternate benchmark SEPTIC TANK:Manufacturer:~- Liquid Cap. qA L Rings used:-- Manhole cover elev: Final grade elev: Tank inlet elev.: Tank outlet elev.: No. of feet from nearest road:FrontX, Side , Rear Ft. From nearest prop. line:Front , Side , Rear Ft. eo No. of feet from: Well Building: ~(Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE 1 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: Width: Y-J , Length Number of Lines:,.,~,'_Area Built Exist. Grade Elev. Proposed Final Grade Elev. Fill depth to top of pipe:c;~ No. feet from nearest prop. line:Front , Side , Rear Ft.~ No. feet from well: No. feet from building 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: ✓ LICENSE NUMBER: S 6/90:cj r- i L~CATI~N• 5TIrT9N 32.31.17.502 NW NW, HWY. 64 isc nsip epartmen o n us ATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT Safety and Buildings Division ST. CROIX I (ATTACH TO PERMIT) Sanitary Permit No-, GENERAL INFORMATION 171504 Permit Holder's Name: ❑ City ❑ Village (,X Town of: State Plan ID No.: COOK, GARY STANTON CST BM Elev.: Insp. BM Elev.: BM Description: Parcel /-0 .ea . 1601(0 .~.ti»?Q QS r/ -1081-70-000 TANK INFORMATION ELEVATION DATA A920027 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic ) S 0~(1 Benchmark Dosipl--- Aeration Bldg. Sewer Holding St/ 9•` Inlet ~x f r ~ TANK SETBACK INFORMATION St/ 1jeoutlet a/. 36 TANK TO P/ L WELL BLDG. Ventto ROAD ^,A-„ _ Air Intake Septic NA UL40"Gffl_r 04- Dosing NA Header~HWI; rr. jpfL /00.38 r Aeration NA Dist. Pipe s~/(yZ~ JUO. 29 Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade-aso .35 s h?c Manufacturer Demand 7 3 102. 2 Model Number GPM TDH Lift Friction System TDH F Forcemain Length Dia. Fi Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH width 01 Lengt / No. Of Trenches IT Inside Dia. Liquid Depth DIMENSIONS 1.2 I N SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING anufacturer: SETBACK CHAMBER Moe m er: INFORMATION Type O 41 ~~n 41 di - System: >/A `t(J 7~dd OR UNIT DISTRIBUTION SYSTEM Header / M611401+ Distribution Pipe(s) r~ / x Hole Size x Hole Spacing Vent To Air Intake Length ~ ' Dia. Length ~j Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over it Depth Over „ r/ xx Depth Of xx Seeded /Sodded xx Mulched Bed/ Trench Center Bed /Trench Edges 26 'Z3 Topsoil E] Yes 0 No E] Yes No COMMENTS: (Include c de discrep cies, person present, etc.) Plan revision required? ❑ Yes [r~tQo a~ WrIIV Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. 1 ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: I i i HR SANITARY PERMIT APPLICATION - couNTY In accord with ILHR 83.05, Wis. Adm. Code .e...,..~.....,...~...e~ + &h4,1~t STATE SANITARY PERMIT # 'I -Attach complete plans (to the county copy only) for the system, on paper not less than 1:1 / j ev 8% X 11 inches in size. Check if revision to ious application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION '/a Y.,S T3 N,R E(or PROPERTY NER'S MAILING ADD SS LOT # BLOCK # ei( .4//, , I , CITY, STAT ZIP Co E PHONE NUMBER SUBDIVISION NAME R CSM NUMBER e-1 -0 III. TYPE OF BUILDING: (Check one CITY NEARE T ROAD ❑ State Owned ❑ VILLAGE ❑ Public ®1 or 2 Fam. Dwelling--# of bedrooms -3 AR p.3~-/08/- 7o sow III. BUILDING USE: (If building type is public, check all that apply) p A -/o8l - G D 5 1 ❑ Apt/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 in line A. Check line B if applicable) A) 1. 19 New 2.E] 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 [0 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 430 Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 12. 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.) (MI /inch) ELEVATION J 0 6 ~ G Y~ / Feet Feet VII. TANK CAPACITY Site INFORMATION in allons Total # of Manufacturer's Prefab. Fiber- Exper. New istin Gallons Tanks Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank 211111P 0 1 El 1:1 F1 F] Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for install on of the onsite sewage system shown on the attached plans. Plumbe 's Name (Print): Plumb 's •gna re: (N p MP/MPRSW No.: Business Phone Number: +J J Plumbs 's Address (Street, City, State, Zip Code) S T / , 14-) 17 IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sat ry Permit Fee (Includes Groundwater Date Issued ssuing A nt Si No St m Approved El Owner Given Initial Surcharge Fee) 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 tie 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 Dy 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'h 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 mainsbovater 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) S T C - loo This application form is to be completed in full and signed by the oMner(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 ' Location of propert 1/4 1/9, Section', T~N-R7W Township Hailing address Address of site Subdivision name_ Lot no. other homes on property? es ~Ho Previous owner of property Total size of parcel _ Sy Ps, Lre~ Date parcel was created _ mo\1i \c"t' Are all corners and lot lines identifiable? =Yes No Is this property being developed for (spec house)? Yes ' No r volume-and page number as recorded. with the Register of Dee s. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARIUUI.1'Y DEED which includes a DOCURENT NURBER, VOLUME AND PAGE HUMBEZ & THE SEAL OF THE ILEGISTLR 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 8 shall also be required. Survey Hap PROPERTY OWNER CERTIFICATION I(we) certify that all statements on this form are true to the best of ny (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 he office of the county Register of Deeds ns Document No. C 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 county Register of deeds as Document No. ~Signature of ap~li.cant . Co-apr1 a C-1 Date of Signature Date of Signature r Mum u A~U A Y ~ ~ of a am f. •---ter.... oak a; s two*: ~ fwR 1'~fQ !!Mt d tlr~ Nodi~w~t Gu~etrc (1~) at ~ 5 090* Mop 27 Mae -b ~i- J, t WWINM any Itt ) b( } "wi n K y. r r • t~ r z r' rL, r I , , ro°> q: ±H , Y rV awl% t'~1 II ~ tl~ _ 20,.. . STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER ROUTE/BOX'NUMBER 'c FIRE NO. S/ CITY/STATE ZIP S"G'l"7 t PROPERTY LOCATION: 1/9 _1/9, Section , TN, R_jW, _261~ Al Town of , St. Croix Coun i Subdivision 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 for a MAXIMUM of $3000 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 systems properly maintained. The property owner agrees to submit to 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 form 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 Department of Natural Resources. Certification form must be completed and returned to the St.Croix County Zoning Office within 30 days of the three year expiration date. SIGNED DATE St. Croix County Zoning Office St. Croix County Courthouse 911 4th Street Hudson, WI 59016 (715) 386-9680 Sign, Date, and Return to above address W-ttont.n De0a'1mor1 Of IravIlry. Labor and Murnan Rllat,ont WIL Utblhlr 1 wit ItLI s/N I • (Attach Soil Profile Location Map ' P To Scale • On A Se crate, Signed Sheet) r.la ~ a jdrso ~ on.:.l foear.arf etrrwwrN,ro v/oesw/rs ►age r we Wt/Ilul► KOV a 4000 l1 a .oor,esa _ . I P _I 1 z,4 fl Ciro It t/ d► Io1tL6e0MOrOae LOC.I,Oe IQMN{W tLC• rt+r - - ' lr„t►wte4nwen DORM Z ~ CS4l LOT BLOCK SUBDIVISION j~itaIw a/rLat:l (3 • ~oruon Oeoth Dominant Color Mottles sitwule In Munsell Unuunp Fatten Loading 100 sg h. nt of r Tee / Gr, C n 1st n e t n ar Depth Trench O.d CIev is SS -11 (3• Morton Depth Oom,nant Color Mottles Structure L,rlwtlnp fatlerl Laa,,gGPty~ n- In Munsell u Ont. Color t f r Or, St. h. Cons, ten Rots Bo nd r 041% Trench 904 El1:v = r 3 I- Ag 13. 1 Mor,lon Depth Dominant Color Mottles Structure llmlunp fetter/ LaOngWa%4 n. In Munsell Ou.St/Cont. Color T t r Gr. St. h. n i t n Roo ! nda Depth Trench Sod Al/A Al 1,4 Elev = / /15 i .f .37 R.1 A4ZO4 - , i 13 Monson Depth Dominant Color Mottles Structure URMU p n factors Le+angGPtY►a n. In Mvn NI S C n . Colot 1 *tur Gr It. Sh, n Is n Awl loymclary owlh Trench B.e Elev : -4114 AU// f, S~ /I ^we CL~ A-11 4~GL~.ild r/ ~ J -All 17 13. / t4ohlon Depth Dominant Color Mottles Slructur! In Llmtllnp aelerl Laanp OPp>a h, Gv M n ell Con t. Color T f I ! h. _Cqmjijjer%Cq Roost Boundary Cepl hence S.. Elev a :S zLt 42 ea /I _ 1s w Additional Remarks: RECOMMEN ED SYSTEM TYPE: - Other Site f f (lures: J I tnaW1f sysfcm Elevation •te signed e1fOhOneNO. • CST Name (Priest) City State Zip I i I I I i I i I I I I I--• i ~ i 11 ! I IT! I j ! i 1 i I I j I I I I ( I I I I , I~ I I I l i I ~ ~i I i I - I I I -42 I I I I i I I I i ~ I I I I ~ I i s~ i i I I 1 ( ~ /b? 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I ~ I 1 I I I i j I _ - I--- -r- -~-i -t- j- I I I f J ( I I j ~ I I t I l l l l ~ l i ! I_ I I i I ~ I I! I f j I I i ' - - , - I I 1 i I ' I I I , , I I ! i I j I ' I j I i I i i I I - T i I i I , I ~ I : i i i v ~ PAGC Of CroSS S~c~1o1, o rl ~ 3vYl~ :~~5• s~~~-~ / J sw •//y~L( ~l F14611 All Well, And 0holvallon Pipe Veal CAP ! Mw-"* 12' Abbe `Sl 7 /1"91 Crude 0 fI , 20• 42' Above P11r 4' Cool IrM To rhtl Geode Veal PIP$ Mor+A for Or IrniMrk Cv.vrlnV Ovrr P11/ 01+U lbvlge tote 0 AIIr/V.1• bevalb Pl1• a P611444146 PIPv 6#10. 0 - ~'Cv,pU1 Tvrohelial Al 0011eM Of 816864 ~1~~•-~ ton / ~~Zrsll, SOIL FILL' DISTRIBU'f101.1 PIPE APPRO`/rU S•IUTIIETIC COVE i r -MikTf-R1J4- aR 9" OF STRm, 2" OF AGGREGATE OR MARai► P. A`! ! ELEV. O 1•~OPlL~Er/; AGGRCGATC FEIT, DISTRIBUTIOM PIPE TV bE AT LEA:;'T _ INCHES BCLOW ORiGIMAI• ';..;AOk AUU AT LEAST LO IWCHEL BUT 1.10 MORE THAI) 42, IMCIJES I FLOW FIIJAL. CILAOC NXIMUM DEPTH OF EXCAVATIOP FROM OKI WAL 6R)\DF WILL. BE IIJCHES tVt()MVM ©EFT1t OF E CAVATION FAOM 0~I4INAL GRADE WILL. Bc . LL INCHES i / i SIGIJCO: ' I • LIGCAISC UUMBCIi:,_y I • • DATE: y -2-- L2 t t o _ L REPT131 STANTON ST. CROIX COUNTY ZONING PAGE 1 09/23/92 11:40 REQUESTS FOR INSPECTION WORK SHEETS FOR: 9/23/92 AREA: JT Activity: A9200270 9/23/92 Type: CONVSEPT Status: PENDING Constr: Address: STANTON 32.31.17.502,NW,NW, HWY. 64 Parcel: 036-1081-70-000 Occ: Use: Description: 171504 Applicant: COOK, GARY Phone: Owner: COOK, GARY Phone: Contractor: O'CONNELL, KIM A. Phone: Inspection Request Information..... Requestor: O'CONNELL, KIM Phone: Req Time: 13:09 Comments: /l'36 Items requested to be Inspected... Action Comments Time Exp 00012 FINAL INSPECTION Inspection History..... Item: 00012 FINAL INSPECTION