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HomeMy WebLinkAbout030-1011-40-050 CD 0 fo > co (D tz C ts, M 0 0 M ki U) CO CL 0 0 M E Z 4) 0 LL 0 moo E M < €v Zo 0) W U) 4i 0 C-4 W CL co o z .N CL (mil m (D c to 0 (D 0 o 0 o-) IDI 0 M M 0 0 0 -0 C-4 o 0) < Z Z ca z Z 0 z 0 Lo .0 0 ca �5� 2 (D .0 LO a 0. o co WSJ E (D E § Fk- 3: 3: a °° • 6 0 0 0 0 IL 0. 0. -i Q ¢ 0) 0) d) -0 cc co 0 r- 0 00 0) 0 CD 0 o L) aye < z U) Q to o U) 'A LO 0 (D 9 0 < Z , to 4) U� CL -D CL E 4) m 40. Z; T r- o o 0 (D 2�' c C,q 0) a) o m o w 0 E ca in (x CIO 0 CD 0. 0 c IL CL 'o L) CL a o U) 0 Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations Safety and Buildings Division INSPECTION REPORT St. CTO.1X SE,SE,3,29,19W (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION Co.A 149144 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: Hartzell Lozier St. Joseph CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No-: r LI) 4,1 030-1013-20 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic p Benchmark, Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet 91 TANK SETBACK INFORMATION St/ Ht Outlet ~,g'041 Vent TANK TO P/ L WELL BLDG. A ir Ito ntake ROAD Dt Inlet Septic d 7 / 3 Z , NA Dt Bottom Dosing NA Header/Man. 43 a(/ Aeration NA Dist. Pipe cje(~ oL G~ Holding Bot. System tp g5.61 PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand 17 Model Number GPM TDH Lift Friction System TDH Ft mead Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED /TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS SYSTEM TO P/ L BLDG7 WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type Of I2Lfj_ Model Number: System: ~O (ooh OR UNIT CHAMBER 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.)° Yy ' ~ { 1 F L 1 ~ ' J f ll J Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710(R 05/91) Date G` Inspector's Signature Cert. No. DILHR SANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05, Wis. Adm. Code STATE SANITARY PER T # -Attach complete plans (to the county copy only) for the system, on paper not less than 1$19'! C 7 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. 5-W PROPERTY OWNE PROPERTY LOCATION ;E: %JL= '/4, S , N, R E (o PROPERTY OWNER'S MAILING ADDRE LOT # BLOCK # O CITY,,STAT ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER ,4 II. TYPE OF BUILDING: (Check one) State Owned V CILLTYAGE f 4 NEAR T ROAD, ~a~c 24 ❑ Public a1 or 2 Fam. Dwelling- # of bedrooms PARCEL TAX NUMBER(S) Z III. BUILDING USE: (If building type is public, check all that aPPIY) D --l tel./ '2 C:1 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. ❑ New 2.AReplacement 3. ❑ Replacement of 4.0 Reconnection 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 ❑ 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 Feet"Z Feet VII. TANK CAPACITY Site in gallons Total of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New F-xisting Gallons Tanks Concrete glass App. Tanks Tanks structed Septic Tank or Holdin Tank Lift Pump Tank/Si hon Chamber F1 F] I F1 F-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): r" Plumber's Si nature: (No Stamps) MP/MPRSW No.: Business Phone Number: r Plumber' dress (Street, City, State, Zip Code): A~~Zo IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing gent Signature (No S ps Approved El Owner Given Initial Surcharge Fee) Q / 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 S T C - 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. Owner of property Location of property !t 1/4 EX 1/4, Section y , TAN-R_Zj W Township Q/ 11 Mailing address Address of site //lJ Fr (Z,~~A Subdivision name / Lot no. Other homes on property? yes No Previous owner of property ~rz~s f~G ~aZN4 Total size of parcel f, 2:1 Date parcel was created Are all corners and lot lines identifiable? c,--`_ Yes No Is this property being developed for (spec house)? Yes k,/No Volume 6 d.-and Page Number 376 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 & 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. 3 p g 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. 6.3 G Sig ture of ap icant Co-applicant 8 /3- 9l Date of Signature Date of Signature SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BU-YER ADDRESS : 8 ( ~~.IJ ~z _ ,A), 3'ydI 6 FIRE NO : LOCATION: J E 1/4, 1/4, SEC. _T,~ 91 N-R l q W, TOWN OF: 1229 ST. CROIX COUNTY 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 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: --Gt~~ DATE: - Ic~ 9 St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS 'INDUSTRY, cc DIVISION LABOR P.O. BOX HUMAN REDLATIONS PERCOLATION TESTS (11J) MAD4SON WI 53707 (I R 83.09(1) & Chapter 145) LOCATION: SECTION: OWNSHI UNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME: /TP COUNTY: MAILING ADDRESS: ~fiG~~x ,C©z fo USE DATE OBSERVATIONS MADE ( g NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PE OLATI N TESTS: I$Residence ❑New Replace r f _ Z RATING: S= Site suitable for system U= Site unsuitable for system o-^ Q 3 -.;2 0 CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) YU I ES LA If Percolation Tests are NOT required DESIGN RATE: ^ If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: 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. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV ON BACK.) B- B- '4oc B- o`b e v. Ifle-<- B- B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER IAFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PERIOD 3 PER INCH P_ 4oll- P- P_ L 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 0c, 5: ` TH Fit It -to I _f s oc? cP~'qq'~J 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 Wisconsin 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: 9V)1O n ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): n X 6 0~}m ,c CST S ~TU, DI STRIBUTION: Original and,one copy to Local Authority, Property Owner and Soil Tester. I~ DILHR-SBD-6395 (R. 10/83) - OVER - FLOT PLAN PROJECT rZG~ der ADDRESS O~ 1~p~ ~d/2 ~SLOI~ ~lvl G 1/4~E 1/4/S3 /T~ N/Rj W TOWN f - COUNTY _Groac MPRS Byron Bird Jr. 3318 DA E - BEDROOM~ CLASS PERC~~ CONVENTIONA IN-GROUND ESSURE Of' CONVENTIONAL LIFT_ MOUND_ HOLDI TANK SEPTIC TANK SIZE LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE ABSORPTION AREA ERC RATE BED SIZE b Benchmark V.R.P. Assume Elevation 100' Location of Benchmark T® C,- s,~c e"CiCc C7 :Borehole Q Well Scale Feet 0 Perc Hole System Elevation ~..2 ,y Dent 12" Grad P_ TYPAR COVERING 2" 12" 3' 4 g' O 3' 3' O 3' 1 Sewer Rock 6" 12' 18, ~O 3 71 wf X61 10 ay