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HomeMy WebLinkAbout030-1071-20-000 o O eo p d o 0 rV O X C M W O N C Y i n C i O w 'O N C O >N ca N > ~ N Z; NOM U p~ O r U ~ O 01O O'C N w aIw 0 0 N ~cN~ a~wy o z y- v E c 7 N Y U U. c0 (0 c0 L O N c 'a E M y C N •p Q 0) N (A O N Ili, a a) 2~ ~ H rn a E 0 0 v 4) 4) N H o d m I c C7 ~ I :w r 0 rn a0i 2 C mF-~ c E d hh~~ N N r+J n 1~ y y O 0 0 N •'v d M L R co 'N c v .2 0 Q !t - N O z m z o N Zzo v ~ aci c ~ E Y .0 Ln 06 a v 'I, > N N L ~ c I m D o a 0 'a U) co 0 E E 0 0 0 a Q •N i IL IL IL a 3 N 0 to d v) U rn rn } J O N O O O O Q N N N LO r- O O 'O ~ C :Z 00 d co y O (O 0 CP m Q co C ° LL 0 N O (I C., N C O ~~r O J O aM- V O (D 7 rn 0) O O M N w O fl N M~ C U d O O U N L II N a O C N N N ai U) N m c p N c N M O O n 0 0 17 V) LO O p_ O N H Z C N n 0 0 0 N O U) Y O z N H ~2" (n O ~ r • € d I V] y ~ 7 Q a E ` A U m 0 n 0 E7ffJ LHRSANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COON STATE SANITARY PERMI # -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ / C~ Q CE 8% x 11 inches in size. check if r vision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROP TY OW R PROPERTY LOCATION t/a S T , N, R B (or)dt PROPERTY OWNER'S MAILI G ADDRESS LOT # BLOCK # ~Il - J_ f- 7,! / 9 J") , ::z 1 STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR SM NUMBER CI 7 L a 7iS' - ' II. TYPE OF BUILDING: (Check one) CITY NEAREST ROA ❑ State Owned 0 VILLAGE 12 ZOWN OF, ARCEL TAX NUMBER(S) ❑ Public [0 1 or 2 Fam. Dwelling- # of bedrooms ~21_ P 111. BUILDING USE: (If building type is public, check all that apply) 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 40 Church/School 8 ❑ Mobile Home Park 120 Service Station/Car Wash 50 Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1.E1 New 2. [A Replacement 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 0 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.) PR7/10 SED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION 3 V,.57 Feet Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank - Lift Pump Tank/Si hon Chamber F1 Fj [I I [I VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installs on of the onsite sewage system shown on the attached plans. Plumber' Name (Print): / Plum is S' natu e: (No Si(am MP/MPRSW No.: Business Phone Number: S~ i,sr 2 - 9 P umbe 's d ress tr et, City, State, Zip Cod . &,e A, 1e" IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Ag nt Signature (No Stamps) Surcharge Approved El Owner Given Initial Fee) Q/ Adverse Determination 0~7( 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 FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP i SECTION_,-,2,~~T 2a_N-R TW ADDRESS J„~~~~Je,, lA,~r ST. CROIX COUNTY, WISCONSIN 1, ),z ~a~q SUBDIVISION N1 LOT LOT SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM oz®~ INDICATE NORTH ARROW BENCHMARK:Elevation and description: Alternate benchmark SEPTIC TANK: Manufacturer: Li5kw5 Liquid Cap. Rings used:` Manhole cover elev:~Final grade elev: Tank inlet elev.:92 /V //-Tank outlet elev.: No. of feet from nearest road:Front , Side , Rear Ft.~ From nearest prop. line:Front , Side , Rear t Ft. No. of feet from: Well , Building: -gyp (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: Width: Length~Number of Lines: Area Built Exist. Grade Elev. 9V14. Proposed Final Grade Elev. Fill depth to top of pipe: No. feet from nearest prop. line:Front , Side Rear_LFt.S No. feet from well:-/ 4No. 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: v 1-2 LICENSE NUMBER: S~9 6/90:cj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING OFi &.`IUMAN RELATIONS DIVISION .,ABAB 97969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION P . 0. B0 MADISON WI 53707 State Plan I.D. Number: NE 4 , NE a ,Sec. 2 6 , T 3 0 - R 19 (If assigned) Town of St. Joseph. Lo~4CONVENTIONAL ❑ ALTERATIVE Fro Pond Lane 7 Holding Tank ❑ In-Ground Pressure ❑ Mound NAME O PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSP Nm7{TE: Brett Kno srmanent r 1376 Fro Pond Lane New Richmond ' BENCH MARK (Peeference point) DESCRIBE IF DIFFERENT FROM PL N: REF. PT. ELEV.. CST RE . PT. ELEV.: Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: Kim A. O'Connell 3259 St. Croix 149045 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTL' ET E}~ V.: WARNING LABEL LOCKING COVER C,~ ? PRROOVIDED PROVIDED: / J ( lC-I YES ❑ NO EYES ❑ NO BEDDING: VENT (D~I VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH 1 ALARM: FEET FROM ( LINE: AI$IN0LE D YES ❑ NO -T C ❑ YES ❑ NO NEAREST I Y -I DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: PROVIDEDLABEL LOCKING OVER ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: AER TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: PUMP ON AND OFF ❑ YES ❑ NO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING: or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID BED/TRENCH TRENCHES: MATERIAL: PIT DEPTH: DIMENSIONS / 9 ~ (O G l GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. STR. NUMBER OF PROPERTY WELL, BUILDING: VENT TO FRESH BELOW PIP.: ABOVE (OVFZR: ELEV. INLET: ELEV. END: PIPES: FEET FROM LINE: AI INLET: .ZY NEAREST-~ ~ T LET, MOUND SYSTEM: Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; ❑ YES ❑ NO ❑ YES ❑ NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: EDGES: ❑ YES ❑ NO ❑ YES ❑ NO [__1 YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH: LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: LEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: ISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO FORMATION APPROVED PLANS ❑ YES ❑ NO ❑ YES ❑ NO PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: CO MENTS: FEET FROM LINE. ❑ YES ❑ NO ❑ YES ❑ NO NEAR UT - 0 .Ae fl ju_xl/ 19 Retain in county file for audit. Sketch System on Reverse Side. SIGN TIT SBD-6710 (R. 06/88) 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. Owner of property ~ A ~ Location of property ~ -1/9 /4, Section T-30 N-R -l W Township .S~ J S p Mailing address 13 7(0 )10 0. PD ~VV` Address of site 3-7 (G t-1 0 el RAJ C Subdivision name Lot number Previous owner of property ~t~► k S f ~ TrlC-tA ~ ~aiof S Total size of parcel Date parcel was created Are all corners and lot lines identifiable? -X-Yes No Is this property being developed for resale (spec house)? Yes N0 Volume ~ 3 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. --X---------------------------------------------------------------------------- PROPERTY OWNER CERTIFICATION I(We) certify that all statements on this form are true to the best of my (our) knowledge; e• 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. S 3-S ~•3 ; and that I (We) presently own the proposed site for the sewage disposal system osa1 s stem (or I (we) have obtained an easement to run with 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 Owner Signature of Co-Owner (If Applicable) ~ 3-1 Date of Signature Date of Signature r+ z H a STC - 105 r a H SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County z ty -(OT S OWNER/BUYER (JIr~C l ` 1 1elA ROUTE/BOX NUMBER (3(00 U d/u6` 6A At*--- Fire Number CITY/STATE ~/E (,y e°rt~l)AfS ZIP PROPERTY LOCATION: SectionZ(:~' T 3U N, R f W, Town of S-- '-j_0 Sdt St. Croix County, Subdivision Lot number. Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists 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 treat- ment 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 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 veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), 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. H E I/WE, the undersigned, have read the above requirements and agree Cn to maintain the private sewage disposal system in accordance with x H the standards set forth, herein, as set by the Wisconsin Depart- ►d ment 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 P.O. Box 98- Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above address. DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY DIVISION LABOR A~Nb PERCOLATION TESTS (115) MADISOP.O. BOX 76 N WI 53707 HUMAN RELATIONS (H63.09(1) & Chapter 145.045) LOCATION: SECTION: OTOWNSHIP/M ITY: OT NO.: BLK. O.: SUBDIVI ION NAME: /L?o NlRjo~l (or sf 1<< COUNTY: OWNE 'S BUYER'S NA MAIL ADD SS: 1 1 ?-/Z- 16-169 USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCI L DESCRIPTION: PROFILE DESCRIPTIONS: ER ATION TESTS: Residence ❑ New Replace s y- 9l RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM.(Dptional) ZS ou ©s ❑u cis au r0 s Ou 0S LL]u ~v If Percolation Tests are NOT require DESIGN ATE: If any portion of the tested area is in the under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: Alld PROFILE DESCRIPTIONS 6'F g 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 OBSERVED (SEE ABBRV. ON BACK.) 9&' !I _ s r B- B- B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES' AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PERIOD PER INCH P- P 7 P- 3 -44WAt 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 p r?9'~ ` ' - ~ l • r~ - 3 , e E _Tit j fr. I, the undersigned, hereby certify that the soil tests reported on this form were made by me in acc d '£fi the rocedures an metho cified in he Wisc nsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of k wledge and be " f. NAME ( n TESTS R C MPLETED ON: /I7! ® s- / ADDR S: CERTIFICATIONNUMBER: [PHONE NUMBER (optional): CST SIGN ~_UR \ DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - 'S/~J -SG'Ai:e D ~e% G. i !8. a3 o,. PAGE OF CrvSS S~C~IVI, o~ A 3r1~ S. Floth All Inlal► And obtstwellall Pipe Yf n Approrid Veal Cap t 12•ADOr• ~L'r~J~rQJr1h J.~ final al Goods s-5'fJ~7 20. 42' Above Ptpr 4' Coal Iron To final Orod• VoAI Plpo ' - lAwsh flay Or SymMlk Co.arlny rln 2- Aypropola Orar Pipe ' OIUIIIIYIIon . Pips 0 0 0 - Tao j Aoprayala BaAaal► Plpo ° PartorvN° Plpo Balov o -•Coupllny TMa,lnoling Al 6ouoa, Of S1►lu0 I/ SOIL FILL; DISTRIBUTIOM PIPE • APPROVED S`WTHETIC COVCR 2" of hGGRE6ATE OR 9M OF s-rRAW T OK tAAKSN HAy ~`~//l '~•'P~ f.NOPAGGRCGATE. t:LF-V. OF EET- DIS-I-RIIjUT110M PIPE TV BE AT LEAST ` INCHES BELOW ORIGIIJAL GRADE :a AWU AT LEASTtO IIJCHES BUT MO MORC THAN 42. IAICHES BELOW FINAL GRADE !•1 IMUM DEPTH OF EXCAVATIOP ROM OKI&V AL 6RADF- WILL BE I1JC.HES 1' HIMVM 9EFT-H OF EACAVATIO" F&OM 04~14INAL rjRAp€ WILL eC INCHEs SIGLICO: LICEMSE LJUMBER: DATE 9/ 110 _