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HomeMy WebLinkAbout006-1040-30-100 C)o I a~i ° I M y O O w a c c 0o a 0 I x I N a3i $ e I '~~y I j M m Qa m a m Ec) 7 f6 O o o° 'Its ~ I N0'ai I U m I m~Q I ai cvw u~ Z c z NNN c 1L C LL C N m C O c 3 o •y E o o a yEco U tL c(V c Q E Q F- to C CD c 0) O O m C) (D A y A E E r w C v o " o Z € V ao Z a co a m o o z v aoi z c c o N H ~ o y Z ~ I E •o I a~ I ~ I ~ L I ~ ~ o I Q Z Z Z O 2 Z Z O N z N m C ~p C N m _ 'R -h m m ~ m U 1 0) y d d U o ooca IE o3 CL E Z~ j ov)tnw > o omNm > o as o •iv ~aaa ~aaa a_ ~ d 0 J U m N N co in ~rn zo a~~ a) a~ p o - O rn m _ i~ a o o E w co C L co C d f!1 Q (q d m N 'C Q z cn I N~~ m Q} to m I N U) 0) N U) U O N w C O •p N N c O 10 E p m a) V c m e C c co a~ FF c v a C, i (D o F" O O N N t t N R N 00 W ~ C 00 C C C N C O Y! Z N N fD N N Z r~.. 'O I~ M O N 7 N-'r .`~.r N C OD • o m U 2 z N o o m °v o u'i o o R 0 - I- Z 2 N z z F- g to E m R € a E a a d • a d d y t y a 4, c rw 7 c 0 _ r A 0 at II) Cc o 0U 0 A s DEPARTAENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING MADISON, WI 53707 W13,, SW4, Sec. 18,T31-R16 000NVENTIONAL ❑ALTERNATIVE State Plan I.D. Number Town o Cylon D Holding Tank O In-Ground Pressure ❑ Mound Ilt assigned) 215th Ave. NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HO LDER~ INSPECTION DATE Gar Hallern Rt.l, Deer Park, WI 54007 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.. Name of Plumber: MP/MPRSW Nn.. Cnu my Sannary Permit Number: Calvin Powers Jr. 1563 St. Croix 135408 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY TANK INLET ELEV. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED. DYES ONO DYES ONO BEDDING: VENT DIA.: VENT MATT HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING. VENT TO FRESH ALARM FEET FROM LINE AIR INLET. OYES ONO DYES NO NEAREST DOSING CHAMBER: MANUFACTURER BEDDING: ILIOUID CAPACI TV PUMP MODEL PUMP: SIPHON MANUV ACTOHER WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: DYES ONO DYES ONO OYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PHOPEHTV IV, ELL BUILDING VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET' PUMP ON AND OFF) DYES ONO NEAREST 101P SOIL ABSORPTION SYSTEM. Check thesoil moistureat thedepth of plowing 11AA1,11TEH 111ATIRIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: BED/TRENCH WIDTH LENGTH NO. OF UISTH PIPE SPACIN(l COVEN INSIUE Uln -PITS LIQUID TRENCHES MATERIAL: PIT DEPTH DIMENSIONS GPAVEL DFPTH FILL DEPTH IDIST'11,IlIFFII, UISTH PIPE DISTR. PIPE MATERIAL NUMBER OF PROPERTY WELL BUILDINGVENT TO FRESH BELOW PIPES ABOVE COVER E EELEV. END PIPES LINE AIR INLET: FEET FROM NEAREST-~ MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- DYES O NO meets the criteria for medium sand. TIONS MEASURED. SOIL COVER TEXTURE PEHMANI NT N1AHKEHS oBSEHVATON WELLS _ ONO DEPTH OVER TRENCH BED DEPTH OVFR TH ENCH HEU UCPTH OF TOPSOIL IS(m[FU OYES SEEUFO DYES MULCHED ONO ICENTER EDGES DYES. ONO DYES ONO OYES ONO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH NO.OF LATERAL SPACING 16HAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER TRENCHES. DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR PIPE IMAN110111MATERlAL IWODISTH DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEVATION AND ELEV.. ELEV. DIA. ELEV. PIPES DIA DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED COHHECT Lv JCOVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS DYES ONO DYES ONO COMMENTS: PERMANENT M A R K E R S: OBSERVATION WELLS. NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE DYES ONO OYES ONO INEAFES Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE. TITLE: DILHR SBD 6710 (R. 01/82) f LHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code CCK;N TY ~ •as,wn w,wn,~w,vs STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than /3!:-) 4(o5 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. PROP TY OWNER PROPERTY LOCATION %a S , N, R J(or PROP WNER'S MAILING ADDRESS LOT # BLOCK # CI , STATE ZIP CODE PHONE NUMBER SUBDIVISION N E OR CSM NUMBER .:j / s 11. TYPE OF BUILDING: (Check One) El State Owned VILLAGE dhi 41,24 NEAREST RDA[ ❑ Public 127"7q 1 or 2 Fam. Dwelling-# of bedrooms - PA NIT Nu ) III. 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 70 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) f~f A) 1. ❑ New 2. ❑ Replacement 3.E1 Replacement of 4. ILlI Reconnection of 5.E] Repair of an System System Tank Only Existing System Existing System ~q 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 X Mound 30 El 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 RECIIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION Feet Feet VII. TANK CAPACITY Site in gallons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New istin Gallons Tanks Concrete strutted glass App. Tanks Tanks Septic Tank or Holdin Tank Lift Pump Tank/Si hon Chamber L1 LJ LJ 1 0 1 F-1 Vlll. RESPONSIBILITY STATEMENT I -the undersigned, assume responsibility for installation of e o its se ,age system shown on the attached plans. Plumber's ame (Pri Plu 's Si natur : Stam MP/MPRSW No.: Business Phone Number: r Plumber's Address (Stree City, Sta Zip Code): IX. COUNTY/DE ARTM T USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date ssue Issuinq Agent Signature (No Stamps) urcharge Fee) Approved ❑ Owner Given Initial Adve a Determinati n 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. 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% 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.63M (R.11ie8) 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 Location of property 1/4 /4, Section /TX4N-R_e,' W Township Mailing address Address of site 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 r 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. _T~, - ; and that I (We) presently own the proposed site for the sewage disposal system (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 Regi ter of Deeds, as Document No. S1g`nature,,6f Owner Signature of Co-Owner (If Applicable) e' Date of Signature Date of Signature Y STC - 105 I SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER ROUTE/BOX NUMBER ~ FIRE NO. CITY/STATE ZIP _ PROPERTY LOCATION: 1/4 1/4, Section, Tom,( N R W Town of ~ , St. Croix Cou ty, Subdivision Lot No. Improper use and maintenance of your septic system could result in its premature fail6re 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 , °..:..1 . DATE : r° St. Croix County Zoning Office St. Croix County Courthouse 911 4th Street Hudson, WI 54016 (715) 386-4680 Sign, Date, and Return to above address 7 + -rt i l j j 1 1 l! I ; j ! I I : ~ I I I I I( I r - I - I i :tz i ' i II I i-- I i I ! ~ i i i I 11 j ~ I 171 I I ~ I i l l i I I I i I ; I I Imo- I ~ I i I --hl-- -~--~---Y~--~--- ~ - - - ~ fi lI I ~ i r, ~ f ~ I Imo- i I III il.- -1--i ~-1--I -----~--~-1- ~ I I I I ~ I ~ I i I I ! I ~ I I I I I , I ~ ~ ! I ~ I i I ~ I I I ' r I ` J f - fi I r : I - I ! ! !