HomeMy WebLinkAbout030-2084-20-000 Z 3
o O
do O
a; o
c � ,
p>
N C m N 8 Y
c C
d
w
L
O) 0)
d?
>
O
O
O O)
O
N N .0 (9 C'O
O
C
N Y,_
OR
N
U
0) i
c O rn O F= m
0 3 0 > w
U Z y f3 0
cn .
Q
'O z
C 0 L O d O
7 f6 C U co c �N
LL O_ N CD C (v U
2r C @ 20 O
t O N C
Q �.� �L.t
O UJ E
N
U = O
t
Z
O d D
c') F- w
i
C C7
O Z : '" c
c
U O N
d Z c
c
co 0
N N O
C
N d
0)
O N Q 0
O Z co Z
CD
N N
c y N y
n `n CD
0 0 0 a
In
•N ! � ao. a
(n J U 0) rn m
7 } M In 00 CD o
C5 C5 -0 o N O O E N O O
`
r
d � I
c 'p m O
Z Cz 76
Cl
O O C L N C
O O O I: CO U y 7
O
O O
O In I- N W a O N
O
U. Oho ° a°i Y c CO y c n
-0 Z t -=a n
N - -. N O O C 0)
O V) M p U
Cl) M V) = H fn
V CC
d m £ d ji
3 Q ` a .T+
fl 47
��1 u V N
E C
C O�n ) a 2 N v C O
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS
LABOR& HUMAN RELATIONS 7969
P.O�DOJC PRIVATE SEWAGE SYSTEMS DIVISION
MADISON,W`11 53707 BUREAU OF PLUMBING
SW4,SE4,S36,T30N—R20W RRCONVENTIONAL El ALTERNATIVE IState Plan l.D.Number:
Town of St. Joseph ❑Holding Tank ❑ In-Ground Pressure ❑Mound (If assigned)
Lot 12 Pine Tree Meadows
NAME OF PERMIT HOLDER: I.ADDRESS OF PERMIT HOLDER INSPECTION DATE:
Kirk Green 756 Sand Hill Point, Hudson, WI 54016 a: j._3,U0 O7
BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV.:
Name of Plumber: MP/MPRSW N,. County: Sanitary Permit Number:
William Schumaker 6382 St. Croix 99103
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL . LOCKING COVER
PR�V ED: PROVIDED:
� 5 �• d [ Y ES ]NO DYES XNO
BEDDING: VENT DIA. VENT MAIL.: HIGH WATER NUMBER OF ROAD: - PROPERTY WELL: BUILDING VENT TO FRESH
/( C ' ALARM. FEET FROM LINE: LAIR INLET.
❑YES NO (�1 ❑YES NO NEAREST'
DOSING CHAMBER:
MANUFACTURER.
:171 NG: LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
ES ❑NO ❑YES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: PUMPANOCONTROLSO ATI NAL NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH
(DIFFERENCE BETWEEN FEET LINE AIR INLET:
PUMP ON AND OFF) OYES NO NEAREST
SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing=FORCE �eN DIAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire,construction shall cease until the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
•iiWiFtl C WIDTH: LENGTH. NO.OF DISTR.PIPE SPACING: COVER INSIDE DIA.. #PIT&. LIQUID
TRENCHES.
€FMENFSIONS V A �) M RIAL: PIT DEPTH:
GRAVEL DEPTH FILL DEPTH IDISTI PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO.DISTR NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
BELOW PIP .lL ABOVE COVER. ELEV.INLET EL GE Vi�NDp, PIPES LINE: - AIR INLET:
4�' Cl q,(.o 4 r I I �- _7 _ FEET FROM
I NEAREST—•-- i
MOUND S_
Moundi�site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA-
❑YES ❑NO
meets the criteria for medium sand. TIONS MEASURED.
SOIL COVER TEXTURE. PERMANENT MARKERS: OBSERVATION WELLS:
1:1 YES ❑NO ❑YES 1:1 NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SO DDED SEEDED. MULCHED.
CENTER. EDGES.
YE ❑NO 1:1 YES ONO DYES ONO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH: LENGTH:• NO.OF LATERAL SPACING: RAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER:
BET#3E CH TRENCHES G
01MENSIO�IS .':_
MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE• M
MATERIAL& ARKING:
".ELEV.: ELEV.. DIA.. ELEV.: PIPES. DIA.:
Ef-EYATFON ANO
UISTRIBLITION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
❑YES ONO 1:1 YES F-1 NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF,. PROPERTY WELL: BUILDING:
IF EET`FIiOX LINE:
❑YES ONO .. OYES ONO NEAREST
QA
Avr-t0 v
Sketch System on
Reverse Side. Retain in county file for audit.
SIGNAT TITLE:
-- ���— Zoning Adminis
DILHR SBD 6710 (R.01/82)
ator ,
INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT
APPLICATION
TO THE APPLICANT:
1. This 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. A new permit may be needed
if there is a change in your building plans, system location, estimated wastewater flow (number of bed-
rooms, etc.), depth of system, or type of system;
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. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed
pumper whenever necessary, usually every 2 to,3 years;
6. If you have questions concerning your private sewage system, contact your local code administrator or the
State of Wisconsin, Bureau of Plumbing, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
I Property owners name and mailing address. Provide the legal description where the system is to be
installed;
II Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat
restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling;
III. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or
repair;
IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project
is in conjunction with University of Wisconsin;
V. Absorption system information: Provide all information requested in ##1-6;
VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed,
number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete
for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if
tanks received experimental product approval from DILHR;
VII. 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. Fill in designer name if
applicable;
VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number.
IX. County/Department Use Only;
X. Comment area for use by county or resaon given when application is disapproved.
Complete plans and specifications not smaller than 8'/2 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; dosing or pumping chambers; 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.
----------------------------------------------------------------------------------------------------------------------------------------------------------
GROUNDWATER SURCHARGE
On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more
commonly known as the groundwater protection law. This change in statutes was the
result of over 2 years of steady negotiation and public debate. The groundwater bill GroundWOLtelr
included the creation: of surcharges (tees,) for a number of regulated practices which Wiscon4,in'S
can effect grounowater. The surcharge took effect on July 1, 1984. All of the water that surfed 1res',S1Jr0
is used in your building is returned to the groundwater through your soil absorption o
system or the disposal site used by your holding tank pumper.
0
The monies collected through these surcharges are credited to the groundwater fund adminis-
tered by the Department of Natural Resources. These funds are used for monitoring ground- t
ate, groundwater contamination in-,estigations and establishment of standards. Groundwater,
s worth, protecting.
SAD-r;39 iR.031/86)
SANITARY PERMIT APPLICATION Coup.
T DILHR In accord with ILHR 83.05,Wis.Adm.Code
STATE SANITARY PERMIT##
—Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER
8%x 11 inches in size.
—See reverse side for instructions for completing this application. PETITION
1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ENO
PROPERTY/J0?WVNEF#i PROPERTY LOCATION
JJ�� ,a %4 S 9C T3D, N, R E (or)
PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME
75—C 'e2i;t/� ow/
CITY,STATE ZIP CODE PHONE NUMBER El CITY hEAREST ROAD,LAKE OR LANDMARK
O
EA,TOWN OF7 VILLAGE: T
11. TYPE OF BUILDING OR USE SERVED:
Number of Bedrooms if 1 or 2 Family 3 OR ❑ Public(Specify):
III. PURPOSE OF APPLICATION: (Check only one in##1. Check##2,3 or 4,if applicable)
1. a. gNew b. ❑ Replacement c. ❑ Replacement of d.❑ Reconnection of e.❑ Repair of an
System System Septic Tank Only an Existing System Existing System
2. ❑ A Sanitary Permit was previously issued. Permit## Date Issued
3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements.
4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy.
IV. TYPE OF SYSTEM: (Check only one in##1 and only one in##2)
1. a. Conventional b. ❑Alternative C. ❑ Experimental
2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP
In-Fill Tank
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a. 54 seepage Bed b. ❑seepage Trench C. ❑ See a e Pit
2. PERCOLATION RATE 3, ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY:
(Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): 7
J� f Feet Private ❑Joint ❑ Public
VI. TANK CAPACITY Site
in gallons Total ##of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper.
INFORMATION New xisting Gallons Tanks Concrete stCon- glass App.
Tanks Tanks
Septic Tank or Holding Tank x ❑ ❑
Lift Pump Tank/Siphon Chamber ❑ I ❑ ❑ ❑ ❑
VII. RESPONSIBILITY STATEMENT
I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans.
Plumber's Name(Print): Plumber's Signature:(No St mps) MPRSW No.: Business Phone Number:
�•'�l;a&4~ 3'c!dA_ 3 2 2 c
Plumber's Address(Street,City,State,Zip Code): Name of Designer:
VIII. SOIL TEST INFORMATION
Certified Soil Tester(CST)Name EPhone
:; Y4
CST's ADDRESS(Street,City,State,Zip Co mber:
I COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater Date Issuing Agent Signature(No Stamps)
Approved ❑ Owner Given Initial �L` SZ11)6,�j harge Fee
�1 �
Adverse Determination S/do�c o Qv a
X. OMMENTS/REASONS FOR DISAPPROVAL:
SBD-6398(formerly Plb-67)(R.03/66) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber
i
i
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
Jrauauce. Should this development be intended for resale by owner/contractgr, ("spec
house"). then a second _form should be retained and completed when the property is
suld and submitted to this office with the appropriate deed recording..
- - - - - - - - - - - - -r - - - - - .- - - - - - - - - - - - - - - - - - - - -
Owner of Property . /�' A
J.ucat lute of Property j _ �. Section 6 , T 34 N - Rj W
Tuwuship
Milling Address
Subdivision Name
Lot Number
Previous Owner of Property . .2e�
Total Size of Parcel
Voice Parcel was Created
Arc all corners and lot lines identifiable? _ You No
lb this property being developed for resale (spec house) ? Yes No
VuIumu and Page Number _Z?-Jg- as recorded with the Register of Deeds
INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING:
/'1. Warranty Deed
1. Land Contract
J. Other recordings filed with the Register of Deeds Office
In addition, a certified survey, if available, would be helpful so as to avoid delays
cal Lhe reviewing process% If the deed description references to a Certified Survey
Map, the the Certified Survey Map shall also be required.
PROPERTY OWNER CERTIFICATION
J (we) een.ti.Sy Vi at ate atatement A on .thiA 6onm aAe tAue to the but o6 my (uuA)
kuuwtedge; that I (we) am (au) the owneK(ai o6 the pnopehty de cAiibed in tie
i.ri6u4matiun Sown, by viAttue o6 a watuAty deed Uconded in the .O66tee o6 VLe
Cuwi t y Regi6 teA u S Ueeda ab Document No. ; and that I (we)
ph ea a u.tx y own the.pn.0 pod e d a.ute Son the a e q-e poa a ya.tem (uA I (we) have
ubtai.ued an easement, to hu.4 with the above deaehibed pupen,ty, bon the
eanAthuCt On 06 aa.id Aya.tem, and the name has been yd�yo��ond)d in the O66.ice
uA .tile County RegiAten o6 Aeed6, as Document No, oa�1S5
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
cn
_ y
S T C - 10 r
.. r
y -
SEPTIC TANK MAINTENA CE AGREEMENT o
St . Croix pull ty
i
UWNEk/BUYEk
kOUTE/BOX NUMBEit /iNE /('all _..__Fire Number _
C ITY/STATEa /o�/,,
1'kUk'E1tTY LOCATION : syi/ It. SE ii, Section 'l' 30_ N , l:_,,;7 v W ,
T o w a of SX. J�� _- , SL . Croix County .
Subd visio e Pt _ o�cJS LUt number 42
I .
lmpruper use, and maintenance of your septic: systvw could resulL in
its premature failure to handle wastes . Pruper u►aiuLenanCe Con -
slbtb ul pumping out the septic tank every LhI*VC ye.►rs or buoller ,
it needed , by at licensed septic tank punMctr . What you hoc il%L0
Lhe system can affect, the function o'f° ta►.e septic Lank as a tr.cac -
menc stage in the was-to disposal system.
St . Croix County residents !say be eligible to receive a grant lur
a ►noximum of 6OZ of the cost of replacement of a failing system,
which was in operation pr"c ,--,- Croix County
acCepted t'2sis program in August' Of 1980. with the reyuireweut chat
owners of all new systems agree to keep their systems properly
maintained. --- - ----
The pruperLy owner agrees to submit to St . Croix Cuunty Zoning a
Certification fo.m, signed by the owner and by u MasLer plu till)4r .
journeyman plumber , restricted plumber or a licensed pumper veri -
lying that (l) the on-site wastewater disposal system is in liroper
operating condition and (2) after inspection and pun►ping ( it neC -
ebsdry) , the septic 'tank is less than 1/ 3 full ut sludge and scum .
Certification form will be sent approximately 30 days prior Lo
three year expiration.
0
s
I/WE, the undersigned, have read the above requirements and agree N
to maintain the private sewage disposal system in accordance with x
the standards set forth, herein, as set by the Wisconsin Depart- b
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 , dates and return to above uddress .
KARA
f
s,
M
..*.t...•+••.......««...«w.•i••rr• � s =4,�, ti's
� �f.�M�N•�•�N»ww • ..» •r.Nfw..».»q•r»N•Y•NSM�•' .
��w,. ffMf»•rMNwfwf•�f»»r».••.M•-.-ffswf-r«»«is..fMf.wf«�M•.PM�•M»f s ..
y vNNf----- nwf» •.«.««»»N.w•».w.�f--s.»-«««f.«..».-.f«w««..�. y� {
3')M1Ret.�M..Y oar�r.lr wir.w...rfiwf...» x
»....oji.»•wN �L.i -.....--»Mf--N».............
f..-»r• «••- � i A
ti Grant"A _nd allow is ..St -Ce+oAa�-......... � t�
� AE
� ' Lot. 12, Pine- Tree Meadows in To>!ri of 3t. aclrwl�r.,.••+
oaeph
�4
� air
widt ti a!�1 Ys�il '■1'w assume is :,t Al
�viompla tba i m too iD 904
etaese>ats, riestrictions and rights-of-way of r +d, i
ti
.rift rrie�r�R ast idnd dw.aar.
day Of
••... .....•f..f. »». ....
Rrkbm
f "•...«.. .,..a..�............. » ..r .........(SZAL) F.
f a$rs>�xs:aAao A tlSOWJ
STATS alp
s
RA,
se-e36,'
P
9 ` 3 12 d
� lY-
a' �' c G c3 c c c'a a. o try !�
N
�O
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR AND P.O. BOX 7969
H PERCOLATION,-'r.tESTS (115); , i MADISON,WI 53707
HUMAN RELATIONS
t' '(H63.09(11& Chapter 145.045)
LOCATION:
W H I;TP/`Mo b N+9H1�1, OTNO.:BLK.NO.: UBDIVISIONNAME:
y or)1 3n R� 0
PI nom` Time
COUNTY: OW R'S BU R S N E: MAILING-ADDRESS: '
Si-. Cr>s 6Alyd''.'IY1�/, f'1�' .. f�u�s° l 5 .
USE "''tT' '' • 'DATES OBSERVATIONS MADE
NO.BEDRMS.: CO R R TIO : O S: TESTS:
Residence i� �„ tofrvew;;''PReplace• : [f._IS 7 1 - 16 — 7
FTi
v r.. I
RATING:S=Site suitable for system U-Site unsuitable for system
NVENT ONAL: MOUND: IN-GROUND UR. : SYSTE -IN-FILL f10LDING TANK:RECOMMENDED SYSTEIyl:loptional)
S ❑U �S DU l�1 S ElU C7 S S NU +;�►� v(l
If Percolation Tests are NOT required DESIGN RATE: .,, 4SS' If,any portion of the-tested area is in the
under s.H63.09(5)IbT,indicate: ! I , Floodplain,indicate Floodplain elevation: /
;'PROFILE DESCRIPTIONS':,,..
BORING TOTA DEPTH T GROU NDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR; TEXTURE, AND DEPTH
NUMBER DEPTH ELEVATION OB`S'ERVED S GH TO BEDROCK IF OBSERVED(SEE ABBRV.ON CK.)
B- � . � 7 r��I f)one_' >,d� 7 ' 1. �:2 S�Qr� 5�2,17'IQSL 141 .2Ir "RI.1 1
i 2,g3'(3nl S,v7,ofi n5 �, .o ,S,
B-Z �,9Z 99,o > ci , l z
L �, s, .G7 s ., .y2 S, 2,sa s 9r,
B- 3 ry.� 97 1 >
7 t,� 7'B�r�'ls,//7�Qs ,`la,r R s, . s� ' s , 3,o R/sw COd
?y ;.�fit' �/ ; a s s,Z,:s n S L ,, 2 RI S Z 0 Sr P.st g Y P
B- 9��� 3 ,,�s-RCS tw , .
B-
PERCOLATION TEST'S
TEST DEPTHt WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER AFTER SWELLING INTERVAL-MIN. p RI O RI D PER INCH
p. . 112 0
d
P- yob; 3v
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 _ q3,
,
k _I
— -- H i$ .. - — ��' - — -- --- - -- �--
P T a
-
Gil, y,
4✓ r 1 C _ (Q _ - I
`+
ID
.iw — -- — —
'� O� 1
ell Fir oo C, _ 51- - - - --- - --
� ISL r
- -- -
4&_1
— -- — -
1,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 I
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:
y
ADDRESS. CERTIFICATION NUMBER: PHONg NU BERloptionali:
15 LA_ So,., CStooll/y 39G" I
• CST
-DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester.
DILHR-SBD-6395 (R.02/82) —.OVER—