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HomeMy WebLinkAbout016-1046-20-100 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 3 ~ LA -1 6 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Anderson, Ellison W. "Al" Glenwood Town of 016-1046-20-100 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: 21.30.15.333B TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM Aeration Bldg. Sewer Holding St/Ht Inlet St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing Header/Man. Aeration Dist. Pipe Holding Bot. System Final Grade PUMP/SIPHON INFORMATION Manufacturer Demand St Cover GPM Model Number TDH Lift Friction Loss System Head T DH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) 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 Mulched Bed/Trench Center Bedrrrench Edges Topsoil 0 Yes 0 No T 9 Yes 0 No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 2955 150th Ave. Glenwood City, WI 54013 (NW 1/4 NE 1/4 21 T30N R15W) NA Lot 1 Parcel No: 21.30.15.333B 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required? Efl Yes Ed No T1 Use other side for additional information. LL- Date Insepctor's Signature Cert. No. SBD-6710 (R.3/97) F b p tic r% County Sanitary Permit Application ST. CROIX COON WISCONSIN In accord with Chapert 12 St. Croix County Sanitary Ordinance PLANNING & ZONING DEPARTMENT so f na~6 y provide may be used for secondary purposes ST. CROIX COUNTY GOVERNMENT CENTER vacy Law. S. 15.04(1)(m)] 1101 Carmichael Road CFtf~17C C4U 'fY i ~ Hudson WI 54016-7710 MM 1 UMW' DEVELOPMENT - (715)386-4680 Fax (715)386-4686 Attach complete plans for he stem on paper not less than 8-1/2 x 11 inches in size. County Sanitary Permit # 4 Check if revision to previous application -7 2/ 1. Application Information - Please Print all Information Location: Property Owner Name /I(e 1 /4 /Ilk 1/4, Sec .7/* b7 / ~r r~dlt' K Sue u'C~e/LSG~ O N, R E (or Property Owner's Mailing Address Lot Number Block Number City, State Zip Code Phone Numer Subdivision Name r CSM Number G/, wv oaf- S 7`7 y3 11 Type of Building: (check one) amity ❑ Village ®Town of l~ 1 or 2 Family Dwelling - No. of Bedrooms: ❑ Public/Commercial (describe use): Va J 60.,- ALP 7( /41 ❑ State-owned Nearest Road II. Type of Permit: (Check only one box on line A. Check box on line B if applicable) Parcel Tax Number(s) ;YN A) 1.❑ Repair 2. Reconnection hnitation on-plumbing ❑Rejuvenation (O 9!- YO /S, 333 Permit Number Date Issued B) 3 33 24 ❑ State Sanitary Permit was previously issued IV. Type of POWT SXqa_m. (Check all that apply) Non-pressurized In-ground ❑ Mound z 24 in. suitable soil ❑ Mound s 24 in. suitable soil ❑ Mound A+0 ❑ Constructed Wetland ❑ Peat Filter ❑ Drip Line ❑ Pressurized In-ground ❑ Holding Tank ❑ Single Pass ❑ Other ❑ At-grade ❑ Aerobic Treatment Unit ❑ Recirculating . Dispersal/Treatment Area Information: 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. System Elevation 7. Final Grade Required Proposed (Gals./day/sq.ft.) (Min./inch) q y. X ' Elevation reir fa 1. Tank Information Capaicty in Gallo Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic New Existing Gallons Tanks Concrete structed glass Tanks Tanks ❑ ❑ ❑ ❑ ❑ II. Responsibility Statement I, the undersigned, assume responsibility for repair/reconnenction/rejuvenation/installation of non-plumbing for the POWTS shown on the attached plans. A license is not required for terralift repair or the installation f non-plumbing sanitation system. Plumber's Name (print) Plumber's Si u (n to MP/MPRS No. Business Phone Number gx c K a/ Z~? 831 7/5' yr8 = ~,~5<9 Plumber's Address (Street, City, State, Zip e) /Y / 3 y 7 Al 44°' ST W III. County Use Only Dis pp Sanitary Permit Fee ate Is ued Issuin gent Signa r s s) Approved Owner Give ial Advers OQ oration J ✓ IX. onditions of Approval/Reasons for Disapproval: / P G- V~Z4h QJ~.`~ V~l~tS~ Yom-- F~t)~ 5I 18,euj ca Rev: 8/05 D O O R WAY T O Q U A L IT Y GOODIN COMPANY Vkofsafrs / Jyiur/ ems' eve, m s2- /10 `r */a!` n O 4C I ~w Few I ! ~ r I I ~ I I ~ I ~ I I f ( I I I Minneapolis St. Paul Duluth Detroit Lakes St. Cloud Brainerd Sioux Falls Fargo Rochester Eau Claire Omaha Wausau Milwaukee Madison (612) 588-7811 (651) 489-8831 (218) 727-6670 (218) 847-9211 (320) 259-6086 (218) 828-4242 (605) 332-3444 (701) 298-3210 (507) 529-1284 (715) 830-1800 (402) 331-6813 (715) 675-2513 (262) 781-1770 (608) 663-0331 ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) This is to certify that I have inspected the existing septic and/or dose tank presently serving the following residence: (Street address) I? yss located at: g, 1/4, ffC 1/4, Section Town_&,,_N, Range /S W, Town of St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of Comm. 84.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service q' Did flow back occur from absorption system? Yes No A- (if no, skip next line.) Approximate volume or length of time: gallons minutes Tank Capacity: loco, f' Construction: Prefab Concrete V- Steel Other Manufacturer (if known): Age of Tank (if known): _ / 9 95' Permit number (if known) censed Plumber Signature) (Print Name) 4- 4,11, CAL- (Title) (License Number) MP/MPRS (Date Form to be completed by licensed plumber (Dept of Commerce Chapter 5 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 9/2008 County Sani y Permi lication In accord with Chapert 12 St. Croix ou ST. CROIX COUNTY WISCONSIN t9'3tsnitary Ordinance PLANNING & ZONING DEPARTMENT Personal information you provide may be used for secondary purposes ST. CROIX COUNTY GOVERNMENT CENTER 30, [Privacy Law. S. 15.04(1)(m)] 1101 Carmichael Road ST CROIX C UNTY Hudson, WI 54016-7710 ach com lete plans for the s stem on (715)386-4680 Fax(715)383-4686 Y paper not less than 8-1/2 x 11 inches in size. County Sanitary Permit # I ❑ Check if revision to previous application Ap lication Information - Please Print all information P Owner Name Location: 0 c~ ~1-s/1~" SGT! , AI(~ 1/4 1/4, Sec Property Owner's Mailing Address ~~I ~ ~ NR ~ E (or) 16e7 tm lKs- /re) ~ Lot Number g City,,'State 11 Zip Code Phone Numer Sabdrv~siu.l l n &w CSM Number /013 1 ype of Bui din 1 7 2 2 5 3 2 2 ~G~W, L g: (check one) J J J C1 1-or 2 Family Dwelling - No. of Bedrooms: ~itY ❑ Village Town of ❑ Public/Commercial (describe use): b r9'n ~t ,p .rJ El State-owned 4 l 11. Type of Permit: (Check only o Nearest Road Y //''ox.na~ e A. Check box on line B if applicable) . Re1'uvenation Parcel Tax Number(s) 1.0 Repair Reconnection 13. Non-Plumbing 4 ❑ A) 0110' Iby(p-ZQ-~ b Sanitation 4 11SL~~ 1 ? 2, B) Permit Number Date ssued ❑ State Sanitary Permit was previously issued ~r IV. Type of POWT System: (Check all that apply) Non-pressurized In-ground ❑ Mound z 24 in. suitable soil ❑ Mounds 24 in. suitable soil E3 Sand Filter 13 Mound A+0 ❑ Constructed Wetland ❑ Peat Filter 13 Pressurized In-ground [3 Holding Tank [3 Drip Line ❑ At-grade ❑ Single Pass ❑ Other 000b Aerobic Treat nt Unit ❑ Recirculating Dispersal/Treatment Area Information: S'a 1. Design Flow (gpd) 2. Dispersal Area is rsaI Area Application Rate 5. Percolation Rate 6. System Elevation 7. Final Grade Required s./daY/sq•ft. posed ) (Min./inch) Elevation 1. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- New Existing Gallons Tanks Concrete structed Plastic Tanks Tanks glass ~ T(G 'dU " ~ - ❑ ❑ ❑ ❑ II. Responsibility Statement ❑ ❑ ❑ ❑ ❑ I, the undersigned, assume responsibility for repair onnenct' n/ ]uvenation/installation of non-plumbing for the POWTS shown on the attached plans. A icense is not required for terralift re it or the in lation n lumbing sanitation system. 50es Name (print) Plumb s i r (n s s): ©P 0 L S/ 4 L MP/AAPRS No. Business Phone Number Plumber's Ad? e~S Street, City, State 1P t ~SZf~ [ ( z~~ ZL III. County Use Only Disapproved Sanitary Permit Fee D at Issuing Agent Signature o stamps) 7N " Approved Owne I Adverse ~j D D De mination Y ~~~•~,at X Conditions of Approval/Reasons for Disapproval: OW +t~.r IV~r++u 5- - r,-i~ I, 411 ot,i ►.n~e~na nce c, e e rK ~ L4 P -e 014 Rev: 8/05 4 jr &-tl~~,5-1 PL ~ - /Ll 1~e) 7 -AAJ a~ SS l sD x "AAr r Y 4 • ,fl9 ~R Q ~I r 5+^° 7 wl P Z~ OIL- 45 ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) This is to certify that I have inspected the existing septic and/or dose tank presently serving t e following residence: (Street address) C~ I csn-tL ~k located at: WW I/4, N 1C 1/a, Section :;Z 1 j own 30 N, Range_IE::, _W, Town of C-,tpt , St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of SPS. 384.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service _ X7 101,0 15 Did flow back occur from absorption system? Yes NoX (if no, skip next line.) Approximate volume or length of time: gallons minutes Tank Capacity: /QQ p Constructio : Prefab Concrete X Steel Other Manufact er (if known): f R- Age of T nk (if k wn): Permit mbe ow/! (Liven e Plumb i at re) (Print Name) IN-ITS ~~c~ ~f- 1 -69 (Title)] ~Ll.~l1AeO-- Z, (License Number) MP/MPRS btb 15 (Dat Form to be completed by licensed plumber (Dept of Safety and Professional Services Chapter 305 and s. 145 06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 2/2012 Wisconsin Department Industry, PRIVATE SEWAGE SYSTEM ounty: ' Labor and Hd Hdman Relations • ST. CROIX Saflity and Buildings Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: P AN~H> 961 meELLISON ❑ City ❑ Village Town of: State Plan D o.: CST BM Elev.: Insp. BM Elev.: BM Description: Pa rue Tax No.: C/U G!/ Ci[/ GU Qs i~lG) ~ ~G~ TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark 9U° 8Z Dosing J -3,3s o Aeration Bldg. Sewer H 6. ov 7St/,aft Inlet 6,60" TANK SETBACK INFORMATION St/~?t outlet ' 6 a , oa TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic >40 NA Dt Bottom Dosin NA Headers r SS.1 ' Aeration Dist. Pipe Hol Bot. System v 55. PUMP/ SIPHON INFORMATION Final Grade anu r Demand Model Number GPM TDH Lift Friction TDH t Forcemain Length Did. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width / Lengt No. Of Trenches PIT No. Of Pits Inside Dia. i id Depth DIMENSIONS I 5 D SYSTEM TO pqjj BLDG WELL LAKE/STREAM G Manu acturer: SETBACK INFORMATION Type CHAMB o er: System: OR UNIT DISTRIBUTION SYSTEM Hea er to- - Distribution Pipes , x Hole Size x Hole Spacing Vent To Ai Intake Length Dia. Length _J~j Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Depth Over Wen Ai Depth over 3 „ xx Depth of xx S /Sodded xx Mulched Trench ter - Sd BOW Trench E ges~~ j~ Topsoil ❑ Yes ❑ No Yes ❑ No COMMENTS: (include code discrepancies, persons present, etc.)/1s LOCATION: Glenwood.21.3 .15W, NW NEI 1 Otp venue ll , `~l ~k -f L.~ ; pE. l ~~a-a;. ~::G .y /~..F" ~np c~!' ! ~y/G} , ~ n G7~ /~'1 ~17.G..i . 01 Plan revision required? ❑ Yes ff-N-'o' Use other side for additional information. I/ SBD-6710 (R 05/91) Date Inspector s Signature Cert. No. 1LNR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY -Attach complete plans (to the county copy only) for the system, on paper not less than STATE A jiTppIT # 81A x 11 inches in size, 4, O O g -See reverse side for instructions for completing this application. ❑ Check It revision to previous application 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. STATE PUN I.D. NUMBER PROPERTY O ER PROPERTY LOCATION ' 41j',4 Ngle J-0 /i/ I/ E ?d , N, R /.S r W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER II. TYPE OF BUILDING: (Check one) State Owned NEAREST ROAD VIL DWN LAQ G~eNwood /SO~ /f ❑ Public W 1 or 2 Fam. Dwelling-# of bedrooms PARCEL TAX NUMEILM(b) III. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo Al - 2 H 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 IV7 TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. QQ New . 2. ❑ 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 ❑ 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: 7GALLONS 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) '70 . W-,r O- ELEVATION D Q / a0 0 Feet 9 ;Z? Feet VII. TANK CAPACITY INFORMATION in allons Total # of Prefab. Site New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass A Fiber- Plastic App. Tanks Tanks structed pp. Ic T nk or H I Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stam s) EM%0" / 0. : Business Phone Number. Plumber's Address (Street, City, State, Zip Code): J 1v 7e G,L eN 4~k 4 k/" IX. COUNTY/DEPARTME T USE ONLY Disapproved Sanitary Permit Fee (Includes Groundwater a e issued lasutng Agent Signature (N0 Stamps) /IJt/I Approved ❑ Owner Given Initial Surcharge Fee) 4 Adverse r in I n ~U! r X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-MS(R.08193) DISTRIBUTION: Original to county, One Copy To: Safety a Buildings Division, Owner, Plumber I STC 104 AS BUILT SANITARY SYSTEM REPORT OWNER L, L, i ~S/l N Ndia S O /y ADDRESS O i v ~1. e /y ! u7 SUBDIVISION / CSMJ_ O~~ - ~Q ~b ;2 fJ LOT # SECTION oc TjAr -N-R1~_W, Town of C"/- ely 4-e-'o vo/ ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 3 . ova' s'h d > 3t~R, tic Nt7M n /off INDICATE NORTH ARROW i Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. i STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNERUMM &ON ANa',~'R ,~o~li' MAILING ADDRESS 1019 SY &ye,!jyLy PROPERTY ADDRESS _:2 9~5'"h h ee 6,C 'V4'o0 oe, (location of septic system) Please obtain from the Planning Dept. CITY/STATE 6PX,1_-/Y4v0 oo/ (pl y 4, / ~ y4/3 PROPERTY LOCATION IV4,> 1/4, _ N 1/4, Section _ .2 T749N-R 455 W TOWN OF _ /V o o d ST. CROIX COUNTY, WI SUBDIVISION , LOT NUMBER CERTIFIEDSURVEY MAP , VOLUME , PAGE . LOT NUMBER 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 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 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 system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater 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. 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 stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. SIGNED: DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 S T C - loo 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 Noel' Sd ti Location of property Nj~ 1/4M.,-= 1/4, Section Z/ , T ,7o N-R /S W Township G~~Nk,o o d Mailing address Pat "Tl Address of site .2 '14'a Z ely4,oocl Ci7`v 40i , cj~&13 Subdivision name Lot no. Other homes on property? _ Yes_P~_No Previous owner of property tea! 1.~i iy C~,pL -,~,y , Jy) v.P 11~ e4.o4'01Y Total size of property 70 14C I? Total size of parcel 7a If 41 Date parcel was created Ap 9q Are all corners and lot lines identifiable? Yes X_No Is this property being developed for (spec house)? Yes No Volume 22je. 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. own the proposed site for the sewage ~disposaltsystem) orr I e(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 the County Register of Deeds as Document No. gApp cCo-Applicant G7~ .4! Dame or Signature Date o Signature mow E -f----'s------•---• , ~sa .s ~r .0-114 .ilr s .s s 4 i • 'a m o 20 Q 4 0 o 44 Q o r, OUR cd .o-v~ .o oz .o-s O ~ T. t LL uVi u YTtt-./~.Pj................ .1Zll'j i'.Fj• .0 . .0 ZL .4-.8 ,tt i AlAz .8 ,8 (F9 N aD , N N - • ti 9 :r . 6 Zr EJ J -j all h LL 0 r . E! f It ~ ci xErr= o-e STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER_ /`y ADDRESS /0 e /V 4r" SUBDIVISION / CSM# ;7- v LOT # SECTION / Tjt9 N-R~W, Town of 6F/- el A/ 4,e-141 a C/ ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM y "o t'h e- 1\ Ho m e n /oe INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK : y/O G Al N ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION I Manufacturer: 10 Liquid Capacity: le-~77V Setback from: Well House Other Pump: ManufModel ize Float seperation s/cycle: Alarm Locati SOIL ABSORPTION SYSTEM Width: Length_ T e Number of trenches Distance & Direction to nearest prop. line: Setback from: well: _ House Other ELEVATIONS Q Building Sewer ' ST Inlet, t2n. ,7 ST outlet PC inlet PC, bottom Pump QOf f Header/Manifold / / . .r I7 Bottom of system Existing Grade Final grade DATE OF INSTALLATION: PLUMBER ON JOB: - 4 ~177~ LICENSE NUMBER: NP S-Vfa r INSPECTOR: 3/93:jt • Wisconsin Department of Industry, Labor and Hi3man Relations PRIVATE SEWAGE SYSTEM County: Safety and BaildingsDivision INSPECTION REPORT ST. CROIX GENE~~RAL INFORMATION (ATTACH TO PERMIT) SanitaryPermitNO-: ff~ eELLISON ❑ City ❑ Village Town of: State Plan D o.: Insp. BM Elev.: BM Description: ° Parcel Tax No.: A94 111 7 > TANK INFORM ATION ELEVATION DATA TYPE MANUFACTURER " , A/ Septic CAPACITY STATION BS HI FS ELEV. c s C • Benchmark Dosing 87 / Cam.. 1C.1 Aeration -3.3 7 Bldg. Sewer Ho /o?• , St/, 4t Inlet TANK SETBACK INFORMATION a St/~t Outlet TANKTO P/L WELL BLDG. Vent to U, a•~c~ it Intake ROAD Dt Inlet Septic NA Dt Bottom Dosi n Aeration NA Header t~g nr, ~ Z r SS 97 Dist. Pipe Hol - - • ~r PUMP/SIPHON INFORMATION Bot. System Final Grade anu er Demand d~ dr S, 7 Model Number GPM TDH Lift Friction TDH t Forcemain Length Did. Dist. To Well SOIL ABSORPTION SYSTEM BED /TRENCH Width ~ Lengt j No. Of Trenches PIT DIMEN I N No. Of Pits Inside Dia. Li uid Depth DI SETBACK SYSTEM TO P/L BLDG WELL LAKE/STRE G Manufacturer: INFORMATION Type O K, System: e, ~>169' 7 OR UAMB NIT o e um er: DISTRIBUTION SYSTEM Headerl.A4,6 }4 ~ Distribution Pipe(s) Length Dia r x Hole Size x Hole Spacing Vent To Air Intake Length ~ Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Dep~Ten r All Depth Over Center- j „ xx Depth of xx S & /Sodded xx Mulched ~d9Trench Edges--~ Topsoil ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.)f{5 _ Yes ❑ No LOCATION: Glenwood.21.39.15W, NW, NE, 150th venue r Plan revision required? ❑ Yes No Use other side for additional information. SBD-6710 (R 05/91) ' Date Inspector S Signature Cert. No. kr SANITARY PERMIT APPLICATION VW■H R In accord with ILHR 83.05, Wis. Adm. Code couNTY PERn~T # -Attach complete plans (to the county copy only) for the system, on paper not less than STATE SA lITSRY8UpO 8/z x 11 inches in size. al g -See reverse side for instructions for completing this application. ❑ Check if revision to previous application 1. APPLICANT INFORMATION PLEASE PRINT ALL INFORMATION. STATE PLAN I.D. NUMBER PROPERTY OWNER PROPERTY LOCATION / 0 /V Ncf fo!1/ N A Y.,S ! T`Q N,R fir)W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # G° e- CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER II. TYPE OF BUILDING: (Check one) ❑ State Owned CITM NEAREST ROAD VILLAGE :6Ve1y'Aa,4aPa ❑ Public ~ 1 or 2 Fam. Dwelling-# of bedrooms AR ELTAX NUMBERO III. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo 2 ❑ Assembly Hall 60 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. UN New 2.E] 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 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ® Seepage Trench 22 ❑ In-Ground 13 ❑ Seepage Pit Pressure 42 ❑ Pit Privy 14 ❑ System-In-Fill 43 ❑ Vault Privy 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 VII. TANK CAPACITY p Feet 9. .Z b' Feet Site INFORMATION in gallons Total # of Prefab. New is tin Gallons Tanks Manufacturer's Name Con- Steel Fiber- Plastic Exper. Tanks Tanks oncrete structed glass App. Se tic Tank or Holdin Tank P Lift Pum Tank/Si hon Chamber Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stam S) MP/M1191111111IhNo.: Business Phone Number: e 1,~ ~I "7t'✓ .~~-d,5~o a~,~ ~d.~' Plumber's Address (Street, City, State, Zip Code): IX. COUNTY/DEPARTME T USE ONLY Sanitary Permit Fee (Includes Groundwater Approved ❑ ODate ssue Issuing Agent Signature (No Stamps) /IYrI Surcharge Fee) .113 ❑ D=DDetermiinarion A X. CONDITIONS OF APPROVAL/REASO NS FOR DISAPPROVAL: SBD-6398(8.08/93) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber i - - ,71 j 7` e e c s /Q~' N j , i-- - _ - _ j - i ~~LHR SOIL AND SITE EVALUATION REPORT Page/ ofd in accord with ILHR 83.05, Wis. Adm. Code roias+v.,aan°F.,wwrawma COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but .$^f C not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. © / - VIYI-,; e APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION / / ;So /V ANor GOVT. LOT 4~) 1/4 F 114,S21 T YD N,R W PROPERTY OWNER: 'S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # /ol S e ve CITY, STATE _ ZIP CODE PHONE NUMBER []CITY []VILLAGE OWN N EAREST ROAD GL A, C .S o/ (.71X) - 367 G,t e? d JXJ New Construction Use [ J Residential / Number of bedrooms Addition to existing building J Replacement (J Public or commercial describe Code derived daily flow 00 gpd Recommended design loading rate bed, gpdift2j,,~- trench, gpd/ft2 Absorption area required 7S"o bed, ft? /100 trench, ft2 Maximum design loading rate ~Zbed, gpdift2 , 2T trench, gpd/ft2 Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design / site considerations Parent material G~,# 0/a L j`-iL L Flood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable for s stem ®S ❑ U ® S E] U CgS ❑ U ® S ❑ U ❑ S RU OS ❑ U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench _!y Le Yle gz;2 0'h 4A ~ IN a s6 114 f-I C s Ground 3 ••~O ~.3 5 C elev. q2• oft S Al j 7, S Depth to limiting factor Remarks: Boring # g:. -/8 0 3 S/ S M e S Ground elev. 68'-y 7, LC Depth to limiting factor FT I T-1 Remarks: CST Name:-Please Print S, Phone: if~f / ~5^ 3cf'' Address' Signature: Date: CST Number: ' PROPERTYOWNER_ 4 Nc%.ySQN SOIL DESCRIPTION REPORT PARCEL I.D.`# O f /Q L/~ eq Page .Z of Boring # Horizon Depth Dominant Color Mottles Texture Structure GPD/ft in. Munsell Qu. Sz. Cont. Color Consistence Botx>c~ry Roots Gr. Sz. Sh. Bed Trench 3 o /o L .2s L S6 i- C S 1 .6 Ground elev. ,,r- 4 14 ft. YO ..5' S N s -7 i 01 Depth to limiting factor i i Remarks: Boring # .25-0 I LO YA Ground elev. f X78 , .h~ .3' ~ ,S t M~- Depth to limiting factor Remarks: Boring # Ground elev. 8 ft. Depth to limiting factor Remarks: Boring # try \.4n Ground elev. ft. Depth to limiting factor Remarks: i i 1 I _i- ~ - Imo- - ~ - i Ilk" _'~L'-~ o o - 1 i . 0,9I SA2 ----1 I - - 17 1---ice ` - --j _I - L-- - ---r--- ~ -_i ~ 1 , _ J 1 STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/ ~~L /~'o/✓ X *c1aR SoA/ MAILING ADDRESS /O l f -e/y4~10-ol &;I-y' PROPERTY ADDRESS :2 9~S~ ~✓~O 7`fj~ ~9- ~~g~f/l,~yo o~ G~ /7~y lsi/^ „SJlia/~ (location of septic system) Please obtain from the Planning Dept. CITY/STATE Cx, 'e'lVGr.JO 00"" 4!5 /~t( Z'r' PROPERTY LOCATION 1114,) 1/4, _IV,)-- 1/4, Section o2 T 70 N-R 45' W TOWN OF GrZ je/S(Ga oo d ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER CERTIFIED SURVEY MAP , VOLUME , PAGE , LOT NUMBER 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 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 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 system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater 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. 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 stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. SIGNED: DATE: (_7 St. Croix County Zoning Office ~ Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 S T C - loo '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&/:1/4, Section T ,3o N-R W Township G~-e/y~vo o d Mailing address 1019 S'viyre f~v G,Leiy4iyod G'i~ !rJ/.~~-'sro/.~ Address of site ,2 ~ ,r r Subdivision name Lot no. Other homes on property? -Yes No Previous owner of property dal lvi A/ Grif.S'L S® N y,Q f~ fd~ 5'01Y Total size of property 7p C,Q to Total size of parcel 7d If C ? L. Date parcel was created Ap 99 Are all corners and lot lines identifiable? Yes ~j No Is this property being developed for (spec house) ? Yes 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. , 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 the County Register of Deeds as Document No. %1_D.~ 111 ignature o Applicant Co-Applicant D e of Signature Date o Signature