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HomeMy WebLinkAbout030-2038-20-000 i n cn O S a n C C d O C CD nl. a d ^ 3 qt ` 1 M CO U) N O s O o CO d w° • (D 7 (D Ul (D O O N '.7 n n N o (O (O -i Q z c N (D (D (D w p Ul A CJ N N ~ a ~ ~ ` 1\ N N N a- O O 0 0 0-0 (D 7 O O ~v CD , v c m m o D o 3 ' :E o 7 N (D = O O CD 0 (D cn ➢ a cwn m ~ a co m _ n N 3 O (O O N ~ ~ ~ n U) 41 A O O r Z O -0 -0 T M O O O z o 0 , ((D c N x. 17 m 0 C) co co O (D C N N c A CD Q O CI N CL 0 N z zD co oz p o a CD CD CD N O C) (a N c N (D CL w (D n (D z (D ' Z N Z (D A z 3 v ° G) 0 c m w C), W (D o CL ~ z c z N c m N .Z1 (D W N O (D CD n ((D ? D L T N ~ ~ C N N - ~ z a a o m ~ v (D a CL 2 CD 1 C a cn C o' o (v 0 0 ~n a o I(D v> O a o o CD CD 0 0 Fo rm - S T C - 1, 04 AS BUILT SANITARY SYSTEM REPORT OWNER Tom- TOWNSHIP 5, f SEC ..5 f N-R- W ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT_ LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H 63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Icc'.%r7L SC V hJ J i r~ 5E U L- i''7" S LA ti Lr ~L /CC1. 0Ty INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used S~ C i 'Sift' /L Elevation of vertical reference point:' Proposed slope at site: 3. SEPTIC TANK: Manufacturer: G1~'S Liquid Capacity: Number of rings used:! Tank manhole cover elevation: Tank Inlet Elevation:_ Tank Outlet Elevation:2 Number of feet from nearest Road: Front,~N Side,O Rear, o feet From nearest property line Front,0 Side,0 Rear, O feet Number of feet from: well building: ,5 (Include this information of the above plot plan)( 2 reference dimensions to septic tank) f s ` PUMP CHAMBER Alaufacturer: Liquid Capacity: Pump Mod e:--,,. Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevat' Pump off switch elevation: _ Gallon-s per cycle: Alarm Manufacturer: Ala/Ym~SLaitch Type: Number of feet from neares property line: Front, Si Rear , Ft. .N mfi" ber of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: 112= X ] Trench: Width: 1.2 Length: Number of Lines:__ Area Built: Fill depth to top of pipe: Number of feet from nearest property line: Front,q O Side, ® Rear, O Ft. Q - Number of feet from well: " Number of feet from building: (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liqu' depth: Bottom of seepage pit elevation: Area Built. Has either a drop box or distribution box O been used on any of t above soil absorbtion sytems? (Check one HOLDING TANK Manufacturer: acity: Number of rings used: Filevation of bott of tank: Elevation of inlet: Number of feet from."nearest property line: Front, O Side, ear, O Ft. Number of feet from well: Number of feet from building: !f Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: Plumber on job: License Number: 3/84:mj Wisconsin Department of Industry, • ' Labor & Human Relations 4INSPECTION REPORT Safety & Buildings Division Bureau of Plumbing o remises Date an . o. sstrt- `oun y Sanitary Permit -e C) w ST jo~'7iE as er ' Plumber irm ame d ess 100, r,-) SC A f-1 i TX Journeyman Plumber Address Owner ress c RCS-'7- y s i Jo f! w~ . _ f t ~ , T i~ 'v ~ Una ~ LAJJA CI X v ;~J' 'A . u - a„ m .....__.,R 1...~~,,,, mss. .U...a. z,a rr _.A.,....a d.~ ~.v <4 (AIL 1~ aj(-, k-)V( tic, Discussed with { )See Attached. e s e pe 1 a 1 st-__ DILHR-M-6192 0,.11/83) Signature-of Dist. Plumbing-Sup. 0 -,Site! DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS 'LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS MAD ISOBOXN, W7969+' 53707 DIVISION BUREAU OF PLUMBING ' MA CONVENTIONAL ❑ALTERNATIVE State Plan l).D Number ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound (11 assigned NAME OF PERMIT HOLDER: ]ADDRESS OF PERMIT HOLDER . INSPECTION DATE: RETIE TERRENCE R. R. 1, Box 462, St. Joseph, WI /~`Jy ~y BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT ELEV.. SE-'4 NE-4, Section 25, T30N-R20W, Town of St. Joseph Name of Plumber MP/MPRSW No. Counry Sanitary Permit Number. Don Schmitt 3205 St. Croix 58859 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL L ROV E OCKING VER ! P O IDED: P ~L~4l 1~r~•~CI L.I~- YES ONO ES~ONO BEDDING: VENT DIA. VENT MATL. HIGH WATER EMBER OF ROAD PROPERTY WELL. BUILDING- VENT TO FRESH ET FROM uvE IAIR INLET OYES V NO AL❑M` NO AREST > r (LI D DOSING CHAflVIBER: MANUFACTURER. BEDDING: I J LIQUID CAPACITY PUMP MODEL. PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED. PROVIDED'. OYES ONO EYES ONO OYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL BUILDING I VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) OYES ONO NEAREST 110 SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH DIAMETER MATERIAL 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 ILENGTF O OF DISTR PIPE SPACING COVER INSIDE DIA #PITS LIQUID n, L RENCHES. MA'T'ERIAL: PIT DEPTH. DIMENSIONS L EI -y GRAVEL DEPTH FILL DEPTH DISTR PIPIPE DISTR. PIPE MATERIAL. NO. DIST.. NUMBER OF ,PROPERTY WELL. BUILDING. VENT TO FRESH BE LOW~PI P ES ABO COVER E N PIPES FEET FROM LINI~ d' AIR INLET. NEAREST 10 MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill m erial for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make cer i that it ON REVERSE SIDE. SHOW ELEVA- OYES NO meets the1kriteria for medium an l IONS MEASURED. O SOIL COVER TEXTURE PER ANENT MARKERS JOBSERVATION WELLS _ OYES ONO DYES ONO DEPTH OVER TRENCH BID DEPTH OVER TRENCHBED DEPTH OF TOPSOIL; SODDED: SEEDED. MULCHED. CENTER EDGES. '~❑Y S ONO EYES DNO DYES ONO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH. NO. OF LATERAL JPACING GRAVEL DEP H BELOW PIPE FILL DEPTH ABOVE COVER BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIP MANIFOLD MA ERIAL. NO. DISTR. In ISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING. ELEV.. ELEV.. DIA ELEV.' a PIPES DIA.: ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING JDRILLER CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED t YES ILJYES ONO OYES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING. FEET FROM LINE: OYES ONO OYES ONO NEAREST r i It t 42 I)AC-S ~y . 04 Sketch System on Retairy county file for audit. Reverse Side. G. C C~„ ~t* ~,J? f f SIGNATURE TITLE. DILHR SBD6710 (R. 01 /82) E=7= Wisconsin APPLICATION FOR SANITARY PERMIT y / ' COUNTY 'E"T (PLB 67) UNIFORM SANITARY PERMIT # pGPRRTrT OF In OUSTRV, LRBOR 6 HUMRn RELRTIOns +Y~ -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8/2x 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER MAILING ADDRESS cc _ PROPERTY LOCATION CITY: VILLAGE: ,.e 1/4 x114, S ,2.T, T. R,,?V E (or) ~ LOT NUMBER BLOCK NUMBER SUBDIVISION NAME ST ROAD, LAKE OR LAND~AZ STATE PLAN I.D. NUMBER TYPE OF BUILDING OR USE SERVED 1 or 2 Family Number of Bedrooms: ❑ Public (Specify): /Y U v~ THIS PERMIT IS FOR A: ❑ New System Tank Replacement ❑ Repair A Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. A Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # issued An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total # of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Arn .1y.4 AA AA AA Lift Pump Tank/Siphon Chamber Holding Tank capacity _AIA Manufacturer: IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure Total #of Pr fab. Site Steel Fiberglass Plastic Gallons Tanks C rete Constructed Septic Tank Capacity Lift Pump/Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): ! ~~.15~ V 7 Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Print): Signatu M PRSW Phone Number: T ,3 (767 Plumber's Address: Name of Designer: Y a),v AIZ-i 1.7 j_ COUNTY/ DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: _ ❑ Disapproved f L 1 ❑ Owner Given Initial i ~GL jt'.2 ' / / Approved Adverse Determination 71 Reason for Disapproval: i Alternate course(s) of Action Available: DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398 ' To be complete and accurate the permit application must include: 1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in a city, village or town); 2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.); 3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks. 4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of square feet to be installed; 5. Complete the section on water supply; 6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi- fication, place your license number in the space provided and sign the permit in the signature block; 7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the permit; 8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation. Failure to comply will void the sanitary permit. 9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable. 10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system, depth of the system, type of system. 11. All revisions to this permit must be approved by the permit issuing authority. 12. A complete plan including a plot plan, drawn to scale or with complete dimensions. 13. Horizontal and vertical elevation reference points that are permanent and clearly shown. 14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s) to system, building sewer and vent observation pipe(s). 15. The permit issuing agent may require a cross section drawing of the effluent disposal system. TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin. APPLICATION FOR SANITARY PERMIT 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 -4 NL 14, Section 2 T N - R C" W Township `j Mailing Address _R, Z 13c"X, 6 .Z Subdivision Name Lot Number l~- _ Previous Owner of Property _-70,tr2 0, w~ceti 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 No Volume and Page Number as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: 1. Warranty Deed 2. Land Contract 3. Other recordings filed_ with-the- Reg-inter-af-Deeds Office 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 the Certified Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTY OWNER CERTIFICATION I (We.) eeAti6y that at btatemen,ts on this 4o" ahe tAue to the beat o~ my (ouh ) knowledge; that I (we) am (ane) the ownet (6) oA the pnopuLty dew cA bed in ,this in~mmation 4onm, by viAtue ob a waAAanty deed neeonded in the OA6ice o6 the County Regis teA o6 Deed ,6 as Document No W_ ; and that I (we) phesentty own the p4opo6ed bite bon the age posat bystem (on I (we) have obtained an easement, to nun With the above d" ck bed pnopeA,ty, ion the eonst Auction o6 said sy.6tem, and the same hay, been duty neeonded in the O~biC(2, ob the County RegZ6teh o6 Deeds, as Document No. ► . SIGNATURE 0 0 ER SIGNATURE OF}CO-OWNER 4(IF APPLICABLE) e 4 DATE SIGN D DATE SIGNED S T C - 105 1;FJ1'I' LC 'D'ANK MA J N'i'LNANCL AGREEMENT ~ 0 SL. Croix County y 0 WN1?It/1iUYLR~ ILOU'1'L/ BOX NUMBER 0 114, Dire Number CI I Y/s'rn'r1:~~ 1 1yC~Z _ PR0PERTY 1,0CAT 10 N 4, Sec t ion l N , It W 1'UWn Of S~t St Croix Couitt - t?1~- - Y `;uhd Lv i~ 1-uu Lut Liumber improper use ttud ntaintUni.tuce of your septic System Could result in its premature failure to handle wastes. Proper ntaiutUUanCe Con- sists 0I puutping, out the septic tank every three years or sooner, it nCUded, by a 11 Cnsed sUhLiC tank pumlUr. Whitt you put into LhC system Can alle!Ct the lunctLou of the Sept LC t_ank a5 is trL'aL- ill Uit t stage i_u the wasLL disposal. system. St. CI- )ix County residents may be eligihic to rUCCIV(' a r,-tnL for it Ilk axlIll uIll of 60% of the Cunt of -rUplaceutU11 L o1 it fall_inl; system, wIt icIt was in operat_ion prior to July 1, 1. 9 St. Croix County accepted this program iu August of 1980, with the recluireill eit L that owners of a L I ilcw -iysLrtilt; ~I i- ce t o keep their systems properly tit aintaiii ed. The property owner it FCU.; L sul;tit iL to SL. Croix County l.0itiit g it Certification fUIF Ill , sigIt ud by the owner and by a master pluill ber, j 0LIr nUyma It plumber, restr ic Led plumber or a Licensed pumper veri- fying t hat (l) the on- site w astewater disposal system is in proper operating condiLLon and (2) niter inspection and pumping (if itUC - essary), t he septic tank is less than 1/3 full of sludge and scum. CertiIF lcit ti.oit form wilt be sent approximately 30 days prior to three year expiration. i 0 1/WL, the nude.-rLi i_gned, have ret.td the above reduirements and agree Cf) to maintain the privatt sewage disposal system in UCCOrdancC with the standards set forth, herein, as set by the Wisconsin Depart- n ment of Natural Resources. Certification form must be completed arid returned ro the SC_ Croix County Zoning Office within 30 days 01 Llie LIt ret year Ux1)11 1Li0 i1 (gait SIGN. C-1 0 U AT L SL. Croix County Z oning; 011ice 1'.0. Lox 9& It anunottd, W1 54015 71.5 - 1 ci 6- 2 2 3 9 or 715-425-8363 5.i.},n, date and return to above address N L C O c W (~D = =a c N 3 .O. m m = m-, O V (p N o -1 3 x o• =r 0) r-L c ; c0 0 c r w w co pr ? 3 co cc m O S z O =r (D n vcmCD CD CA cn~~ 11131 N O a p 0 co A) p « N m m o m o w CO 0 0-0 M CA co " 0 3 n o~°~ m co omr,.f cowot° co= =O 1 O O L c ~ m CO 3'w? c~ m N w cn m _ m 3' 0 o O Mm % < (N Ch. ~ Qo v mN1 0Dc-~~ G) woo -4=w ° ° O c? 'O O p C' O =(DDCp ?ate' vi C CID - cn Z N k; a ° N m CA (D =r 0 r-O (D 0 ca (D F =r CD CD M CD CL o 3 -4 Nan. -1 = :E 0 M r. S ? o Q0 CL - ?-•0 > a mN=a(a w N ~wr- Q. c0 M- C 171 v 3 m ° N ~ 0 ' y = CD C =r °~.o cn00=Cco a o = 0 G) wow <CC 00 m CL s CL=r00 M. r4. 00mo =r SD ;z o 0 CL o po:::> 3 O 0 =3 0 CD w 9~ _ - 3 co m _ Z 0 INbUS QEPARfMENTOF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS NDUSTRYY, DIVISION LABOR AND, PERCOLATION TESTS (115) MADISON, WI 53707 P.O. BOX 76 HUMAN RELATIONS (H63.09(1) & Chapter 145.045) LOCATION: SECTION: TOWNS HIP/ML",CI LFTY: f ONOLK. NO.: SUBDIVISION NAME: 4, 4 W1 COUNTY: OWNER'S/BUM'S NAME: MAILING ADDRESS: USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS: Residence ❑New ©Replace RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONVffl D: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) os❑sou as❑u ❑ sau as u If Percolation Tests are NOT required DESIGN RATE: [Ffloodplain, an y portion of the tested area is in the under s.H63.09(5)(b), indicate: indicate Floodplain elevation: / PROFILE DESCRIPTIONS BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH -THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH P- P- i 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 E _ f f Sil~►'~~ lx'~ I f 1 I hl ~1 t 1 s, - U ; } IN E v1 It 3 I ~ ~ k- F i. 6 3 s_ t ,i I ± t . L- f r - 3- 3 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: ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): CST SIGNATURE:, DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DIL.HR-SBD-6395 (R. 02/82) - 0 V` R - a 1 LL /CIO i, s3 .i rho ;.3-3 sy exvs~/ivC- j ~Iv r; to r y~v K~ ~5, 30` 46- ~lf / C ct-r Y 3 ° • c c r c 1 Y 8 y 9,57 j n/~~~Vtr rj-,e- 5~ ~ i; f T RT Y6 7osIF /w et - P, JI'll C,6-