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HomeMy WebLinkAbout020-1356-22-000 I - ST. CROIX COUNTY ZONING DEPARTMENT • AS BUILT SANITARY REPORT Owner' • rr Property Addr s ici City /State o) s-� '. Legal Description: N G FICE. Lot Block` ubdivision/CSJM # �U I /a ,a, Sec. To2IN -R W, Town of PIN # 7L� f SErTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION Tank manufacturer A1 Size ST/PC aGd l Setback from: House Well P/L ZQ Pump manufacturer Model Alarm location (HOLDING TANKS ONLY) Setbacks: Servic Vent to fresh air intake e Meter location Aland location SOUL ABSORPTION SYSTEM f Type of system: /L I idth Length -5�6 ' Number of Trenches Setback from: House Sa' WelLo-� P/L Vent to fresh air intake .S'D ELEVATIONS Description of benchmark Elevatio -,*,vo Description of alternate ben Elevation Building Sewer �� ,� ST/HT Inlet A2 ©s ST Outlet 0"3 PC Inlet PC Bottom Header/ManifoldJ Top of ST/PC Manhole Cover Distribution Lines () ,22X, d9 ( ) O fl ( ) Bottom of System O /d 7 2:5' _ O A07. O U O Final Grade Date of installation d/ 9P rmit number State plan number Plumber's si nature License number U9 Dat� - Inspector Complete plot plan a NOTICE Please provide the following: • A plan view sketch showing everything within 100 feet of the system. • Two horizontal reference points to center of septic tank manhole cover. • Show alternate benchmark, if applicable. 3� PLAN VIEW J � o �!' D < S INDICATE NORTH ARROW Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count y Safety and Buildings Division INSPECTION REPORT 'GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: ST. CRO X Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)). 344609 Per@i�b ftk NarIlg� A & CHERYL L ❑ City CST BM Elleev. -. C:U e Town of: State Plan ID No.: Insp. BM Elev.: BM Description: a Parcel Tax No.: m � l ot � Y1. = CSI" a a*j 020 - 1356 -22 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV. Septic Benchmark 2.65 J am, d Dosing 13 Aeration Bldg. Sewer Q1 Holding t/ Ht Inlet !J 86 9 TANK SETBACK INFORMATION St/ Ht Outle l �'� d S lll. S3 TANKTO P/L WELL BLDG. Air to I ntake ROAD '04 at ir Septic /�j r — NA D Dosing NA Header /Man. ,N Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade (..33 it . 3 Z Manufactu emand t 3$ Model Number GPM TDH Lift F' on Syste DH Ft Force Length Dia. H Dist. To well SOIL ABSORPTION SYSTEM TRENCH width / I Length 6 No. f T nches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 � DIMENSION SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING M�acc SETBACK CHAMBER ju " " INFORMATION Type Of f OR UNIT Mo �I,Nu er: System: -ty DISTRIBUTION SYSTEM Header / /Manifold u Distribution Pipe(s) x Hole Size x Hole S acing Vent To Air Intake LengtK Dia. Length Dia. pacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed/ Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc. r T T �' – �'s `► `P` °`` ° i^� LOCA HUDSON 4.2 1. Q84 GRA RANGE E 2ND – LOT 22 0 = � b� to _ _qq Plan revision required? ❑ Yes % No Fi 2 Use other side for additional information. yj SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. G - ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: a.. ... .._... _ �. ° ....... � e e £ P i I ._.... emm e S ! i 9 d � Y � 9 i k r 3 r e t y s 4 i £ � F i � i e. ....... .,. � ..m.. w... ...... Vim.. �. E ..._ e .. _ mm. . e .a .v.. .. ...m ... f ( j 3y ee .e t §. a.•N.e ., „.. ee ..,.e e.,. .. ,. +.....: a ,,.. e.e. ,.,m . ....� �. ..... .... . ...L.».«.« .............w . e ,.. i” E ........, e _ ee . ..... e. .e .:.. L »n a• .........:. �., ;^° .... k .. _ e. a ...�. ---- .. , o ..m .. .e. ..... ......, e �.. } ..�..„.. 'a° .�. f d 1 t l 3,jj "m a. m. ,.._ . . { a 3 d � � i E 2 � e .. .. _. e e e ...... � e. F s S £ £ £ f 3 i f r i e r v S � . �� �••. �� 9 f P °. 9 a 6 } < e £ e L e { Safety and Buildings Division 201 W. Washington Avenue Vi scons i n SANITARY PERMIT APPLICATION P O Box 7302 Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the sy r s County than 81/2 x 11 inches in size. 11 \ ( — L • See reverse side for instructions for completing this a ion /�� f State Sanitary ermit Numb Personal information you provide may be used for secondary purpose t o [Privacy Law, s. 15.04 (1) (m)). [Check if reviprevious sion to pr application , �'l State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRIN A N Property Owner Name 7 rop y Lo6tica /4 S T 2 ,N,R ` E(o W Property Owner Mailing Add s A t Block Number � , < 1.� i 2 � r City, Sta e ZiDyo e Phone Number ion Name or CSM Number a S ( ) r ae lb II. TYPE OF BUILDING: (check one) ❑ State Owned ° it Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms ° town o f C III BUILDING USE (If building type is public, check all that apply) Parcel Tax Nu ber(s) 02� 1?,5( a� t^Jp 1 ❑ Apartment/ Condo 2 ❑ 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 IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1 New 2. ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an ___System ________ System_____________ Tank Only______________ Existing System - --------- Existing Syrstem B) ❑ A Sanitary Permit was previously issued. Permit Number 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;&eepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit A f3l []Vault Privy 14 ❑ System -In -Fill ^�r+c 56 l VI. A SYSTEM INFOR ATION: 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/da /sq. ft.) (Min. /inch) Elevation ` - � - , /4: eet Feet Capacity VII TANK in to allo Total # of r Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturers Name Concrete Con - Steel glass Plastic App New Existing structed Tanks Tanks Septic Tank or Holding Tank Q El ❑ ❑ 1 ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ 1 ❑ ID ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plu a 's Name: (Print) Plumber's 4 (No Stam MP /MPRSW No -: Business Phone Number: Plumber's Address (Street, City, State, Z Cod IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sinitary Permit F (includes Groundwater ate a Issued Issuing t Sign ture (No Stamps) Approved ❑ Surcharge fee) Owner Given Initial 7r�' Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: IF V SBD- 6398 (R.1 1/97) 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 maybe renewed before the expiration date, and at a 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 and Buildings Division, 608 -266 -3151. To be complete and accurate this sanitary permit application must include: I. 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 on 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 for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new /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 81/2 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; 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 contamination investigations and establishment of standards. PLOT PLAN PROJECT ADDRESS 'NW 1/4 NW 1/4S 14 /T 29 , N/ 19 w OWN Hudson COUNTY ST. CROIX `+ MPRS Shaun Bird 226900 DATE 8/3/99 BEDROOM 3 CONVENTIONAL )00( IN -G ND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 Gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .8 ABSORPTION AREA 572 # of chambers 18 IL BENCHMARK V.R.P. Top of 1 /1/2" pvc pipe ASSUME ELEVATION 100' ❑ BOREHOLE O WELL *H. R. P Same as Benchmark SYSTEM ELEVATION jL idewinder High apac ity Leaching hamber with 31.8 t ^2 per chamber 3 4 Grade at System Elevation 150' 221' 32' 0' 25' 97' od AC 0' Vents 2 1 -1 81' 5' 81' B -3 23' 9% 2 -3'X 56' Trenches Slope Pro 3 6' 10' 0' Bedroom T House B -5 B -2 Ld 1 Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page 1 of 3 'Labor and Human Relations Division of Safety &Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 8 1/2 ,' s in size. Plan must include, but S Croix not limited to vertical and horizontal reference poi 4) }d[rgction an°!o d of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and disyA'm tVhearest road. 020- 1021 - / ' " REVIEWED BY DATE APPLICANT INFORMATION — PLEASE 1111�l? ALP, ATION '`, PROPERTY OWNER: PEPPERTY LOCATION Kernon Bast 1 ? 'r?ct Q . LOT 1/4 1/4,S T N,R (or) W NW PROPERTY OWNER':S MAILING ADDRESS ST Rcgx # BLOCK # SUBD. NAME OR CSM # 948 LaBar e Rd. Cou>uTY 22 Na Grass Ran= Spr Addn CITY, STATE ZIP CODE f'HtJN CITY ❑VILLAGE [TOWN NEAREST ROAD Hudson, WI. 54016 7.1 .6 -. Hudson M&Iiit-chen Rd. [x] New Construction Use [ Residential / Number o ms 4 [ ] Addition to existing building [ ] Replacement [ ] Public or commercial describe Code derived daily flow 600 gp d Recommended design loading rate • 7 bed, gpd /ft •8 trench, gpd /ft Absorption area required 858 bed, ft 750 trench, ft Maximum design loading rate .7 bed, gpd /ft .8 trench, gpd /ft Recommended infiltration surface elevation(s) 107.05 ft (as referred to site plan benchmark) Additional design/ site considerations trenches spaced to code 4.00 below surface el. Parent material outwash Flood plain elevation, if applicable na ft S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable fors stem 12 S El ❑ S CCU [ S ❑ U ❑ S ® U $7 S ❑ U ❑ S r7 U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Roots GPD /ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench .................. ................. .................. ................. .................. ................. .................. 1 1 0 -12 10r33 none 1 2mqbk mfr 9W 2f r; -6 2 12 -32 10 r 4/4 none sil lc Ground 3 1 32-41 10 r 5/4 c 2d7.5 r 5/6 elev. 1 4 41 -84 5 r 4/6 none cos OSQ M1 na Depth to limiting I � factor 84 `Cv Remarks: Boring # 1 0 -12 10 r 3/3 .2,. 2 12 -27 10 r 4/4 none sil Ic:!sbk mfr 9W if Ground 3 27 -45 5 r 4/4 none r 0A asg mvfr nn 9W -7i elev. 4 5 -84 7.5 r 4/4 111 5 ft. Depth to limiting t 8 factor +84 Remarks: CST Name: -- Please Print Gary L. Steel Phone: 715 - 246 -6200 Address: 1554 200th. Ave. Richmond WI 54017 Signature: Date: 8 CST Number: m02299 _ Z PROPERTY OWNER Kernon Bast SOIL DESCRIPTION REPORT Page PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trerxh 1 0 -12 10 2 12 -26 10 r 4/4 none sil lcsbk mfr aw Ground 3 26 -84 7.5yr 4/4 none cos osg ml na na .7 .8 elev. 10 ft. Depth to limiting factor +84 Remarks: Boring # 1 0 -8 10 r 3/3 none 1 2msbk mfr qw 2f .5 .6 `4 " 2 8 -24 10 r 4/4 none sil lcsbk mfr w if .2 .3 Ground 3 24 -84 5 r 4/6 none cos 0SQ m1 na na .7 .8 elev. 1 Depth to limiting factor +84 Remarks: Boring # 1 '' S 2 6 -21 10 r 4/4 none sil lcsbk mfr w if .2 .3 U Ground 3 21 -41 5 r 4/4 none cos OSCF ml C1w if .7 .8 elev. 4 1 -84 7.5 r 4/6 none cos osg ml na na .7': .8 1IV fJ 4 Depth to limiting factor —84 Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD- 8330(8.05/92) 7 STEEL'S SOIL SERVICE Gary L. Steel Kernon Bast 1554 200th Ave. CSTM2298 Nw4Nw4 S14- T29N - R19w New Richmond, WI 54017 MPRSW -3254 town of Hudson (715) 246 -6200 lot #22 -Grass Range Second addn. This soil evaluation was conducted to satisfy a Zoning requirement, it may or may not be suitable for your use. The location of the test may may not be as shown as permanent lot lines were not established at the time the test was conducted. N 1 =40' BM.= top of 12" pvc pipe C el. 100' ` Alt. BM.= top of 1z" pvc pipe C el. 106.30' ° ,2l 32- ♦� pa 9% � � a Gary L. Steel 8 -20 -98 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address Property Address (Verification required from Planning Department for new construction) City/State Parcel Identification Number U 6 I LEGAL DESCRIPTION Property Location AW i/4, L ZV4, Sec. _Z-f T N -R--d W, Town of U :!&,b S�/✓ Subdivision Lot # Certified Survey Map # , Volume ` . Page # Warranty Deed # �C� �� , Volume ! Page # -3 Spec house ❑ ym no Lot lines identifiable yes ❑ no SYSTEM MAINTENANCE Improper use and maintenanceof 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 a licensed pumper. What you put into the system can affect the function. of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a masterplumber, joumeymanplumber, restrictedplumber or a licensedpumper verifying that (1) the on -site wastewaterdisposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the thee ear expiration date. 6 / l �'� SIG TURF OF APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. SIGNA` URE OF APPLICANT DATE Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * ** ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed i • v 608040 STATE BAR OF WISCONSIN FORM 2 — 1982 KATHLEEN H. WALSH WARRANTY DEED REGISTER OF DEEDS ST. CROIX CO., WI DOCUMENT N o. ��li. .1446PAGE 6 13 RECEIVED FOR RECORD This Deed, made between KERNON J. BAST and 48-04 -1999 11:00 AM DONALDA J. SPEER —BAST, husband and wife, _ VARRANTY DEED EXEMPT # ,Grantor CERT COPY FEE: COPY FEE: conveys and warrants to CORY A. B E D N A R and CHERYL L. TRANSFER FEE: 110.70 BEDNAR, husband a wife RECORDING FEE: 10.00 PAGES: I ,Grantee Witnesseth, That the said Grantor, for valuable consideration, conveys to the Grante THIS SPACE RESERVED FOR RECORDING DATA NAME AND RETURN ADDRESS the following described real estate in St. Croix County, State of Wisconsin: / f � f. Lot 22, Plat of Grass Range Second Addition, Town of Hudson, St. Croix County, Wisconsin. PARCEL IDENTIFICATION NUMBER This is not homestead property. (is) (is not) Exception to warranties: easements, restrictions, and rights -of -way Dated this day of August A.D., 19 9 9 � J_ Bast—,.n ( SEAL) D n 1 — (SEAL) _ (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) State of Wisconsin, ss. St. Croix Count authenticated this day of 19 Personally came before me this day of August , 19 9 9 , the above named Kernon J_ Bast and * Donalda J_ Speer —Bast TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by §706.06, Wis. Scats.) me known to be the person �_ who executed the foregoing DIANE M . BARRON ' strument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY Notary Public State of VNisconsin Kernon J. Bast 948 LaBarge Rd. Notary P lic, �(� County, Wis. q (Signatures may e enttcated or ac nowledged. Both are not My commission is permanent. (If not, state expiration date: necessary.) • Names of persons signing in any capacity should by typed or printed below their signatures. STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc. WARRANTY DEED Form No. 2 — 1982 Milwaukee, Wis. r V � w KI 1 Vl i i i ( D i i i i v i, ;- i i `• • i ;, • — %0 v .•-. N 1- N 0 * r m N In %0 .••. N N % 0 N .r () �t I ^I Z In N In In In OD In OD r- w OD M N N o W) In %Q OD w V) V) V) Z V) Z 0 Z V) Z Z o Z Z Z Z Z Z 0 Z Z co F �s ¢ W w w 3 333 33 WWWW 3 W W ), w N y C C C M Os 0% In In t" h In C ^' v v N N N v N Ln P, M (`') v N N In N N! N* 0 O O M vv O cn r) (D O O M.. 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