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HomeMy WebLinkAbout020-1302-80-000 ST. CROIX COUNTY ZONING DEPARTMENT ;- AS BUILT SANITARY REPORT Owner ­710e k PREME Property Address 4)j Or ny �� 1 �-, N � 1 9«9 City /State N "So= r s Sy��h -,... f - t ST GRW � Legal Description: �,?., .z COUNTRU" f Lot Block — Subdivision/CSM # t/� t /4, Sec. --�, T N -RAW, Town of u,//.s,l PIN # SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION `Tank manufacturer a �f Size(OPC /0c1 Setback from: House Well P/L Pump manufacturer Model Alarm location (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM Type of system: h- Width 3 Length ? 5 Number of Trenches Z Setback from: House Well P/L Vent to fresh air intake ELEVATIONS Description of benchmark rill dl L 2 Elevation / Description of alternate benC�7nark Elevation Building Sewer �� ST/HT Inlet 1 00, ST Outlet f- ? PC Inlet PC Bottom Header/Manifold Top of ST/PC Manhole Cover »D , Distribution Lines l D , 9,(0 (Z) Bottom of System Final Grade O O ( ) Date of installation 111 41�f Permit number '>`��// 1 7 State plan number Plumber's si nature cl License number a2615�2`- Date W// Inspector Complete plot plan Q 1 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. PLAN VIEW W� i�41 f z r i INDICATE NORTH ARROW Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM y: Saf2ty and Buildings Division Count INSPECTION REPORT St. Croix GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 344617 Permit Holder's Name: ❑ City ❑ Village W Town of: State Plan ID No.: Town of Hudson "CT Elev.; Insp. BM Elev.: BM Description: Parcel Tax No.: eC 49 �' Z It r r 020- 1302 -80 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic lio6d Benchmark Alt. BM Q 9 ZV Aeration Bldg. Sewer q, loop � s" ing St /Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet S l ode. Z' TANK TO P / L WELL BLDG. Air I to ntake ROAD Air Septic ± U 0 / b l t 16 1 NA D A Header /Man. 7. Aeratio NA Dist. Pipe / " BOG' olding Bot. System /,0 tv y 6 PUMP/ SIPHON INFORMATION Final Grade ' l) St �r Manufacturer Demand cover Model Num TDH I Friction stem TDH Ft L oss Forcemain I Length Dia. Dist. well SOIL A RPTION SYSTEM 7- P✓ BED //fREN04 Width r Lent F No Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMemstems �J Z' DIMENSION Manufacture : SETBACK SYSTEM TO P/ L BLDG WELL LAKE / STREAM INFORMATION Type O CHAMBE Moe u be : SS' 1� r System: J � DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length —10 Dia e ms Length —3r/ Dia. Spacing _:� I tI A Z 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.) Inspection #l: /I /1 d /fI Inspection #2: Location: 751 Oriole Lane, Hudson, WI (SE1 /4, NE1 /4, Section 7 T29N -R19W) - 27.29.19.1496 sewer lam,,. o f YAW--:5 & 1 1r 4a C4 Plan ~i ❑ Yes ❑ No Use other side for additional information. p G SBD -6710 (8.3/97) Da4 Inspector's S ature Cert. No ADDITIONAL COMMENTS AND SKETCH I SANITARY PERMIT NUMBER: 9 P e &e a p � F a ° n ! f g d f 9 t i 1 3 i s .� e tee_.. mee�.a �. �� .ee - -. ., me e ... .,,e E 3 e e t e e s � t i a e e 3 4 , f w 4 4 ai $aqi jjj E z �.... . # # _ gg FI`.. 1+R, . ..��# 2 # 4 I E 3 F f r ,® i 1 m- # j { F i E # # # ¢ P 5 pmI s Y � 3 : a e # • Safety and Buildings Division SANITARY PERMIT APPLIC 2 01 W Washington Avenue Visconsin In accord with ILHR 83.05, Wis. Ad �� P O Box 7302 Department of Commerce Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, o spa er not I,l,, unt than 8 1/2 x 11 inches in size: ` 7 • See reverse side for instructions for completing this application � A s e San ary ermit Number Personal information you provide may be used for secondary purposes j�CD eck i ievi on to previous application [Privacy Law, s. 15.04 (1) (m)]. ��V� NTy� State Pin l . Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INFO Prope Own er Gl.il St 8 �? Z`r "� 1 aj T , N, R (or) Property Owner's MaillWg Address Lot Number Block Numbeer O A Cit State tip Code Phone Num Subdivision Name or CSM Number / ( > �v r�I ' T— II. TYPE OF (check one) ❑ State Owned 11 C Nearest Road 3 ❑ village L / Q j Ck.`tN Public 1 or 2 Family Dwellin No. of be drooms Town OF III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) - a - i _Z`i. l 1 9 10 1 ❑ Apartment/ Condo a�� f3 L' Z ' 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. �S New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an ------ System _______ System_____________ Tank Only______________ Existinl,- System _________E ---- System 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 110 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 N Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit ✓ — 3? 74 �iea c/� ❑ ault Privy 14 E] System-In-Fill ' y 01 h /• e g 74 � VI. ABSORPTION SYSTEM INFO MA ION: 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) Tr t cy4 i 50- Elevation 'V 4;2 !03 , S Feet /07, Su Feet VII. TANK Capacit gallons g Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existing strutted Tanks Tank Septic Tank or Holding Tank i6ty — i LJaz k i, L f' ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ 1 ❑ 1 ❑ 1 ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumb "s Name: (Print Plumber's Signature: (No tamps) MP /MPRSW .: Business Phone Number: ✓ i w► �. / i� !) kt °�i 772 3 L / Plumber's 4ddress (Street, City, State, Zip Code): al vfk ►1 59h L�-J z, a IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved #nitary Permit Fee (Includes Groundwater D ate I ssued Issuing Agent Signature (No Stamps) Approved E] Owner Given Initial d'D Q Adverse Determination �� I Surcharge Fee) �[ X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 IRA 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 may be 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: 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. 11. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. 111. 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. N 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. JOB ea4 TIMM EXCAVATING SHEET NO. I OF Route 1 Box 192 WILSON, WISCONSIN 54027 CALCULATED BY l DATE (715) 772-3214 (715) 386-5443 MPRS #3224 WI MPCA #696 MN CHECKED BY DATE SCALE . ......... ........... ........... ........... 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L ........... ­­-�­­­111�1­1.11­ .......... .......... .......... ................ ........... .......... -­­­_ ........... ... . ....... ................. .......... PRODUCT 205-1®lrrc, Groton, Mass. 01471. To Order PHONE TOLL FREE 1-BW225-M Wisconsin Department of Industry, SOIL AND SITE E V'A LU AT I ON RE PORT � Page � of 3 Labor and Human Relations 1 Division of Safety d, Buildings in accord with 11-1-11`143.05, Ws. Adm. Code UNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in siia Plan must include, - but . PARCEL I.D. # not limited to vertical and horizontal reference point (BM), direction and i� pf slope, "0 or dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION REVIEWED BY DATE REVI EW PROPERTY OWNER: i/ A'�vl� PROPERTY LO 4 C A PR �U,y� / �f S / f o - G4 4IAy y GOVT. LOT � 1/4 1/4,S 2 T Z9 ,N,R /f E (or) W PROPERTY OWNERS MAILING ADDRESS �2i8 �ipv��Q ��` LOT # BLOCK # SUBD. NAME OR CSM # 33� ,�oB TS ST y� 33 }{ t)M Ri f'� H I'lIS �Pti/1Sr: 2- CITY, STATE ZIP CODE PHONE NUMBER []CITY �111LLAGE N NEAREST ROAD T,uG �!N 55/0/ lG�) z2 -5SS5 t fUpso,.� Vf" New Construction Use ( piesidential I Number of bedrooms Additxxt to existing building ( J Replacement ( ] Public or commercial desaibe Code derived daily Now boa gpd Recommended design loading rate / bed, gpolft trttcit, gpd/ft Absorption area required � bed, 111: / 6719 trench, ft Maximum design loading rate � bed, gpd/tt we Recommended infiltration surface elevation(s) S� P 9 3 It (as referred to site plan benchmark) Additional design / site considerations Parent material S' 5 GG !� v�(°Kti D T Flood plain elevation, if appliFable It S -Suitable for Syst cmv of MOUND IN-GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK U - Unsuitable for stem CC'S 0 U ❑ S L�Sl1 C�3� 0 U Mix - � U ❑ S Ci? ❑ $ L SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Bour�ry Roots GPD /ft Boring # Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed ttlydt [3 2— t1" e 3 LF AJ N Ground 3 y'3U /D S" Si� �•� 4 S 5 /a 3 e1 5L f t /p ,C' 14 — f S Depth to limiting W S teSt sit APPR VI DD fac Remarks: Boring # 5 1 If 56,E � S z of - S i .6 13 L - Z/ �D J�iP 3 /3 --- 5 / Z 41e �,f S v� S ( . 3 / -5z io ,e y s/ ��► ivy 'M A'e 7,6 �s . . Ground J c 05. 7 z ft. Depth to limiting factor Remarks: / CST Name : — Please Print 'P O Q E R T '4 L((? I' Ck 7— Phone: 71J _ . 3 P6 F �J S C�' Ne i L P D • R UP S O.J W �S S� /�O gnature: Date: CST Number: ORIGINAL PROPERTY OWNER SOIL DESCRIPTION REPORT Page Z 3 PARCELIA.# Ga 7 33 0 f131; Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bou ckvy Roots GPD /ft In. Munsell Qu. Sz. Conl Color Gr. Sz. Sh. Bed Trench e- 12- /6 � ,312_ �— S✓� S' e M�'�/ S /U� S y 11 - 26 /o 3/3 �Si /, Z�+ 1�,� •,nf /` es Zf • 5 � Ground - Id y S� Z �ilr� ij ` �C S — • S elev. . y,PArr -/y ye S 1� nor s o , s �., � • s i - G Depth to _ limiting r factor I r Remarks: Boring # / 10;1A i�Z CD, Afrr& —p S / // � e fit( � �2 S �-� N Ground elev. 17 Z - 7S S. 0, , i Depth to i limitig 0 fac 3 Remarks: Boring # /S -21 /o c s 2-f Ground - 7, S YR y 9 y ��► 9� �rivfc' cs 5 y'. elev. Y y/ 6 . s - /d 7 SL ft. r Depth to A ; limiting `o s y `{�' 46A, 2 factor > t Remarks: Boring # _ i f Ground elev. ft. Depth to limiting factor Remarks: cen eoon�o nc �nm I � J , O ppeyvk 'q GO / o Na • Ld r �. I.o i -t 3 3 I 3 0 P��rs 13 or - %'PAV -4 j a .Z)P (A/'A) SO 3 70( G f � �• L, g2 1 �Z9 yG s4 �o A e — ' OA.) p / 3. ,S'i 50 666 S TELL - T1 � cC�, 13-2- 61eUA-rI`oo S / 13 A. M6U64, l °� 13 ,5 /a 2 s Z �dw TZ'�ti GCS /0 3• 5'o Z ENV �' �i s E��- � � �o 0 ? /^��04w - 6 7 t � 3 df3 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 Y✓ }�^ a�_ �C ✓ Parcel Identification Number. LEGAL DESCRIPTION // Property Location S �F 1 /4, /Ur ' /a, Sec. , T ZF N -R LI W, Town of 17 i Subdivision AZip Yi S E Lot # 33 Certified Survey Map # 52- ° rte , Volume , Page # �2 Warranty Deed # _ J��)���o , Volume /3 , Page # ��� Spec house ❑ yes 'ono Lot lines identifiable ZF yes ❑ no SYSTEM MAINTENANCE 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 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, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal 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. I/we, 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 I septic ystem has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 three y expiration date. - 7 /a y SI ATURE OF PLICANT DATE OWNER CERTIFICATION I (we) certify all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the pro described ve, by virtue of a warranty deed recorded in Register of Deeds Office. z , SIGIATURE OF APPL ANT 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 DOCUMENT NO. WARRANTY DEED ! STATE BAR OF WISCONSIN FORM 2 -1882 ' -P Humbird Land ® Corporation, a Minnesota Corporation � �� _..... ._.._ ............ . ............ - ....... I RKd�suxMe r� _.._......... _ ......... .... ...........__._............ _. _....._.......... _ 1 JUN 0 3 1998 ........ !.. convl•yx auul warr :ulta to .. Joseph..T_, .tind.Joseptilne.,A., Ryan, Husband - __ - _- 8:30 A M and wife,.. _ . _ . ............. *645W of heeds ....... ......... .......... I ...... ......._....... ........ _ - .__.._... -_ .. .. .... L ctun.t ro —� '! _.... YM i, ,� „ j ............... -- ...................... .......... the following described real estate in ...... St. Croix -- County, —' - -- State of Wiscunsin: Lot 33, Humbird Hills Second Addition, Tax Paretl No: Town of Hudsdn, St. Croix County, Wisconsin i i i I i I I� � ANSFER FEE II ti t I; f This J s. not_._..... - , _ homestead property. f! 61Ak (is not) ii 1' Vxceptioo to warranties: Casements, restrictions and rights -of - way of record, if any ii 1 is r v u Dated this .. ... 28 th ........................... day of - - -- May ......., 19.98..... !I i HLMBIRD LAND CORPORATION ` s (SEAL) f .(SEAL) ...... - ........ BXr.. ............ Austin J. Baillon, Its President ..... ... ............• ................. ....( -EAL) ...... ..... ........... _..(SEAL) AUTHENTICATION ACKNOWLEDGMENT ._._._. - STATE OF VVAM1t?(gIN MINNESOT ................ •--. ...... ........ .-. ......... ........ ---- _.......... I.....— Ramsey ........ ............. .......County. at_lillarAicated th day o. .. ...... - ...... Personally came aeforo me this _• 28th day of May-- . ............................... 19.99.... the abo -c named Atlst_i n- J,__Ba i l l on Presi dent of ....... .......••_,_ ....... r= • Numbird Land Cor oration TITLE: MEMBER STATE BAR OF WISCONSIN - -- (If not, - -.-•.................... ............. -•- - - ---- -- - --.._....-- .......... • . ......................... _ ............... authorized b y § 706.06 , Wis. Sta *.s.) . to me known to be the pe rson ..........., who .xeclt± ed t,. `Z. foregoing instrument nd acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY ..... l/VL/1�.�.�.1A4 1 1 �1�MV,r. ^J.1�N•A^hrl ^.° 1 �i( i 1 3 t.1 : fJN ?. ✓ .... :f �TiTA Hyrq¢i.rd- Land. Corporation ........ .Paul A. Bai i l on <' Y:. a7Jt, GC)IINTY �........ ................ ........................ Notary Puhlic (Signatures may be authenticated or acknowledged Both 13� Commission is pernlanent.(If not, state expiration are nat necessary.) .late- .._..January 31 .. .................... ..... O .. { •Nu.nes ... nct.ann.+ nicnins it; any capacity ehwild be lyvetl ;r, ih,res. OL LOT 34 g 0 2.02 ACRES - 00 1 u \ 87,932 SO. FT. _ j LOT 27 \ ': \` ••' N ' —' 2.14 ACRES PONbING 93,106 SQ. FT , EASEMIENT •. \\ EL.= 972 S89 299.46' \ 1\ ; H84 "E 198.7 W A `\ LOT 28 \\ \� Nf 2.23 ACRES 97!078 SO. FT. I I 33' 1 33'` 1 I EASE .. O LOT 3 w {p O 2.01 ACRES No 87, 369 SO. FT. N87 °52'18 "E / 330.79' w EL. = 969 )NDING I 1 1) to o6 P�� 3EMENT V Pl ay LOT 29 N w 2.00 ACRES m w I — O 87,164 SO. FT. p N89 "E 223.78' i I I / ' CHICKADEE — LANE SECTION CO {' 1 "E 230.51' w N89 ° 39'42 • V o S84 °30'57 "E 317.62' I o O 0 t _ I 6 6' w 1f 1 m I ' CA c, I I LOT 30 LOT 32 OD 2.01 ACRES 2.00 ACRES D N 87,649 SO. FT. w m � 87,162 SQ. FT. z OD 0 z n 0 O ! ®�• 1 2 CJ1 Z LO m o W m PONDING EASEMENT m / �