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HomeMy WebLinkAbout020-1327-40-000 A ST. CROIX COUNTY ZONING DEPART AS BUILT SANITARY REPORT Owner Z— U-- Property Address 7/9 �ros1, a r to ; 199 City /State WG,( c � / — s r cao�x / Legal Description: ) `` Lot 3 Block AIA Subdivision/CSM # Misr W1 C_ ' /4 '/4, Sec. 25, Tc N -RAW, Town of h�u ` PIN # ?,n -/f? ;� - 5�y SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION Tank manufacturer / C Size�C4 Setback from: House / Z Well P/L �s Pump manufacturer 4A 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: 22eac A Width Length -'S Number of Trenches `Z Setback from: House Well 9? P2 5"? Vent to fresh air intake SS ELEVATIONS Description of benchmark /� / Elevation Description of alternate benchmar 11of �/ ' Elevation 33 p Building Sewer ST/HT Inlet 3 ST Outlet 9 / 6 1 PC Inlet PC Bottom Header/Manifold Top of ST/PC Manhole Cover 9(0 - r7 Distribution Lines ( ) O ( ) Bottom of System (7) Final Grade Date of installation 6 l /b7 Permit number State plan number —" n. Plumber's signature License number Z Date / ill Inspector i �Mr.- Complete plot plan � 1 � a I 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 Ti t le 0 INDICATE NORTH ARROW Wisconsin Department of Commerce Safety and Buildings Division PRIVATE SEWAGE SYSTEM County: INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary PermitNo.: ST. CRC Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)). 324795 Permit Holder's Name: ❑ City ❑ Village IN Town of: State Plan ID No.: LUEHRS, JAMES HUDSON CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: d( U U XZ "g - 020 - 1327 -40 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic �� Z C)0 Benchmark '15, Dosing �� 3 Aeration Bldg. Sewer Holding 6 1 Ht Inlet _ 2 3 TANK SETBACK INFORMATION (b Ht Outlet TANKTO P/L WELL BLDG. vent to ROAD D Air'h�ake Septic f ±7 / NA D tom Dosing A Header / Man. Aeration N Dist. Pipe T G.N .� Holding Bot. System L O PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft oss m ead Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED / E Width Len No. Of Trenches pIT No. Of Pits Inside Dia. Liquid Depth DIMEN311vas 3 s I - Z , DIMEN I N LE G 1 nufact er: SETBACK SYSTEM TO P / L BLDG WELL LAKE/ STREAM / INFORMATION Type Of r H odel Number: System: V yZ Z �� OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) r ( x Hole Size x Hole Spacing Vent To Air Intake Length /O/ Dia. Length '7 Dia. _ Spacing A M AJA 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.) LOCATION: HUDSON 29.29.19,NE,SE 718 CROSBY DR — ST. CROIX EST LOT 32 ©l b S' a� �Q Sewer Plan revision required? ❑ Yes ❑ No Use other side for additional information. (r SBD -6710 (R.3/97) Date Inspector's S057ure Cert No. r � r r ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: € T T-" .. ., .�e �m, n 4 . m. .... e< _. _ e e. .. � 4 } a e 9 . rma r i € d 11-1-1_j' F A AL, I d 1- F -; - 1 1 Vh 14 .x I E F t e x a E � s § t ®� � _m. _� eee _ ...� .. � eeme �_.�. .....,. mee,� ,._._. , €, .m em i ., v e t .� �.�. ._ .. »..... n ._ ..m... ��.. ee.�..�. .,.m. T . _s' __ ,_. .a _....., m F u . m r ` F } r: c 111 D- w.. py: � L VIA- �F € s € € S IZE"- a a € e I + � P t a ( E r @ u �es aN. F 3 j . ....... ................� _ ...,.,.......... ....,_ _. ..�._ ,.... �.. �, ..me..�P... _,tea.. nn._ ,. ., .....,,.. .... .,...m. ....�..�....,. ... .... .. _, e ....s._ ..m....�..... ,m,.,....,. ?....... r .- .«...�Pae«.w Safety and Buildings Division SANITARY PERMIT APPLICATION 201 W. Washington Avenue Wisconsin In P O Box 7302 accord with ILHR 83.05, Wis. Adm. Code Department of Commerce Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, on paper not less County //�� �� than 81/2 x 11 inches in size. 4 4 , C+ r - E - \ X • See reverse side for instructions for completing this application State Sanitary Permit umber 3 ,A4 - 19S Personal information you provide may be used for secondary purposes ❑ Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)1 State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N Propert Owner Name Property Location /� 1/4 5� 1/4, 5 T 2g , N, R J E (or) W Property Owner's Mailing Address Lot Number Block Num r 7/8 n 3 z City, ate Zip Code Phone Number Subdivisio or tSM Number TY PE OF BUILDING-16 (check one) ❑ State Owned ❑ rt� Nearest Road `/ ❑ Vd age / Public 1 or 2 Family Dwelling - No. of bedrooms 7 Town OF k-06 an Ill. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 21 , • I I 1 3 1 ❑Apartment /Condo 10 ?1, — t 3 Z - 7 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 online B, if applicable) A) 1. gL New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an - _____System __ - ___ - _System ___ ____ __ ____Tank Only_____ ______ Existing System __ _ Existin�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 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12X Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit ��� �/���Y ' 430 Vault Privy 14 ❑ System -In -Fill 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 '600 6 1 ?4 312 � � � Feet Feet VII. TANK in Capacity Total # of Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existin structed Tanks Tanks Septic Tank or Holding Tank 11 cx /Lc:V i ns G+ ® ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ I ❑ 1 ❑ 1 ❑ 1 ❑ ❑ VI11. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plum er's Name: (Print) Plum is P / Signature: (Na tamps) M PRSW No.: Business Phone Number: a k- � W,_ � r� s 3 L ��� - 77z - 3Z Plumb is Address (Street, City, State, Zip Code): pia A "% l �' d IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (ncludesGroundwater ate Issued Issuing Agent Signature (No Stamps) Approved E] Owner Given Initial Surcharge Fee) p Adverse Determination -7 X. CONDITIONS OF APPROVAL / RI S FOR DISAPPROVAL: SBD 6398 (R.11/97) 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. 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 typ e. 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. ---------------------------------------------------------------------------------------------------- i 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 /x rnPs Le-zeArs TIMM EXCAVATING SHEET NO. OF Z Route 1 Box 192 WILSON, WISCONSIN 54027 CALCULATED BY '�� �� DATE (715) 772 -3214 (715) 386 -5443 MPRS #3224 WI MPCA #696 MN CHECKED BY DATE SCALE ~= YO y3 , ... ..... ....... ............:.....:......:..... .. ... ... try .... ... :..rte • 4 ...:... y... . : ..... . .......... ..... } .... � ........ Q 1 /:.... , ° b'._ .... �y ,rylGj .. tFI Ltrr2� .... ..... ... } yet irl�s �c .... ._. , ` .. f . /D�o ��.! � .......... ..... . ..... .... O . ........................ ks . . ... _.L.s PRODUCT 205-1 �Inc., Groton, Mass, 01471. To Order PHONE TOLL FREE I - 800-225-6180 JOB � L�LG I1If TIMM EXCAVATING SHEET NO. Z OF Z Route 1 Box 192 WILSON, WISCONSIN 54027 CALCULATED BY DATE — (715) 772 -3214 (715) 386 -5443 MPRS 03224 WI MPCA #696 MN CHECKED BY DATE SCALE .......................................... ........ .. ..... .... .... .. - . ................... . ..... ..... ..... ..... .... .... ..... ..... ..... ..... ..... .... .... .... .... ..... ..... .... .. .. ...... .. ... ..... ..... .:.. ... . ``' t . � F . .. 13 _ f . .. .. ................... ........................... . .. .... . . . ... .......... ............................ ................. ............... . ......... ............ ............... ................ ............. ............. ............ ........... ........... ................ .......... .......... .......... ........... ........... ................ . ................ .................. ............. ........................................ ................ ................... .. .... ........... ........ .. ........... ........... .......... ---------- --------------------- ........... ........... ....................... ....................... ........... ................. ----------- ----------- ........ ...... ........... .......... ........... ........... ................ ........... ................. ----------- --- ........... .... .. ........................................... ............. PRODUCT 205-1 �Inc., Groton, Mass, 01471. To Order PHONE TOLL FREE 1- 800 - 2256380 Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page 1 of 3 Labor aid Human Relations Dimsion of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code Co Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or I.D. # dimensioned, north arrow, and location and distance to nearest road. �. APPLICANT INFORMATION— PLEASE PRINT ALL INFORMATION EDB PR OPERTY OWNER: PROPERTY LOCATION i Bridgeland Dev. Company GOVT. LOT NE 1/4 '. /4,S 29T14 N,R ' (or) W PROPERTY OWNER':S MAILING ADDRESS LOT # I BLOCK # SUBD. TIME 11736 117th St. 32 na S . CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE [RrOWN ' °ETA Lakeland, MN. 55044 (612) 985 -5000 Hudson y Dr. j New Construction Use [X] Residential / Number of bedrooms 4 [ ] Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow 450 g pd Recommended design loading rate • 7 bed, gpd/ft - 8 trench, gpd/ft Absorption area required 643 bed, ft2 563 trench, ft Maximum design loading rate • 7 bed, gpd /ft - trench, gpd/ft Recommended infiltration surface elevation(s) 93.00 It (as referred to site plan benchmark) Additional design / site considerations na 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 M S ❑ U ®S ❑ U CRS ❑ U 13:S ❑ U [2S ❑ U ❑ S ® U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Y Roots GPD /ft Boring # Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench 1 0- 10yr3/3 none 1 2msbk mfr QX if .9 .6 2 8 -16 10 r4 4 none Ground 3 16 -6 elev. 9 6.0 ft. 4 65 -84 5 r4 4 none cos os ml n .8 Depth to limiting factor +84" Remarks: Boring # 1 0-1 10yr2/2 none 2c-pl mfr 9W if np ,.2...,..''' 2 13 -26 10 r4 4 none si Ground 3 26 -82 10 r4 4 none cos oscr ml na n .7 .8 elev. 9 5.7 ft. Depth to limiting factor + 8211 v Remarks: CST Name:— Please Print Phone: Gary L. Steel Address: 1554 20 Ave. Ne Richmond WI. 54017 m02298 Signature: Date: CST Number: 8 -21 -96 PROPERTYOWNER RridgPiand Tev- C'n_ SOIL DESCRIPTION REPO Page 9, I PARCEL I.D. # pending Lot #32 4 Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft . Boring # Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench Li 2 9 -19 if .7 .8 Ground elev. 96 ft. i Depth to limiting factor +84 Remarks: Boring # 4 > 2 19-20 10 r4/6 none sl 2m r mvfr if .5 .6 Ground 3 1 20-80 10 r4 4 none ms 0sa mvfr na na .7 .8 elev. 9 6.0 ft. Depth to limiting factor +80 Remarks: Boring # 1 10-8 10 r2/2 none 1 2csbk mfr cs if .5 .6 S '. 2 8 -32 Joy r4/4 none sil lfsbk mfr gw if .2 .3 3 1 32-84 10 r5 4 none cos 0SQ ml na na .7 .8 Ground elev. 97.0 ft. Depth to limiting factor +84 Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD- 8330(8.05/92) ' J STEEL'S SOIL SERVICE Gary L. Steel Bridgeland Dev. Co. 1554 200th Ave. CSTM2298 NE 4SE a S29- T29N -R19W New Richmond, WI 54017 MPRSW 3254 town of Hudson (715) 246 -6200 r lot #32 -St. Croix Estates Second Addn. N 1 " =40' BM.= top of 12 pvc pipe C el. 100 � 3 h , 31' D 1s p, 1 , 2�1 M Gary L. Steel 8 -21 -96 I STEEL'S SOIL SERVICE Gary L. steer CSTM2298 1554 200th Ave. MPRSW -3254 New Richmond, WI 54017 (795) 248 -6200 To whoa it may concern; This soil evaluation was conducted to satisfy a zoning requirement, it may or may not be satisfactory for your use. The location of the system may or may not be as shown, as Permanent lot lines had not been established at the time of the test. Gary L. Steel ST CROIX COUN'T'Y SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer ,, Z c we.S L- iii 4, r y Mailing Address Property Address - 7 12; d,- (Verification required from /Planning Department for new construction) City/State dS ���' Parcel Identification Number f� 2 v - f 2 - 7 — IYD LEGAL DESCRIPTION Property Location 49 %4, .5; r t /o, Sec. Z-? , T -R /Y W, Town of Subdivision i - Lot # 3 - Z Certified Survey Map # Volume , Page # Warranty Deed # �'�?/ �� Volume Page # 3 . Spec house ❑ yes ® no Lot lines identifiable R yes ❑ no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper mainteii�. consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the sys:. 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 masterplumber, journeyman plumber, restrictedplumber or a licensed pumper verifying that (1) the on -site wastewater disposal s��� is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full f ;1L._ I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with th- set forth, herein, asset by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. stating that your septic system has been maintained must be completed and returned to the St. Croix Counry Zoning Office wtui., y of the three Zyearex 'ation date. IGNATURE Of kPPLICANT 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 owners roperty described above, by virtue of a warranty deed recorded in Register of Deeds Office. 3/ I NATURE OF AP 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 rIVAJ St,30 ��c 1•R�`3fioAc.�`•35� DOCUMENT NO. STATE BAR (r' WISCONSIN FORM 2 -1982 WARRANTY DEED O ddedand asm Cmnam a : r , Mawat ST. CROIX CO. WI _ -_ JUL 01 use con cys acid warranu to 10:15 A M James r u chn an d Claris wi i . .. O k 4)4j� husba� and wife _ - onaft the following descrPbed real estate in St. Croix County. State of Wisconsin & 1 . IAt U _ St. Croix Estates Second Addition in the Town of I3odemii. SL Croix County, Wisconsin. This is not homestead property. Exceptions to Warranties: I Dated this 12th _ day of 19 9s (SEAL) SEAL) � (SEAL) (SEAT.) • AUTHENITTCATION ACKNOWLEDGMENT Signatures authenticated this day of STATE OF MINNESOTA 19 Oakmta County Personally came before me, this — 'LO day Of t,.� lggg the above named TITLE: MEMBER STATE BAR OF WISCONSIN Krz��tli- (if authorized by 706.06, Wis. State.) This instrument was Ordked by to sue known to be the person who executed the bmcgoing instrument and Kknowtedg lama 20141 Icenk -*I- WSW CRAAA III It (Signatures may be authenticated or acknowledged. Both are not necessary.) Notary public Dakota • County, MN t4 commission expires January 1, 2000. t10tM PU9U�f M OMWTA MOM Mr �Omlttis5�0a 6�WresJart.3t.2000 •Nar,es of persons signing in any capacity should be typed or printed below their sipatures. sB2 NfF 0021 WARRANTY DEED STATE BAR OF WISCONSIN, FOR M NO. 2 -1982 N rn -n \ \ S3? o ♦ ♦ 03. ♦ ♦ s \ \\ \ > OS V\ L- \ 0 y O W� \ X34 3 , N m i Sr (3) �y \ �2 0 4'g � i ♦ ♦ lo, / ) � � A O n u, 00 w� r Qx Q m / v W 10 V) V1 r�w V o -1 :H V 1 / / / /� / (� n U) ^` ' V / I ,61 / 3 „t �S) 0 1 { I I ,@b' 96£ M „b£,9£,OON I m CD .4- -I z t 0 w °' o W 0) O N 1 1 A _N 01 I (D W O l W 0) O m ( D) D N n lT U D - -'� U N N X A \JV O N { N I N Lo -n uj -Q { w I I � I I A 00'99 90'Obb I N I { 1 90'909 3 „ti£,9£,OOS Z 6Z NOLL03S OD @Z NOIIJ3S ,bZ '69Z 3 „tb£,9£,OOS CD C°, � o S 8 N 6Z '33S 'b/13S 3Hl � 1Sd3 d0 3N1 N 1�1 � " 3 � rn ao rn I L7 - 0 rM IL7 n