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HomeMy WebLinkAbout040-1231-40-000 ST. CROIX COUNTY ZONING DEPARTMENT F3 AS BUILT SANITARY REPORT 6 � rro Owner Naa 4 't'� Property Address 5 A a City /State /emu W��.r/ w L+ 'OUNTY Legal Description: ZI I W G UPFlcl Lot l Block Subdivision/CSM # '/4 '/4, Sec. s ,TAN -RAW, Town of PIN # SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer s °d ees%`e v Size ST/PC / d�Le lG S4 Setback from: House 2O - Well ,57d; PAL Pump manufacturer Model Alarm location g (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM Type of system: v J Width S Length 73 Number of Trenches 2 Setback from: House Well P/L Vent to fresh air intake ELEVATIONS Description of benchmark A o e Elevation Description of alternate benchmark -e-- Elevation ?Y, Building Sewer 'y "I t ST/HT Inlet 4 /_2 ST Outlet PC Inlet PC Bottom 7 6l Header/Manifold Top of ST/PC Manhole Cover 22 - Distribution Lines () 72 () g%1 Y Sr ( ) Bottom of System O `/ I O ( ) Final Grade O O ( ) Date of installation / / Permit number 3 9 /G 7 State plan number Plumber's signature C ✓� License number F . f' 4 Date Inspector A y Complete plot plan � 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. i PLAN VIEW s e- � D v INDICATE NORTH 0 W , b it;consfi .DepartmentofCommerce Safety and Buildings Division PRIVATE SEWAGE SYSTEM 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)J. Permit Holder's Name: ❑ City ❑ Village ❑ jown of: State Plan ID No.: Nelson, Marcia I Town of Tro CST BM Elev.:- Insp. BM Elev.: BM Description: Parcel Tax No.: L ( IM -Q l t TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic +00 /(, 6-D Benchmark too. D Dosing U Alt. BM . QO g2. 62. Aeration Bldg. Sewer $t • en Holding St/ Ht Inlet �Z- TANK SETBACK INFORMATION St/ Ht Outlet �k Ventto TANKTO P/L WELL BLDG. Airintake ROAD Dt Inlet Septic >1 en 13/ NA Dt Bottom (4 !l•✓�0 $S•& 7__ Dosing 19 NA Header/ Man. ' q2- le- Aeration NA Dist. Pipe q.2. yr Holding Bot. System R. /Z Cj•c98 4 1•(00 PUMP / SIPHON INFORMATION Final Grade r Manufacturer Demand St cover A 3 q� -BZ. Model Number 'GP TDH Lift , p Friction 3•`F System TDH \p �t' Head Forcemain Length 104 Dia. 2 `� Dist. To Well T_ SOIL ABSORPTION SYSTEM BED/TRENCH Width / Lengt r No. enches PIT No. Of Pits Inside Dia. L epth DIMENSIONS 5 TS It DI N I N SYSTEM TO — O P I L BLDG WELL LAKE I STREAM LEACHI INFORMATION Type Of Ma cturer: SETBACK CHAM , r e N um er: System: � ZO 'Y /,30 OR IT DISTRIBUTION SYSTEM Header / nifold R Distribution Pipe(s) &r r x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length 3 Dia. � Spacing 7 ICO r 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 #1: 1 / Inspection #2: — --i Location: 692 Buttercup Court, Hudson, WI (NE1 /4, SE1 /4, Section 3 T28N -R19W) - 3.28.19.1140 ), 21 _r - I-, ( ?­ Sew or le, fra — 4 , Q c rs Plan revision required? ❑ Yes M No I Use other side for additional information. 1 0 - 3k 1 0 1( SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. I� I 1 ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: , TA e € - - -_',r_ .m.. a ( E F t 3 # — t — T �- 5 ...F. ® �mm. .,......�. ,, f ... .:. ........ € w. �.....�.., ,.e...,..».. ; �e. j ({ ...,..v..- }q �.....�. ..... _ �,,..,..�" M.«.em .e_ e ..... F......,.,,.uw. mw...e...m.,.. ..�. _ AE 1 fl g < f # t 2 S f ¢ # w Safety and Buildings Division Visconsin SANITARY PERMIT APPLICATION 2 1 Box Washington Avenue Department of Commerce In accord with Comm 83.05, Wis. Adm. Code Madison, WI 53707 -7302 0 Attach complete plans (to the county copy only) for the system, on paper not less County than 81/2 x 11 inches in size. 0 See reverse side for instructions for completing this application State Sanitary Permit Number 353I Personal information you provide may be used for secondary purposes JK Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION Property Owner Name Property Location l , 4 1 , c 1/4,e 1/4,S T, ,N,RIp E(or)dc Property Owner's Mailing Address >> Lot Number Block Number /® t` �' G f-a A, e— /T / City, State Zip Code Phone Number Subdivision Name or CSM Number II. TYPE OF BUILDING: (check one) ❑ State Owned C] ❑ it Nearest Road Village Public 1 or 2 Family Dwelling - No_ of bedrooms own OF Y III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo a /V 0 ' 12 3 r— V4 - o o d 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. g New 2 ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an ------ System ________System Tank Only Exi sting System Existing System B) 4 A Sanitary Permit was previously issued. Permit Number 3S 16 Date Issued r0-11S - I q 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 FZSeepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORP 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) 7 Ele�vat 76 7 O .J �- , rt0 Feet $5 ' ;e,6 Feet VII. TANK Capacity in gallons Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existing structed Tanks Tanks Septic Tank or Holding Tank /e /y1 i'� G.4rPy ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber X Q I j r B 7' r� ® ❑ 1 ❑ I ❑ 1 ❑ ❑ Vill. 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 Stamps) P PRSW No.: Business Phone Number: °a c �Lc v �7 r-3 ,P G� Plumber's Address (Street, City, State, Zip Code): d2 IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued Issuing Agent Signature (No Stamps) � Approved C] Owner Given Initial Surcharge Fee) Adverse Determination 1) S R ONDITION OF APPROVAL OVAL /ASQN�FORDISAPPROVAL: <� ° e � fir• �„ e � SBD -6398 (R. 4/99) DISTR UTION: Original to unty, One copy To: Safety a 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. .y 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. -Vi 1. Tahk 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 8 1/2 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. ---------------------------------------------------------------------------------------------------- GROU,NDWATER 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. ,'cc. .�1 S.�' Sc 3 T� �� Ya n/—. n � l� � /�' ��v Ste. u��- l `�a5'a 1 �� z o� h P� l � GQ ,�,u s � � � a` 'f r� a i l ' P� i l � 0 �� Q , a � o ,�� �m t � � d v � � a 1, -.. �� ��� �`�0`0. �� � � 1 � 1 � .N � ��. ``� '`�� \ '�\ � \ � r � � haj�'�27yQe� �'���- To�u.NS Wisconsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page —L- of Bureau of Integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code Attach`complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # a 0- APPLICANT INFORMATION - Please print all information. Rev' wed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location e�.5' Govt. Lot ,t, 1/4 j,'1 /4,S 3 Ta?' ,N,R 19 E (or)CO Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# City State Zip Code Phone Number ❑ city [2 village 2S Town Nearest Road G7 Gt Cf S O •�/ e-j S e ) TY d ® New Construction Use: Residential/ Number of bedrooms 7 Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow . Zc! gpd Recommended design loading rate • -S bed, gpd /fF trench, gpd /ft Absorption area - required bed, ft - ZS_ trench, ft Maximum design loading rate r S bed, gpd /fi 6 trench, gpd/ft Recommended infiltration surface elevation(s) L.L+i.d �V ? /. 70 ft (as referred to site plan benchmark) Additional design /site considerations j 4� A C.�r eA 9� ` 7a Parent material 0dYC,, & e- 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 system J R] S ❑ U 5d S ❑ U US ❑ U 1 14 S❑ U ❑ S R] U ❑ S MU SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 _ in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Q 1n5 C710 Grou elev. nd 3 3�~ ,s rP `/ 6 - - S Depth to limiting factor in. Remarks: Boring # y, ' ` C Ground elev. q .9a ft. Depth to limiting factor in. Remarks: CST Name (Please Print) Signature Telephone No. Address ® Date CST Number SOIL DESCRIPTION REPORT PROPERTY OWNER Page a of PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed . Trench 2 b 6 7- S Yeq $ C M.: e h7 Gro 3 3"! $ S Z.Bo Depth to limiting f ctor �in. Remarks: Boring # ........................... Ground elev. ft. Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Boring # ........................... Ground elev. ft. Depth to limiting factor in. Remarks: I Boring # ................. Ground elev. ft. Depth to limiting factor in ' Remarks: SBD -8330 (R. 07/96) I a T^ci'u- J/�e /S�.J ,U� S,E.j Scc �Ta� GQl4' GJ ytT �/co.yv�`Ji�Laooc� Tac.Je1 e ear I U I � r r � 3 TYa.�s r - Sent by: EDINA REALTY HUDSON WISCONSIN 715 386 1502; 10/11/99 9:13AM;J #512;Page 3/5 t ru` _ It us at tons try, SOIL AND SITE EVALUATION REPORT Pa 1 s . , tats ar�e;,.tun Reltions ag � Dviiioin or Safety d aulfeLnpa in accord with ILHR 83.05, Wis. Adm, Cade COUNTY Attach complete site plan on paper not less then 8 12 x 11 inches in size. Plan must include. but 5t. Croix not liirnited to vertical and horizontal reference point IBM), direction and % of slope, scale or PARCEL I.D. N dimensioned, north arrow, and location and distance to nearest road ending APPLICANT INFORMATION PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER PROPERTY LDCATION Richard Stout GOVT. LOT NE 114 SE 114,5 3 T 28 ,N,R 19 xH(cr) W PROPERTY OWNER':S MAY.ING ADDRESS LOT a BLOCK s SUBO. NAME OR GSM R 1353 Awatukee Trl na Country Wood CITY. STATE ZIP CODE PHONE NUMBER fTY EJVILLAGE CgOWN NEAREST RO Hudson, Wi. 54016 17151 549 -6731 Troy Tower Rd. New Construction Use pQ Residential / Number of bedrooms 3 ( Addition to existing building l I Replacement ( Public or commercial describe ;ode derived deify flow 4 50 and Recommended dwgn loadwq rate • 5 bed, gp"2 . 6 tit no 2 9l� Absorption area required 900 bed, h ' 750 trench, h Maximum design loading rate .5 bed, gpd/It -6 trench, gpCM Recommended trt5lvabon surface elevations) 98.35 It (as relened to site plan benchmark) Additional design / site considerations na Parent materail ground moraine Flood plain elevation, if applicable na h S IL Suitable lot system CONVEWIONAL moms IWOROUND PRESSURE AT•GRADE SYSTEM w FILL HOLDM TANK U= Unsuitable for stem i WS D U C� S O U [� S 0 1.1 :0S [J ❑ S AU C] S M SOIL DESCRIPTION REPORT Depth Dominant Color Modles { Structure GPD /ft Haring � Horizon Texture I �f�n� Y ROOD Bed 7ra1c� in. Munsell Qu. Sz. Cora Color Gr. Sz. Sh. 1 qw 1E .5 1.6 - 10 10 r3/3 node 1 rnsbk mfr 2 10 -26 7.5yr4/4 none scl 2msbk mfr yw if .4 .5 Ground 3 26 -84 7. 5yr4/ 6 ' none s Ogg mf r na na 15 eWv. 10 it. Depth la limiting l aw. Remarks: Boring 1 0 -15 LO r3 3 none 1 2msbk mfr 17W if .5.6 t 2 2 15 -28 7,5 r4/4 none sal 2m6bk mfr if .4 ?.5 Ground 3 28 - 7.5yr4 /f) none lfs ors mvfr na na .5;.6 ' Wev. � 101.2ft. Depth to titniDng motor Remarks: CST Name:- -Plure Print Gar L. Steel /J phan Gary 715 246 -62 00 Adniasc: 1554 2 00th Ave. , 10 -30 -95 N ew Richmond, Wi 5 _ Sent by: EDINA REALTY HUDSON WISCONSIN 715 386 1502; 1001/99 9;14AM;) #512;Page 4/5 • ` PROPt,gnOWNER_ Richard Stout SOIL DESCRIPTION REPORT p Z of — ti PARCEL9D.o W riding Boring d ftorizon depth Dominant Color Mottles Texture Structure GPD /tt x:; : in. Munselt Ou. Sz. ConL Color , Gr. Sz. Sh. Consistence ftn*y Roots Bed t7� 3 1 0 - 10 r3/3 none 1 2msbk mfr gw if .5; .6 2 10 -41 7.5yr4/4 none scl 2mgr mfr gw if . .5 Gnxwnd _ 3 1 -82 7.5yr4/4 none Ifs osg mvfr na na .5' .6 elev. 001A to factor Remarks: Boring a +r': 1 _g 10yr3/3 none 1 2msbk mfr gw l f .5 .6 >s' 4 • ;Y;xr 2 -'t 8 7.5yr4/4 none scl 2msbk mfr gw if .4 .5 Grorxid 3 18 - -39 5yr4/4 none sl lmsbk mfr gw na .4 .5 elev. A - 10 _- 39 B ,q 7 .5yr4 / �I none sl 2mgr mvfr na na .5 .6 Ala lirniong faGior +84 Remarks: _ Goring ✓r 1 0 -14 10 r3/3 none 1 T 2msbk gmvfrna if .5 ,b 5 2 14 -2 7,5yr414 none sC.l 2msbk if .41 .5 Ground 3 28 - 7.5 t�l /h none Ifs os na � .5 .6 011 ft I 0"I" to rnreng l lacV ,. -- Remarks: t3oring li f Gm w —._. elev. lackx Remarks: w Sent by: EDINA REALTY HUDSON WISCONSIN 715 386 1502; 10/11/99 9:14AM;) #512;Page 515 STEEL'S SOIL SERVICE Gary L. Steel Richard / stout �` 1554 200th Ave. MPRSW town o w n o f Troy Troy N -R19W New Richmond, W 54017 o1;m o lot #69- Country Wood (715) 246 - 6200 N 1 UM-= top of 1" steel pipe 9 el. 100' Alt. BM.= top of P steel pipe el. 103.00' i r?4 7_ 3� 4 � 1 � � � .3 Lz i io to Gary L. Steel 10 -30 -95 ;i Sent by: EDINA REALTY HUDSON WISCONSIN 715 386 1502; 10/11/99 9:13AM;J #512;Page 2/5 :. tar', C(,MYUTEC ':�MvEp cc10M N "41'26'E rAs -, 594 00 -. 89 3 72' A, 4 • A 2 ,v ACRES ~ 3i,n76 so W V 0 ``' , 'fir. ••. •'- . 6a Safety and Buildings Division 'Cons SANITARY PERMIT APPLI ATION 201 Box Washington Avenue V Department of Commerce In accord with Comm 83.05, Wis. Adm. Code Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, .- per riot kss County than 8 1/2 x 11 inches in size. e d • See reverse side for instructions for completing this appllcAtior: P tate sanitary Permit Number � � Personal information you provide may be used for secondary purposes „ r fl heck if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. R Sta Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT NFOI Property Owner Name , Cp y atior.. e / — s `, Tqs' 1 T , N, R E (or V&1 Property Owner's Mailing , Address J ✓`;, Lot "ti Block N City, State F } Zip Code Phone Number (di io a or CSM Number JJ 1 -1 11. TYPE BUILDING: (check one) ❑ State Owned C Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms �� ° V own o 1111. BUILDING USE (If building type is public, check all that apply) Parcel Tax C N . uumber(s , ?$ �� 1`4 0 1 C] Apartment/ Condo © / O —) Z — �� — &LYD 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, gg„New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an ______System ________System _____________Tank Only______________ Existing System _________Exlsting 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 12 ®,Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit r 43 ❑ Vault Privy 14 E] System-In-Fill X VI. AB SYSTE F RMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 1 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) 97 & Elevation ys� 7 /0x_ Feet 11f B Feet Site VII. TANK Capacity gallon Total # Of Prefab. Fiber- Plastic Exper. INFORMATION Gallons Tanks Manufacturer's Name Concrete Co Steel glass App. New Exist strutted T nks T nks ll� Septic Tank or Holding Tank a In t ,� CS 1�C�'^ RL ❑ ❑ ❑ 1 ❑ ❑ Lift Pump Tank /Siphon Chamber Si3 .� �,.t! ❑ ❑ ❑ 1 ❑ ❑ Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. ap Plumber's Name: (Print) Plumber's Signature: Stamps) All MPRSW No.: Business Phone Number: r Plumber's Address (Street, City, State, Zip Code): - r7 C ®.1/ 4 e y e IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps) `Approved E] Owner Given Initial dD surcharge Fee) Adverse Determination � -�t 1 I ” X. CONDITI NS OF APPROVA / EAS FOR DISAPPROVAL: 15 is t ©. l „at . Pl _- D p ,,. , a t C On co y To: e & Buil 'ngs ision, r, PI r ` 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: t. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed.' Il. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. lit. 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 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale Jr 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 doss; 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 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. ,�jyL Yr � ' ,� o'T /���5 ill .1��•�� Sf %�SJ' '/ � � / � �� � a T 7 CO�iJdf�i�'L,7or� l Yc� -V i G' y P' v' -f a 41 1 J f 40� riNi 's��^l nsin Department ofIndustry 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 COU �l Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must incl Cro' x not limited to vertical and horizontal reference point (BM), direction and % of slop ale or A L LD r t dimensioned, north arrow, and location and distance to nearest road. peri 1 1 Ll APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATI N 1501f-- EWW �0 PROPERTY OWNER: LOCATION Richard Stout GOVT. LOT � 1/4 SE 3 � 19 � or) W PROPERTY OWNER':S MAILING ADDRESS LOT # OCK # SUBD. NA 1353 Awatukee Trl �.st °69' a Countr o CITY, STATE ZIP CODE PHONE NUMBE - VILLAGE 2gTOWN OAD Hudson, Wi. 54016 V15) 549 -6731 1 Troy Tower Rd. New Construction Use Residential / Number of bedrooms 3 [ j Addition to existing building (j Replacement [ j Public or commercial describe Code derived daily flow 450 gpd Recommended design loading rate • 5 bed, gpd/ft • trench, gpdtft Absorption area required 900 bed, ft 750 trench, ft Maximum design loading rate • 5 bed, gpd/ft - trench, gpd/ft Recommended infiltration surface elevation(s) 98.35 ft (as referred to site plan benchmark) Additional design / site considerations na Parent material ground moraine Flood plain elevation, if applicable na ft S = Suitable for system CONVENTIONAL I MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable for system g] S[I U a C:] U [3 S U 1 13 ❑ U I CIS 1 2M ❑ S EN SOIL DESCRIPTION REPORT Boring# Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounday Roots GPD /ft in. Munsell 11u. Sz. Cont Color Gr. Sz. Sh. ` Bed Trerxh 1?' 1 0 -10 10yr3 /3 none 1 12msbk mfr gw if .5 .6 2 10 - 7.5yr4/4 none scl 2msbk mfr gw if .4 .5 Ground 3 26 -84 7.5yr4/6 none s osg mfr na na .5 .6 elev. 10 ft. Depth to ­77I limiting fact Remarks: Boring # ti .. 1 0 -15 10 r3/3 none 1 2msbk mfr if .5.6 2 2 15 -28 7.5yr4/4 none scl 2msbk mfr qw if .41.5 MEMO 3 28 -80 7.5yr4/6 none Ifs osg mvfr na na .5.6 Ground elev. - 1 Depth to limiting factor +80" Remarks: CST Name:— Please Print Gary L. Steel % Phone. 715 -246 -6200 Address: 1554 200th Ave., New Richmond W' . 54017 10 -30 -95 Signature: Date: CST Number: Muzzqu PROPERTY OWNER Richard Stout SOIL DESCRIPTION REPORT Page oi'__3 PARCEL I.D. # Pending Boring # Horizon - Depth IDominantColor I Mottles (Texture I Structure Consistence Borrri3y Roots I GPD /ft in. , Munsell . f + Cu. Sz. Cont. Color Gr. Sz. Sh. Bed iTrerch 3 `' 1 0 -10 10. r3/3 none 1 2m'sbk mfr gw If . 5'i .6 ><hx 2 10 -41 7.5yr4/4 none scl 2mgr mfr gw if .4j .5 i Ground 3 1 -82 7.5yr4/4 none lfs osg mvfr na na .51 .6 elev. 1 01. &t. Depth to limiting factor +82" Remarks: Boring # ,.... >. >_ 1 0 -9 10yr3 /3 none 1 2msbk mfr gw if .5 2 9 -18 7.5yr4/4 none scl 2msbk mfr gw if .4 .5 3 18 -39 5yr4/4 none sl lmsbk mfr gw na .4'.5 Ground elev. 4 39 -84 7.5yr4/4 none sl 2m r mvfr na na .5 .6 10 ft. Depth to limiting factor +84" Remarks: Boring # 1 0 -14 10 r3/3 none 1 2msbk mfr gw if .5' .6 2 14 -28 7.5yr4/4 none scl 2msbk mfr gw if .4 .5 3 7.5yr4/6 none Ifs osg mvfr na na .5 Ground 10 ft Depth to limiting factor +84" - Remarks: Boring # i Ground elev. ft. Depth to limiting i factor Remarks: S130- 8330(R.05/92) f - STEEL'S SOIL SERVICE Gary L. Steel Richard Stout 1554 200th Ave. CSTM2298 NE4SE4 S3- T28N -R19W ' New Richmond, WI 54017 7 3254 town of Troy (715) 246 -6200 lot #69- Country Wood 1 " =40' BM.= top of 1" steel pipe C el. 100 Alt. B1yI.= top of ! ' steel pipe C el. 103.00' C 3 -1� qv G l o t k r3r 82, Gary L. Steel 10 -30 -95 • r f �r 1 j� r { h ,... _ t _� 1 . � __ __ _� �' I __ _ .. - �= __ ,. i 1 , ,� t �� ! �. _} { I .. (' PAf.,t GF PUMP CHAMBER CROSS SEC T IDIJ AMD SPECIFICATIO JS VCUT CAP 4 "C.I. VENT PIPE WEATHERPROOF APPROVED LOCKIAIG > ?_5 FROM DOOR, JUUCTIOU BOX MAMHOLE COVER — WIMDOW OR FRESH 12 "MIU. AIR IMTAKE GRADE I I `I" MIIJ. 1 CO►JDUIT 18 "MIN. v _ -_ - - -_ 11� IhI LE T PROVIDE _T AIRTIGHT SEAL i I *' A I I I ({ ALARM B I II I I o *APPROVED i i oN JOINTS WITH ELEV. FT. APPROVED PIPE _ -� 3' ONTO P15LOCK � OFF D SOLID SOIL COMCKETE RISER EXIT PERM11fED OIJLy IF TAMK MAWUFACTURE.R HAS SUCH APPROVAL SEPTIC E SPECIFICATIOMS DOSE TAUKS MAWUFACTURER: 7L`y'1 IJUMBER OF DOSES: PER DAy TAIJK SIZE: e;�lJ GALLOUS DOSE VOLUME ALARM MANUFACTURER: iCC /J- e z IMCLUDIMG BACKFLOW: jag' 9 GALLONS MODEL ►DUMBER: �� y CAPACITIES: A = ,S I MCHES OR 3SO GALLOU5 SWITCH TYPE: _ /'VenS/L B= I"CHES OR GALLOIIS PUMP MAU UFACTURER: �So v Ia�S C= T c IML14ES OR �Q GALLOWS MODEL NUMBER: _ Edo Y D =_INCHES OR 1a GALLOWS j SWITCH TYPE: MOTE: PUMP AMD ALARM ARE TO BE MIMIMUM DISCHARGE RATE _ e6 GPM INSTALLED OU SEPARATE CIRCUITS VERTICAL DIFFEKEWCE BETWEEU PUMP OFF AMD DISTRIBUTIOU PIPE.. 116_ FEET + MIIJIMUM NETWORK SUPPLH PRESSURE , , ' FEET + jl FEET OF FORCE MAIN Y3 = � /loo FZFRICTIOIJ FACTOR. _ 2-7 FEET TOTAL D9MAMIC HEAD FEET IIJTERiJAL DIMEIJSIOAJt OF TAI.1K: LEfJC7TH ;WIDTH ,LIQUID DEPTH 3g It I SIGLIED:- i •-' Goulds - Submersible Effluent Pump 3871 EPO4 EP05 APPLICATIONS • Fasteners: 300 series Fully submerged in high ■ Motor Housing: Cast iron stainless steel. grade turbine oil for for:efficierifheat transfer, Sp ecifical ly desi red f r o the g le of running '_:'lubrication and efficient strength. and durability. Capable 9 following - 9 uses: d without d heat transfer. damage to . • Effluent-systems dry 9 • w ■ Motor Cover. Themtoplas _ • Homes components. tic cover with integral handle Available for automatic and •Farms Motor. manual o elation. Automatic and float switch attachment p • Heavy duty sump 1 PO4 Single phase: 0.4 HP, models include Mechanical points. Water transfer 15 or 230 V Hz, 60 1550 ■Power Cable: Severe d RPM built in Float Switch assembled and �y • Dewatering overload with preset at the factory. rated oil and water resistant. automatic reset ■Bearings: Upper and lower • SPECIFICATIONS EP05 Single phase: 0.5 HP, FEATURES heavy duty ball bearing 115 V, 60 Hz, 1550 RPM, construction. Pump: EPO4 built in overload with ■ EPO4 Impeller: Thermo- • Solids handling capability: automatic reset plastic Semi -open design 3 /4 maximum. • Power cord: 10 foot with pump out vanes for AGENCY LISTING • Capacities: up to 55 GPM. standard length, 16/3 SJTO mechanical seal protection. Ip. Cana" StanduftAssodaft • Total heads: up to 24 feet. with three prong grounding n EP05 Impeller: Thermo- • Discharge size: 1' /i NPT. plug. Optional 20 foot asd d f (GSA listed model numbers Plastic enclosed • Mechanical seal: carbon- length, 16/3 SJTW with end in F" or "AG".) rotary/ceramic- stationary, three prong grounding plug improved performance. BUNA -N elastomers. (standard on EP05). ■ Casing and Base: Rugged • Temperature: thermoplastic design provides 104 °F (40°C) continuous superior strength and 140 °F (60°C) intermittent. corrosion resistance. • Fasteners: 300 series Mss FEET stainless steel. 10 • Capable of running dry without damage to s 30 components. Pump: EP05 8 s -% • Solids handling capability: e %* ma)dmum. a W • Capacities: up to 60 GPM. _ • Total heads: up to 31 feet s zs- 8 • Discharge size: I%* NPT. z s • Mechanical seal: carbon- } - G i s rotary/ceramic- stationary, D 4 BUNA -N elastomers. o o � • Temperature: 3 10 104 °F (40°C) continuous 140OF (60°C) intermittent 2 5 f, 0 0 10. 20 30 D 50 GPM tt^ 0 2. 4 * 6 8itf0 12 m'At %'CAPACITY O 1995 Gouids Pumps. br - -` . '. , , „�. <. 1= 9ftecds Mai/. 1995 ~ ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer `(� Cj j C k )( Mailing Address U `e a S G CJ &j YC1.1 `L' Property Address (Verification required from Planning Department for new construction) City /State 4�'a d : 5: 6 . Parcel Identification Number LEGAL DESCRIPTION Property Location 1 /4, — :e - 1 /4, Sec. 3 , T F N -R Town of Subdivision CJoc 4- , Lot # Certified Survey Map # , Volume . Page # Warranty Deed # p`f,�;� . Volume / ��5'� , Page #. Spec house ❑ yes IRL no Lot lines identifiable g 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 master plumber, joumeymanplumber, restrictedplumber or a licensedpumper 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. 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 three year expiration date. U /& 1, SIGNATURE 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. SIGNATURE OF APPLICANT DATE I * * * * ** 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 STATE BAR OF WISCONSIN FORM 2 - 1998 61 1 154 WARRANTY DEED KATHLEEN H. WALSH REGISTER OF DEEDS Document Number .1459 PAGE 454 ST. CROIX CO., WI RECEIVED FOR RECORD This Deed, made between RICHARD O _ STOUT 09-29 -1999 9:00 AM WARRANTY DEED Grantor, EXEMPT R - - -- — -- CERT COPY FEE: and MARC IA K NET RON , a si p p erson, — COPY FEE: TRANSFER FEE: 104.70 RECORDING FEE: 10.00 PAGES: 1 Grantee. Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate in St Croix County, State of Wisconsin: Recording Area Lot 4, Plat of Country Wood, Town of Troy, Name and Return Address First National Bank of New Richmond St. Croix County, Wisconsin. PO Box C New Richmond, WI 54017 040- 1231 -40 -000 Parcel Identification Numbt;r (PIN) This -Q ; n - homestead property. (is) (is not) Exceptions to warranties: easements, restrictions, rights -of -way and covenants of record. Dated this 9 4th of Sept 1999— R i ch a -d 0 Stout (SEAL) (SEAL) (SEAL) (SEAL) * * AUTHENTICATION ACKNOWLEDGMENT Signature(s) State of Wisconsin, ss. St - rrni x County authenticated this day of Personally came before me this 24th day of September 19 9 9 , the above named —R. ichard0. Stout * TITLE: MEMBER STATE BAR OF WISCONSIN to (If not, ����t \itt1�� me known to be the person who executed the foregoing authorized by §706.06, Wis. Stats.) RY PuBSk�r� i trum t and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY ✓N V� VA Janet P. Stout ; MAUREEN K ' 111A L 11 Awai Tr- Hudson, Wi. 5401 6 Notary Public, State of Wisconsin My commission is permanent. (If not, state expiration date: (Signatures may be authenticated or acknowled'Ve�l. , �] `t�Ct . �— � necessary) ` 't ' Names of persons signing in any capacity must be typed or printed below their signature. STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., inc. WARRANTY DEED FORM No. 2 - 1998 h ilwaukse WIS. I OD N D �J q m O N N q N ~D �F y m \ \ N U) ,96'9££ 3 „6Z,LO,OON v V) W m m '8LZ OD N loo•5l£ (M„85 I p 8 I •O n O Q m W °—° z cr m W °-0 ti / io 3 m w n m 2 to c v 10 II 55'SL£ 3„63,LO A o 1 c r = Z I- ”' m m ? / N N / X04 I O O D C,) Cl) r) i� 10i I / , � o ' ,£O:BLb 3 „6Z,LO,OON 1 m m pp= 1 0 N .4 00 r.O � mo m m D fff �u :0 O v Z n � � rn ' O°-gl£ ,06'98ZZ M„60,10.00S 143S �_ 3Hl 30 3N1l 1SV3 i�1_► GPJfl '�d