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HomeMy WebLinkAbout020-1009-20-000 ST. CROIX COUNTY ZONING DEPARTME AS BUILT SANITARY REPORT -E Owner # - t Address S „D;; City /State ,, GOUNr ,` Legal f Description: Lot A T Block Subdivision/CSM # --- '/, '/, ' Sec , To N -R�, Town of PIN # G J., -� c�� — 0 a 0 -/ago - �d SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION Tank manufacturer W 1vaa� Size ST/ot Setback from: House 3 Well 70 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: 6-4 Y2-0-10- Width a Length � Number of ✓EM s Setback from: House S Well P/L 2 8' Vent to fresh air intake 5 ELEVATIONS Description of benchmark — rm N A/ OTZ _ Elevation /,v Description of alternate benchmar 1 :;nx& O,� `V r Elevation Qy ' Building Sewer 5� s ST/HT Inlet g3 ST Outlet , )--fP PC Inlet --- i PC Bottom Header/Manifold 9 Top of ST/PC Manhole Cover 91 �S Distribution Lines ( ") 93 O ( ) Bottom of System 9 a Final Grade (1) / Date of installation a /W/ 9 1 �Permit number 3 d 24 y2 ? State plan number Plumber's signature License number 1 ,5 63 Date aI 9 Inspector Rod Complete plot plan Or 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. rij 6& �dt j PLAN VIEW b ¢� f ti b fy� 1 i f ti O r INDICATE NORTH ARROW Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Buildings Division Count y ST. CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) SanitaryPe,Ir,�iL% Personal information you provice may be used for secondary purposes [Privacy La s.15.04 (1)(m)). 33 11JJ / 66 GL N EL Holder am: ❑A�ga/gage Town of: State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description: Parcel TaxNoL: t bti �� - To o,�- 4ouv dCL a iW o 020 - I 00g- Zo TANK INFORMATION ELEVATION DATA A9800018 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septi [ l S� j u v o Benchmark a Z'� /aZ.B? t Dosing Aera ' n Bldg. Sewer Hol Q/-W Inlet qS7 S. TANK SETBACK INFORMATION K 6D4#,Outlet TANK TO P / L WELL BLDG. Air Intake ROAD Dt Inlet Ititc Septic qD+ � �jD' 7� C,' NA Dt Bottom ttif� Dosing ✓ j NA Header / Man. q SZ q3 Aeration NA Dist. Pipe q.� ' 93,2 Holding Bot. System /0. Lo' qZ Z7 92 PUMP/ SIPHON INFORMATION Final Grade 7-Z ` r'5 67 Manufacturer Demand St MAv k CoJ,, Model Number r / GPM TDH Lift Lri e ctl S m TDH Ft Forcemain I te ngth. - Dia. Dist. To Well - 1 F F SOIL ABSORPTION SYSTEM ENCH width Length No Of Trenches PIT No. Of Pits Inside Dia. L quid Depth DIMEN I N [� 5y DIMENSION SETBACK SYSTEM TO P / BLDG WELL LAKE /STREAM LEACHING Manufa rer INFORMATION Type O f CHAMBER Model Number: System: ( cm V(,w L +Z� 5 l� OR UNIT DISTRIBUTION SYSTEM +,1fi G'v� (C - Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. `/ Length �Z Dia. Spacing 6 SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of Seeded/Sodded xx Mulched Bed /Trench Center Bed /Trench Edges To ❑Yes ❑ No ❑Yes ❑ No —7t COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON 10.29.19.45A,SW,NE 1056 SCOTT ROAD Q C � �k" V ' 0 5 U �J Ana ��hae -c� P-?4 code Plan revision required? ❑ Yes © No Use other side for additional information. a j SBD -6710 (R.3/97) Date I nspector'A ignature ert. N . r ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: G��`Ci�te III 4'J Y q -... \I f� as dfy��� v 4v� I f l oud � ° W�.e,� -t'b t WO a j I. �d _ V i sconsin SANITA Y PERMIT APPLICATION 2 01eE. W and shn sion � �¢ P.O. Box 7969 Department of Commerce In acco f . - ILHR 83.05, Wis. Adm. Code Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the sy is em, on paper not less County ' than 81/2 x 11 inches in size. ST %, CQ`p • See reverse side for instructions for completing this application State sanitary Permit Number X07 (024 The information you provide may be used by other government agency programs ❑ Check it revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION Property wn Name Property Location ®� r w 1/4 N E 1/4, S j T c 9_9 N, R t FIr) W Property Owner's Ma ing Address Lot Number Block Numb r I City, { tate Zip Code Phone Number Subdivision Name or CSM Number udSo .54 © (Z f5 ) 311 .00 I1. TYPE OF BUILDING: (check one) ❑ State Owned 't Nearest Road El Village n Public 1 or 2 Family Dwelling - No. of bedrooms Town OF I'C' 1RocK I11. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) /to. a 9. /9.3&43 1 ❑ Apartment/ Condo - �ooC>9 p 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreationa a l y 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 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 9 5eepage Bed 21 E] Mound 30 [] Specify Type 41 E] Holding Tank 12 Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ 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 7� 0 1 4 #3 (0 2 j/k , ---- W 1 Z Feet 97,/ Feet Capacit VII. TANK in g allon s Total # of Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existin structed Tanksl Tanks i k ��OrO W UAL. El El El 11 1:1 Lift Pump Tank /Siphon Chamber ❑ I ❑ 1 1:11 ❑ I ❑ I ❑ VI11. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. PI ber's Name: (Pri Plumber's Signatur Stamps) r111AWPRSW No.: Business Phone Number: 0. I t� (� �� c�j l Plumber's A( dress (Street, Cit , State, Zi Code): IX. COUNTY/ DEPARTMENT USE ONLY ❑Disapproved Sanitary Permit Fee (includes Groundwater D ate Issued. Issuing Agent Signature (No Stamps) ®Approved ❑ Owner Given Initial d0 Surcharge fee) Adverse Determination �� X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL. SBD-63W (R.11/96) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber 1 ,� . 1� �11e�Carvw EI 100 � b D. v , k c� Y f `' 1'1)¢.)56 --• • • PAGE OF San wT- C. r�SS S �c�lon oar filth Ak IM'14 And OD►uyQIIGA Plpd 7qO IN U 10—u o � APpfor d V.M Cap `I�'I flnol G,.d. '�.�SO^ J J S w y� nrE Y, s 'e c- r� to 20 - {2'Apor. Plpr N l" 4 Coal kon To Flnol clad. V pip, 0Y� tWL I1.f OI S vnl h CoruM 0#6( Pip, ° �� Oltlrlorlla. ' Plp• t Ire AYV�4gal'a 0.n.a1A PIP. ° P.rlwal.d Pip. (I$Ia. •, ° �CouPllnl T.r.Ilnallnp AI Oallom 0l iftl.m Pf` u(�vSep in..� 1 c�rr.c�t 97,1 to..T Ion SOIL FILL • DISTRIBUTIO1.1 PIPE 2"0 FAGGREGA1F. -./r APPROVED $y )XTu ETIC COVER I�AT FZJJ\(_ OR I" OF STRAW OR tiARSN HAy tLEV. OF •' Z FEI: T 'b OPlz -21/2 AGGREGATE DISYRIgJT101J PIPE TO BE AT LEAST ._ AWU AT L 1 ►"I CHES BCLOW ORIGIMAL GRADE EAS7L0 1).JGHES BUT 1.10 MORC THAM `12 I)JCIIES BELOW FINAL G11ADE • i M�cUt DaprH o f F-xc,tvnr1o0 FXOm oi{ IWgI 6 na WILL B !'UNIMVI�J pEP111 of EXCAvATIaN i�oM er�►41}J E � — INCHES q GRAPE WILL BE �_•_, INCHES SIG140: LICEUSC DUMBER: J DATE 110 _ Wiscon §in Department of Industry SOIL AND SITE EVALUATION REPORT Page o f 3 Labor and Human Relations Division of Safety &Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY 5' * Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but C NO not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # pz0 -/094 3� dimensioned, north arrow, and location and distance to nearest road. /bjp $0 APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION RE EWim AY DATE r Z• ll• PROP TY OWNER: PROPERTY LOCATION O 0 �,,�� GOVT. LOT SW 1/4 M 1/4,S 1 aT al N,R f 9 (or) W PROPERTY OWNER'ff MAILING ADDR LOT # BLOCK # SUBD. NAME OR CSM # D St. .5 Go f4 1 1 CI STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE ;WOWN NEAREST ROAD Z yo/ fo (7jt) 3 S / - Co L AJ n sag New [ ] Construction Use �Q Residential / Number of bedrooms � [ ] Addition to existing building Replacement `[ 1 Public or commercial describe Code derived daily flow 'Vso gpd Recommended design loading rate _ bed, gpd/ft 4r trench, gpd/ft Absorption area required /. /{3 bed, ft .5 03 trench, ft Maximum design loading rate _ bed, gpd /ft g trench, gpd/ft Recommended infiltration surface elevation(s) _ 9�,Z ft (as referred to site plan benchmark) Additional design / site considerations Parent material 19" t' W 4S I-. Flood plain elevation, if applicable N4 ft S = Suitable for system _CONVENTIONAL MOUND IN ROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem ! X S ❑ U ❑ S Do U ❑ S ICJ U ❑ S 6d U SOIL DESCRIPTION REPORT ?o* 50 PI R P !I Depth Dominant Color Mottles Structure GPD /ft Boring # Horizon Texture Consistence Bax>dary Roots .................. in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Tnich / /a Si / sbk 4 s .1. >{ ___. Ground .3 • -C ." I elev. 1 Depth to limiting f ct� Remarks: Boring # ' v2 / ,� o1rr• 64 k YhTr C S 2 , g O , Ground S D 7ri S YA r 7 .k elev. 9" ft. Depth to limiting factor„ „* Remarks: CST Name: - Please Print /) n N- s Phone: 7 45-- Address: (i L Signature: Date: CST Number: • - (o ` �� t3T 5.3� PROPERTY OWNER SOIL DESCRIPTION REPORT Page Aof .3 PARCELI.D.# Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench . :i �M�'; Ground le Depth to limiting fact Remarks: Boring # 4.; 4 Ground elev. ft. Depth to limiting factor Remarks: Boring # '.. Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD- 8330(8.05/92) /osb SGc7�/Q4� .5w_ Taq wr,� c�.., Nom. -,,. 'C"� � _ ��1�• _ «?lost I o i ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer 0 p V Mailing Address _ A0 S !o SL o -tf RC Property Address _ k UA S CyN [ i S L S (Verification required from Planning Department for new construction) 0 Q 0 - /D! n » k0 City/State Lk-d S T Parcel Identification Number O j n— 0 0 9- .16 LEGAL DESCRIPTION Property Location 5 %4, %4, Sec. /D , T -aN -R_J� Town of RudS a r Subdivision C; y - Lot # V/A Certified Survey Map # Volume , Page # Warranty Deed # , Volume /a S I , Page # _. Spec house 0 yes 0 no Lot lines identifiable IX yes 0 no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of um in out the septic tank p p g p 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, 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 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. SIGN , A,TfJRE OF APPLIC 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. ST GN61 1 1TRE 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 • y Vol V PAO l3 SFi STATE BAR OF W15CONSIN FORM 2 - 1982 WARRANTY DE1FD DOCUMENT 1`10. p - c- „1 Kimberly R. Kukla, a /k /a Kim Kukla, a /k /a Kim R. - --- Kukla . - ,/kla Kimbe ly Rae xtI a, a D i ng le — JUL 30 1997 �i 1:20 P.m conveys and warrants to RMne y ( Nel con a single person TN SPACE RESERVED FCR RECORDING DATA NAME AND RETURN ADDRESS the following described rest estate in St _ Crai x _ . County, State of Wisconstw 020- 1009 -20; 020 - 1010 -80 PARCEL. IDENTIFICATION NUMBER (See Attached Exhibit "A ") This is homestead property. Gs) MOM Exception to warranties: Easements, restrictions and rights -of -way of record, if any. Dated this day of July A.D., 19 9 (SEAL) (SEAL) . Kimberly R. Kukla a/k /a Kim Kukla, a/k a im . auk a, a c a un rTy (SEAL) R2a k] n (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signatures) State of Wisconsin, ss -- St. Croix C.ot, authenticated this day of 19� Personally came before me this day of July , 97 the abo%e named — -- — Kimberl R. Kukla, a //a Kim Kukla, a k a Kim R. K a / /a Kimber Rae I I I LE MEMBER SiAI E BAR OF WISCONSIN Kukla, a single person, (If not, _^ authan_ d by §'t1b Ob, \ \'u, t,ns) to me k Am to he the pers who e ecuned the foregoing utstru nt and ackn"I h Sme. THIS INSTRUMENT WAS DRAFTED BY , ,+ At torneX Kristi Ogland _ — H� T-- 5Qn -, W- _ 15 401 ---- ---- -- - - -- Notary PuYlc. _— Count ?: \\5s Ggnaturrs mad he authentt,aicd -n ackno%%Icdged Both are not n Is permanent. (11 ^ t Bre pees sate l �'�#a'�'dVfftY : % q Notary Pubhe- State of Wisconsin SlArt-w%ROFwIa WA RR\\ I N DI D II — \,,. 2 -1482 - •• "h,�.*E'e. N VOL 1254 PACE 414 EXHIBIT "A" A parcel of land located in the N 1/2 of SE 1/4 and the S 1/2 of NE 1/4: of Section 10, Township 29 North, Range 19 West, Town of Hudson, St. C:-oix County,- Wisconsin described as follows: Cor , mencing at the East 1/4 co:-ner of said Section 10; thence N00 0 01 1 51 "W along the east line of the NE :./4, 2- 1 0.75 feet; thence N90 0 00 00 "W, 1312.43 feet to the centerline of a '.'own Road and the Nly R/W of abandoned c & NW Railroad, said point being the point of beginning of this description; thence N01 along the :enterline of said Town Road, 248.19 f ^et; thence N89 0 21 1 11 "W, 204.63 feet to a 3/4" iron pipe; thence N00 0 34'38 "E, 15.29 feet to a 3/4" iron p:.pe thence N88 1 14 1 28 "K, 273.92 feet to a 3/1" iron pipe; thence SO4°09'11i' 104.68 feet to a 3/4 iron pipe; thence 986 0 03'02 "E, 17.28 feet to a ;:/4" iron pipe; thence S02 0 53 1 43 "W, 282.97 feet to a 3/4" iron pipe; thtnce S89 0 48`40 "W, 846.62 feet to the West line of the NE 1/4; thence S00 "PF along said West line of the NE 1/4, 1334.48 feet to the Nly R/W of abandoned C & NW Railroad; thence N42 0 01 1 18 "E along said abandoned railroad 1. /W, 1710.18 feet to the beginning of a 2914.68 foot radius curve concave !:Fly whose central angle measures 4 0 59 1 13" and whose chord bears N44 0 30'55 "E and measures 253.61 feet; thence NEly along the arc of said curve, 253.69 FP_e.t to point of beginning. d v 0 , t y a , N 88 -14' - 28"W 3 273.92' CREC. AS '274, o_ 204. NOTE; N8 21' -11" W N 88 171.63' (REC AS 1725) 33. a I OF CO 0 v ` a co � N00q 34' -38 "E I C(,Gl V a 1 15.29' (REC AS 15') a 4 J S 86 03' -02 "E I 17.28' (REC. 17') j W w i � N i O I EXISJWG HOUSE 8 — O QD FARM M� p - NA �n N p N z 1r 1 Q , N CD JIN W I CEf en NA%A in co i r CL9RVE DATA TO CENT = 04t 59' -13" R - 2914.68' L - 253.69' CH = 253.61' C.B.- N44 30' -55 "E CURVE DATA TO R/ W 6 - 04 Od - 42" R = 2914.68' L _ 207.46' C = 207.42' Ce -; S 44 -03'- 30"W a� 0 . Comm 4 at t DBE i /X, 2210.75