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HomeMy WebLinkAbout020-1308-20-000 ST. CROIX COUNTY ZONING DEPARTM AS BUILT SANITARY REPORT ' +� " Owner Address reJ ;/- City /State /-6:, o , 4d,j Gl � i j couNrY 20 INC, OFFI�lf Legal Description: ; 1 Lot e2 Block Subdivision/CSM # �L� 1 ' % -�= Sec. ,(f TAN -RLIW, Town of x) PIN # 00° -c SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer nW ('0 /rJ e- Size ST/PC // � S P Setback from: House .2-o WeI1Z P Pump manufacturer - Model t-- Alarm location - (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM 1-4e.H C+PAe,ry Type of system: M061 t"TbIt Width f Length 1� 5 Number of Trenches Z Setback fr m: House 9 1 ,0 0 1 Welll - n,0 PIL MI 56 Vent to fresh air intake ELEVATIONS Description of benchmark `75 -1/ o � o = CL z0c"95 ns r Elevation v Z �' Description of alternate benchmark TIo a - Elevation s'. 4 ,79 �7©5 Building Sewer ST/HT Inlet ST Outlet � PC Inlet PC Bottom Header/Manifold P. 03- Top of ST/PC Manhole Cover . 7 Distribution Lines (/) 0. 1 L?Y VS (Z,) ( ) Bottom of System /2. (2) ( ) Final Grade ( ) ( ) Date of installation Permit number -307 63 State plan number Plumber's signature License number Jk71 `211 Date Inspector % o 10 L, A 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. JL P W I � i is ` iq+a'►Z J� `2 Jr 2- 5-' 'T u 7 gz I 7` � I INDICATE NORTH ARROW `—" Wiscd4lsin Department of Commerce PRIVATE SEWAGE SYSTEM , Safety and Buildings Division Count y ST . CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary3P5Tea Personal information you provice may be used for secondary purposes (Privacy L s.15.04 (1)(m)]. Permit Holder's Name: Ilage Town of: State Plan ID No.: SUNDBY , PAUL CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 10-0 1 1CO I?,d8 -2-C) TANK INFORMATION ELEVATION DATA A9800024 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Bench p 1 4 t� Dosing 6kft - I•` 1774 Aeration Bldg. Sewer 4?A,ea V Holding �t Inlet�J7 TANK SETBACK INFORMATION N S Outlet 70 S 7 5-3 TANK TO P/ L WELL BLDG. Air Intake ROAD Dt Inlet Se tic (,C y�, �,, ;! 311/ NA Dt Bottom Dosing NA Header / Man. Aeration A Dist. Pipe i✓d g3 Holding Bot. System 12 70 PUMP/ SIPHON INFORMATION Final Grade UQ Manufacturer Demand S 5'. -7 Model Number PM TDH Li Friction TDH Ft Forcemain Length Dia. Dist. To well SOIL ABSORPTION SYSTEM BE Width Lengt No. Of Trenches PIT No. Of Pits ia. Liqui th i DIMENSION � DIMENSION SYSTEM TO P / L I BLDG WELL LAKE / STREAM LEA ING Manufacturer: SETBACK INFORMATION Type O � CHA um er: Syste 6— OR UNIT DISTRIBUTION SYSTEM 13 l,lti— Header / Mani old Distribution Pipe(s) [ k 17 x Hole Size x Hole Spacing Vent To Air Inta e Length 140 Dia. Length9 'f Spacing 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 El El No ❑ Yes E] No COMMENTS (Include code discrepancies, persons present, etc.) LOCATION: HUDSON 16.29.19,W,SE 948 WAXON LANE o dIt, (ci g Plan revision required? [] Yes 10- No Use other side for additional information. , SBD -6710 (R.3/97) Date (- Inspector s Signature Cert. No. Safety and Buildings Division �•p�.�i SANITARY PERMIT APPLICATION Bureau of Building Water Systems 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County C V 6 % than 8 112 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Per NNu�mmberr The information you provide may be used by other government agency programs ❑ Check it isio io pPevlous qalication [Privacy Law, s. 15.04 (1) (m)). X 0111? L61! . State Plan I.D. Number I. APPLI TION INFORMATION w - PLEASE PRINT ALL INE MATION Property 06/er Nam y Location S A, S 14 T , N, R E (orb Property wner's Mailing Address < Lot Number Block Number q4Q 01 v City, State Zip Code Phone Number Subdivision ame or CSM Number 1V .5� l ( & /?Z ) L II. TYPE 0 F BUILDING: (check one) ❑ State Owned a vi e N e arest Road E] Public 1 or 2 Family Dwelling - No. of bedrooms own of o afK$ A) III BUILDING USE: (If building type is public, check all that apply)) / Parcel TaxNumber(s) 1305 1 ❑ Apartment/ Condo l i*l l+('+ �Q• ' I � "_ O 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 9New 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 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 KSeepage 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/da sq. ft.) (Min. /inch) Elevation ", 0— Feet 3— Feet Capacit VII. TANK in Ca allon Total # of Prefab. Site Fiber Exper. INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existin strutted Tanks Tanks Septic Tank arm - IYSt D0-A` � ,� e , ; A) ❑ El El E] E] Lift Pump Tank /Siphon Chamber /AC 6 r 1,ve— ❑ ❑ ❑ ❑ ❑ 1 ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plum er's Name: (Print) Plumboi 's Sig ture: ( Sta ps) /MPRSW No.: Business Phone Number: 4 Z l 9 1 71, 2Ve Plum is Address (Street, City, rate, Zip Cod 1 5T — . 2 S `{ IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved f p?)o n �� itary Permit Fee (nclude, Groundwater ate ssue Issuing Agent Signature (No Stamps) Npp ❑Owner Given Initial A roved Surcharge Fee) Adverse Determination (A 112 X. C019DITI N OF APPROVAL/ REASONS FOR DISAPPROVA A u,�sJ wart s! "` f,•.� ,�,r SBD -6398 (R. 05/94) DISTRIBUTION: 06inal to County. One copy To: Sufet Buildin s Divi ion, Owner, Plumbe s q�D rZ _ /l oL)J L)S t - h ! IL4 D �J�f�lC Li WiS, S 7Z -S r . tg �� G � � �, S, r� - /.� C' �►•� � max, ST'�.Sc�N -Z 400*PW. l o t ' c4>as 3� IU F007 -m cP.�oa Cvn.vt �o�T Lit.) Gov- �,- wfconsin Department of Industry, SOIL AND SITE EVALUATION REPORT P . ; Lalio - arxt Human Relations p ap- Of Dry isgn sof.$afety &Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION (14epov E - AlA X O N GOVT. LOT wEST SE 1 /4,S Ko T 2 9 ,N.R. q E 1 PROPERTY OWNERS MAILING ADDRESS LOT # BLOCK # S BD. NAME OR CSM # 5q1 cr . 'Ra . A z Ft &ASANT- u t'ew CITY, STATE ZIP CODE PHONE NUMBER []CITY ❑VILLAGE ffOWN NEAREST R OAD voSeo 4. 5 . 5Va/` (Z2) 96. 3y38 HUDSo,J I cry. Tv + (-') Construction Use ( Residential / Number of bedrooms 3 4 0 Addition to existing building I J Replacement ( YSo ] Public or commercial describe - Code derived daily flow 6 gpd Recommended design loading rate bed, gpoltt • P trench, gPdA? Absorption area required bed, ft trench, ft Maximum design loading rate • ? bed, gpd/ft ' — k trench. gpoltt Recommended infiltration surface elevation(s) 6-1w- . 3 ft (as referred to site plan benchmark) p� Additional design / site considerations TRCwcl.t S o,a S I o �L2 -- t-u CO- D R o f B o K p Parent material S S e 13 U R kti A;? D7 Flood plain elevation, if applicable N ' . ft rU= Sui uitable for for system �N la 1rJD ❑ U IN PRESSURE AT GRADE S FILL WXDW TAN( Uns L [�'$ C'i'S ❑ U Q-8 ❑ U CS o u ❑ S SOIL DESCRIPTION REPORT Boring # 13 9 9- Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed tench 0-'7 /o y 3/2-- 5/ 2,. sdk .� ufR c- a . .C, id, - 7 .S YR IN 15 1,µ►, f e ,tM:2 C 5 • '7 L Ground C 41 y /0Y�e S/tl _ C.S. D, S 6 2A � • "7 • � ref I 1 Depth to limiting -• factor > fo t Remarks: Boring # o - P 10 YR z/z s ( z f s6k 0 -fR es E 8- i0 7 -S yR yry (s i,A-► 9 8 Ground C a 0 -9 /o yR s/ cs- D, S cQ.2 _ _ • ' • �' elev �j�L ft Depth to limiting factor ..I Remarks: CST Name.— Please Print Ro t3Et2 T IA L d R i C N . Phone: 7 3 94 - a 185 Add ress: ( 55 © ' NEi L 'R D. t-u Wis. SgO!!o 5 3 CS rh 24 fL Signature: ( � Date: CST Number: ORIGINAL This tftt std AppRO f V� a co nve RllOt1!{j septI. system. PROPERTYOWNER V�f2� wAXo� SOIL DESCRIPTION REPORT F 2 f_ 3 PARCEL ID. # ` Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bamd3y Roots GPD /ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Taxth A E l O.7 Io y 2/z — s z w, sbK ��ie cs Z S .� 6, 7 -z0 /0 y Y 1 6,4h 1 j, Sbk .� S r f . y . s Ground B 10 - 27 / O y R Y / y S( l f S bk Ao' f le c S ('� • 5 elev. y 3 • 2 ft. C 7 y le Yk S /( c .S' D. S c�.Q -- 7 Depth to limiting factor � p i c � S Remarks: ! Boring # A 0-/0 / aye 3/2 S( 2 SAC nN v-•le CS Z ' •SI.� f3 s 1 • S vIR (s 1. f Sbk t. ,P 3 . 1 . .p Ground s elev. C , y y6 /o y R siy C . S• 0. S cP,Q -'7 { , 1 mi l- /d ft. Depth to limiting 1 factor I Remarks: Boring # S( 2 ^.. s d �►�► v� �2 S . r . 5 �j F s, o - /o yR 3/.2— k C S . ----- - . l l' iv /n VP- 31y Sr'� /J. sbk -..A S if . y � •S T3 L •30 /o y� y/� S• / l f s6,� ,L„ f, ' s l of (! .,S Ground 2 ' elev. %D yve �6 s , A 5/ ft. 13-" i Depth to + L.' � o f d 12- in, o R t' i d ,4 (3 u E limiting C y"IQ factor /b yi2 S/ Remarks: Boring # s 13 Ground -- elev. ft Depth to limiting factor Remarks: can anenio ncInn% c wSST PRop, L , N w � y3 w N '1 y � 1 i l O Q ♦ Iw C "1 Q H � o C W C-A rD b N N C u n O V3 o •� ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer z S Mailing Address Lj��� 1 Property Address 14 L���� (Verification required from Planning Department for new construction) City /State &t�,!2�2�f� Parcel Identification Number WD LEGAL DESCRIPTION Property Location IJJ04 - '/4, .5 '/4, Sec. llo , T 9 N -R_Zj W, Town of Subdivision PGATI4 Pl exj , Lot # Z Certified Survey Map # , Volume , Page # Warranty Deed # _ 22TE -��YI Z ZI l , Volume / I ,ZQ • Page # �7!7 Spec house ❑ yes W('no Lot lines identifiable o 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, 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 ear expiration date. SIGNATURE OF APP ANT 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 perty described above, by virtue of a warranty deed recorded in Register of Deeds Office. v" SIGNATURE OF AAfLICANT 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 H WARRANTY DEED z Docum,rnt \umher _• / U Rourn Audress APR 8 1.996 8:00 A.' may;. Parcel I.D. Number: 030 - 1308 -'0 Vernon Waxon and Irene Waxon, husband and wife, comes and warrants to Paul C. Sundby and Shannon J. Sundby, husband and wife, the folio described real estate in St. Croix County, State of Wisconsin: Lot 2. Pleasant Vicw in the Town of Hudson. This property is located in t DNR well adc_= area This is not homestead property. Exception to warranties: Easements, restrictions and rights - of=•.%a` of record, if am. Dated this � � day of April. 1996. —. Vernon Waxon Irene Waxon i AUTHENTICATION Signature(s) Vernon Waxon and Irene Waxon. husband TRANSFER and wife, authenticated this_ 44- day of April. 1996. pa Kristina Oglan TITLE: MEN4BER STATE BAR OF WISCONSIN THIS INSTRUMENT WAS DRAFTED BY: Kristina Ogland Attorney at Law Hudson, WI 54016 =U) 9 0• CA _ M _ �m ID / D p - — N 90 ° 00 X 00 ° E " 96 (1 fn r O C7 r. a -f �I m of x f- cn � (A I y I 0 _ . -4 z < z N - I N : m M CD 90•16Sc C� OD y N � � t71 s wo RI loo In () •► 0:U \ m q m all 0 C 0 W W z OD 1 E 3 �► a l ov4� / 20 . 1g � m m m T m m " to �- ^ z m C- 3 • r► m z /0 , / _ �� j r -I I <n 0 O C O y W 0 � V V P 74 U) O i 1 l _ _3T 1.95 9 °56 57 E — 311. 95 XI — / / `9y Cie ^ o I o ate, :0 m .8 r Z09 / 00 \9 s -� ' / Z :3 0 o•ZO °/zo9 • 10, 'oolow 1. ` --- ZO w o w .. O 3 \ N A N 0) V W O z z W CID 4 N z z CD Cjj Z p° 0 WH D 1 w0W.r) 0 M m n In cn ' -12� m- � m z -0 :C (A / m \ / a 0 OD OD m 0 : v m _z � � � w 3 v \ t o z z �+ ` \ - f 47)