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HomeMy WebLinkAbout020-1312-50-000 (2)S C C Pl nd Zonin t. YOI Owner: Miller, Sam 816 Moon Beam Rd Hudson, WI 54016 State Permit: 259473 Issued: 0311311996 POWTS Dispersal: Non -Pressurized In -ground Permit: New County Permit: 0 Installed: 07131/1996 POWTS Detail: Trench - Seepage Bedrooms: 3 WI Fund: POWTS Pretreatment: NA N uIeS Issuer/Inspector As Built Mary Jenkins Yes Jim Thompson S _. , : Yes Maintenance Scheduled Pump Date Pumped 7/4/2002 7/26/1999 7/26/2002 4/28/2006 4/28/2009 Plumber Other Reouirements McDonell, Mike 1st Notification 2nd Notification 3rd Notification 04/20/2006 04/20/2006 Additional Notes Monev Owed $0.00 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER s 4 M M ADDRESS (fox "f yL 1+.-D so wr r SYo/c SUBDIVISION / CSMI -F M NE y D LOT k L SECTION. T -7-? N-R / �,�,J, Town of N(l DS C N4 ST. CROIX COUNTY, WISCONSIN FI SHOW EVERYTHING WITHINIEW 10 'rrENCH A Fig /v.M-- �1:13•Sa = ya,iz AIA tE Q at A slope_ s% r INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. a I/ BENCHMARK: o P O t Cm"T P!c- ,4T 5F coc.VE.2 E / :- 3.(a Z ALTERNATE BM: Tc,P sC Z3 FoyirpA7/o n/ /= y, 7S= SEPTIC TANK (2 PUMP CHAMBER / Manufacturer: W E i Sir ✓L Setback from: Well i House_ Pump: Manufacturer Float separation Alarm Location — HOLDING TANK INFORMATION Liquid Capacity n Other To /Jf edQA%Fk of Nau tf Model# Size Gallons/cycle: SOIL ABSORPTION SYSTEM Width: S Length Co O Number of trenches Z Distance & Direction to nearest prop. line: Setback from: well: House yL� Other 51f To IVECae1VFi2oF44QIr6E ELEVATIONS IO,(o•= 473,52- C).So' Building Sewer — ST Inlet. ST outlet PE. inlet PC bottom _ Pump Off 36, Header/Manif`b�ld Rw P Top BoIll OIL. Wr tRtom of system Q - Existing Grade 9•Final grade 0 9 3yZ DATE OF INSTALLATION: PLUMBER ON JOB: —7;" LICENSE NUMBER: INSPECTOR: 3/93:jt Wisconsin Department of Industry, Labor and Human Relations Safety and Buildings Division GENERAL INFORMATION PRIVATE SEWAGE SYSTEM INSPECTION REPORT (ATTACH TO PERMIT) Permit Ho de -Name.- ❑ City ❑ Village ❑ Town o MILLER, SAM ]{ CST BM Elev.: Insp. BM E ev.Elm : BM Oexription: 11 TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic 0,-n Dosing Aeration Holding,. TANK SETBACK INFORMATION TANKTO P/L WELL BLDG. ventto Air Intake ROAD Septic NA Dosing NA A Aeration Hol PUMP / SIPHON INFORMATION Manufacturer Demand Model Number M TDH Lift Ion 5 stem TDH Ft Force n Length Dia. Dist To Well SOIL ABSORPTION SYSTEM ELEVATION DATA sP. CROIX -7/3 I STATION BS HI FS ELEV. Benchmark Bldg. Sewer { P cl St/)A Inlet St/Vt Outlet ase Dt Inlet Dt Bottom Header /_ Dist. Pipe /o.3P Bot. System 2. S' n Final Grade g, S G -�� olsT ��' G, 7s , BED/TRENCH DIMENSIONSSETBACK Width S r Length/ G No. Of T4enches T No. Of Pits Inside Dia. L quid Depth INFORMATION SYSTEM TO PIL BLDGo1 WELL LAKE/STREAM LEACHI CHAMBER OR UNIT - Manua Type nw}Cinv-., System: Lr LLj s I d5E. M e Num _ DISTRIBUTION SYSTEM ---- ����rr x ,o,esae x Hole spa rIntake Length Dia `� Length Dia Y Spacing �� --i SOIL COVER x Pressure Systems Only xx Mound Or ade Systems Only Depth Over C,, '/ Bed / Trench Center �a — Y�o Depth Over / Bed 3 ?' �b xx DepthO Fx;x; Seeded/Sodded xx Mulched /Trench Edges Topsoil Q Yes ❑ No Q Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDpSON .1/ 2y.��2j9.1y9W r 3W r ddLOT /�42 , , TANNEY LAMB rOE"�Cf. /�(�Nl .Qti[ ��/1 :?l'D r, ; .. , c", �ro n ,ce -�4 d CS .r, 1 ,� awkn 6� . ��,., � is P � � Plan revision required? ❑ Yes E]-No !, Use other side for additional information. s( 76 D--6710 R 05i91) DDts t Inspector'sSignature ceert No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: �. ■ .. try ■Lf7�1 SANITARY PERMIT APPLICATION In accord with ILHR 83 05, Wis Adm Code Safety and Buildings Division Bureau of Building Water Systems 201 E Washington Ave. 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)z0 than 8 112 x 11 inches in size. -.7 State Sanitary Permit Number � 5el; -V73 • See reverse side for instructions for completing this application The Information you provide may be used by other government agency programs ❑ Check it revlston to previous applicatxx, (Privacy Law, s 15 04 (1) (m)I. State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N Prop rty Owner Name 492 �L Property Location �1/a 14,5 L T ,N,R /f E(o� PropertyOwner's Mailing Address Lot Number Block Number O Y Ae Z- Z1 41 L City, State Zip Code Phone Number Subdivision Name or CSM Number vsa W S'�d ( >-;2- 7-AA1Vi5V 4l A5 TYPE F BUILDING: (check one) ❑ State Owned � ❑Villa'tyge Nearest Road Public 1 or 2 FamilyDwelling- No. of bedrooms Town OF v 5 O %a IV 6jZ5 III, BUILDING USE: (If building type is pubic, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment / Condo 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. I 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 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ;Seepage Trench 22 ❑ In -Ground Pressure 42 ❑ Pit Privy 1 I❑ 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 Flev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) rdR• 3 A" Elevation9t,21 q '7 -5/0 '10 , 9'Feet 17 4. Z— Feet VII- INFORMATION Ca act in gallons Total Gallons # of Tanks Manufacturer's Name Prefab Concrete coy_ steel Fiber- glass plastic Exper App New Existing structed T nk Tanks Septic Tank or Holding Tank OOO / G.� r a ® ❑ ❑ ❑ ❑ ❑ L ift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VII(. 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) MP/MPRSW No : Business Phone Number: jw/,<06� i 5 Plumber's Address (Street, City, State, Zip Code): zca/E < < %4A✓ " IX. COUNTY / DEPARTMENT USE ONLY ❑Disapproved Sanitary Permit Fee (1.0.dtc,ound.elM ate Issue Issuing Agent Si nat re(NoStaplps), �A roved pp ❑ Owner Given Initial sarcn.rgeiee) 6.% l Adverse Determination /��/ X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: 5H11 5398 (H 05Nd) DIST■iOVTION "u,,lto Ctwniy,0, (9pVTo: S.i.tya ►lumbw 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, 608-266-3815. 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 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. Vill. 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 tanks) 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 sped fications 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. *47' /n ILLSe gr(p MOON 1 rqk*l S y ST'E � r, "A" _ a�. 3' "I "- 90, 7 ' 514 � f onopoes-03So0 1e Wisc Of trod Human Relations g LaborasinDepartmentofIndustry, Labor• SOIL AND SITE EVALUATION REPORT Page i 3 _ _ Division atsafety & Buildings in accord with ILHR 83.05. Wis. Adm. Code Attach complete site plan on paper not less th hes in size. Plan must include, but COUNTY / not limited to vertical and horizontal refere s 1(% and % of slope, scale or PARCEL I.D. • dimensioned, north arrow, and location a to ne APPLICANT INFORMATION-Pl. RI FO N REVIEWED BY DATE PROPERTY NER: �fn ER: P JUL 2 0 '395 PROPERTY LOCATION GOVT. LOT SW 1/4/411,v 1/4,SIZ T Ill ,N,R% 9 E(or)W PROPERTY OWNF@':S MAILIN DR QOL�T 5 k S i x� TZT L T at BLOCK i SUBD. NAM�pR CSM N 7 A �r 4GL` CI ,oAT�sw �' 21 .S' zt7t610"R Cy ❑CITY OVIJ4GE UOWN NEAREST ROAD buji fob tZ6 IV- j�New Construction Use Residential/ rooms uNti ( )Addition to existing building [ ] Replacement [ J Pudic or commercial describe Code derived daily flow gpd Recommended design loading rate 0 ,6 bed, gpd/ft2in 17 trench, gpd/ft2 Absorption area required bed, ft2 trench, 11:2 Maximum design loading rate C.% bed, gpd/ft20.$ trench, gpd/ft2 Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design/ site considerations,EVALUI&Tfclj 46nNiL FOB LpTAPt'ok%VAL Parent material Flood plain elevation, if applicable ft $ Suitable for system U . Unsuitable for stem ENTIONAL S ❑ US NO ❑ U IN- ROUND PRESSURE seS ❑ U AT BADE 2S ❑ U Y TEM IN FILL HOLDING TANK S ❑ U ❑ S Boring # 1 Ground ele Ct It. Depth to limiting wtor Boring # El Ground elev. fL Depth to limiting factor �ro.n SOIL DESCRIPTION REPORT Horizon IQ Depth in. 0-S Dominant Color Munsell /0 3 I Mottles Qu. Sz. COM Color I Texture L Structure Gr. Sz. Sh. / n,sbK Consistence m r Barrlary CS Roots 0 GPD/ft Bed Trends tJ. O. $� 5;t 1 mstk m CS �z/9-//4 myse414_ S r m% o.77 Remarks: 0-26 L rtisbK m Cw J rJ; 7/ OyK S`3 -' S,� / m sb M �►- c 5 i"� O.Z 0.� 6Q.� .LT 1)-22 7 4 4 ` S r th ,7 1 I Remarks: T Name: —Please PrintR V y \ NNSoN - Phone: 4- I -U Q PbiAddress: p U A`.ac j Y Signs Date: 7 Z1 n/ CST Number: �i PROPERTYOWNER SOIL DESCRIPTION REPORT Page —Z ! PARCEL I.D.* 1-4L Ground elev Cti ifa ft. Depth to limiting y 3 Boring # in Ground elev. �_<it. Depth to limiting ctor 7 •� Boring # 0 Ground elev. 93A fi. Depth to limiting ctor Boring # 13 Ground elev. If. Depth to limiting factor Horizon Depth in. Dominant Color Munsell Mottles Clu.Sz.Cont.color Texture Structure Gr.Sz.Sh. Cor>sisten� Bo � Roots GPDlft Bed rerxi� ?, -17 r7 34 I&Yk-9 1 re 4 -- L S, L I m -SLY, 1 n. sbk rn nr v�Fr cs c5 i l o_4 o.z o.S o.3 0.7 10.% Ramarke* MOM © t ®-a r JBP.avacks mom MMM Remarks: onn 000t,10 nr�, _Lo-r 4 1 IVoeTla GG JL $EN- nmakk- / "198�j PIPE: J 186,06 QJ� <_1qof /j)ICLEle- $I(p n�� �a ^! t3 FArrf k(D�t Go S ySTFM Ef. _ ,q'_ /'rsliyNff' P✓4 VENT -1" STRAW COVER f N—Er GRAVEL BELOW PIPE INSPECTION TEE M PLAN 2" GRAVEL ABOVE PIPE PERFORATED PIPE SECTION +ice tiv �4� v" pr(\,IEnT INSPECTION PIPE m y" PVL IN10,", /5,T_ HOUSL _ OMURENCE) FOOTING 4" PVC. L T 1000 GAL T 39" TANK 47' STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER S14117 W)1z_Lfie MAILING ADDRESS RO Sl :#- Z t- ? PROPERTY ADDRESS &/(o MG *6 U dEAZII (location of septic system) Please obtain from the Planning Dept. CITY/STATE 0 ,D S O u CAI f PROPERTY LOCATION S �/ 1/4, � 1/4, Section �, TAN-R 1� TOWN OF /4 U DS 6 ni , ST. CROIX COUNTY, WI SUBDIVISION TAN ICE � R (0 6F_ 9 LOT NUMBER U Z.- CERTIFIED SURVEY MAP ,Q 1114 L, VOLUME (,o , PAGE'5' , LOT NUMBER 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 licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. 1/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. SIGNED: DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11193 8 T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. ------------------------------------------------------------------- Owner of property :51q /'I') /%//[-" Location of property_ !�1/4_W 1/4, Section Z,,T�N-R / 9 Township N U p LO N Mailing address BD X `Z 8Z _ H O DS o N c.v / 5 t/D/,6 Address of site �R /!p /jyp p /is,/ Q Subdivision name �+-g,�y�Y/lj,cE Lot no. Other homes on property? Yes No Previous owner of property RN N -DA L L S y/M.h Total size of property Z , 2 rA G Total size of parcel Z , 7- ,q[ Date parcel was created 9 - I �I 3 Are all corners and lot lines identifiable? iC Yes No Is this property being developed for (spec house)? K Yes No Volume /0 3l and Page Number as recorded with the Register of Deeds. ------------------------------------------------------------------- INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the office of the County Register of Deeds as Document No.p Sr , and that I (we) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the office of the County Register of Deeds as Document No. -� t/$ �-45- 0 a 1� -:4 lei VL ', S ature o Applicant Co -Applicant 3-13-t� Date of Signature Date of Siqnature