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HomeMy WebLinkAbout020-1289-20-000 (3) r - ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANI'T'ARY REPORT w r� O ner , z% a Address - ff 9 CT Q0 City /State xwole �IVo�S1C,t R If�R C �!k ' N - _ O� FI Legal Description: ct Lot 20 1 Block Subdivision/CSM # E , Sec. A , 1 �-1 N- R_tq__W, Town of _ HLj PIN # C a,0 - la �r SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer !' r'.5 Size ST/PC I 24 Setback from: House ' Well ��IL Pump manufacturer Mode Alarm location (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake 46 � ~ Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM: Type of system: _$: c w,'n��^ Width --3 Length �� - � - -�, ? A umber of Trenches Setback from: House � Well P/L Vent to fresh air intake ELEVATIONS Description of benchmark rr o,, P ; n,, n c ,, C nc; Elevation f 3 6 Description of alternate benchmark ' �., �c S , S c z Elevation ) Building Sewer ST/HT Inlet `0. ST Outlet- PC Inlet PC Bottom Header/Manifold$q.' 4 1 Top of ST/PC Manhole Cover Distribution Lines Bottom of System Final Grade ( ) ( ) ( ) Date �I / Hermit nu ber 3 lJ /Ste plan numb ate of installation 2 er Plumber's signature r r g , i e se number ip / / °- ate I I Inspector coTnplete plot plan a it — 1 NOTICE: Please provide the f011owin : • 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. f ��L PLAN VIEW IV C7 (' ; J'G �✓9 `-' '� apt '� a J A 7 �q1 INDICATE NORTH ARROW Wisco ?Isin Department of Commerce PRIVATE SEWAGE SYSTEM Count Safety and Buildings Division 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)]. 315847 Permit Holder's Name: ❑ City ❑ Village IEJ Town of: State Plan ID No.: OLSKI, KRISTINE HUDSON CST BM Elev. I Insp. BM Elev.: BM Description: Parcel Tax No.: ��^, 020- 1289 -20 -000 TANK INFORMATION ELEVATION DATA A9800239 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. eptic (,�j I•,G Bench 2 3(o 10 q 102.3(e 8 Dosing u $ ' Z , p /00 -3/ Aeration Bldg. Sewer Holding I inlet I (eD `Q•7� TANK SETBACK INFORMATION �lf Outlet 1I4 90 -SQ TANK TO P/ L WELL BLDG. Air int ROAQL Dt Inlet eptic IDO � lq 0 10 NA Dt Bottom Dosing NA Header / Man. g ISq t5,45 4L I Aeration NA Dist. Pipe Z'�rs I'L $g.. Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade P - 03 91. 33 Manufacturer Der St .Wawi -ojL .l g3• Model umber GPM TDH 1 `riction System gt la. H TDH Ft Forcemain Len Dist. To well SOIL ABSORPTION SYSTEM BED N H Width Length o. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIME $•7 DIMENSION SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREAM LEACHING Manufacturer: INFORMATION Type O CHA Model Number: Syste d+1 N A.. `� ' OR UNIT DISTRIBUTION SYSTEM Header/Manifold tr Distribution Pipe(s) x Hole Size x Hole Spacing I Vent To Air I 9 1 v th b Dia. Length Spacing n ake� Len l � �]�re. � 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 26.29.16,NW,SE 7 5 N. M ADOW DRIVE mc, -- ; d Plan revision required? ❑ Yes [lo Use other side for additional information.} SBD -6710 (R.3/97) Date Inspector's Sig re C�Cert.No.. NVI PERMIT APPLICATION o E. Washington Ave 'sion n In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Department of Commerce Madison, WI 53707.7969 • Attach complete plans (to the county copy only) for the system, on paper not less County r than 81/2 x 11 inches in size. � 1 f ?6 • See reverse side for instructions for completing this application State San itar Permit Number 5 0 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 I. APPLICATION INFOR T - PLEASE PRINT ALL INF RMATI N gdo Pro erty Owner Name " P � operty L ation tf L,. lvtvi/a S)L- 1/4, S .?/, T 2, , N, R E (or& Property Owner's fling Addres Lot Number Block Number City, tate Zip Code Phone Number Subdivision Name or CSM Number r-- owso - o ! ( cif) - ?1 " l/1? cao &7 II. TYPE F BUILDING: (check one) ❑ State Owned ❑ Cit Nearest Road 15 Village ��11 ff -- Public 1 or 2 Family Dwelling - No. of bedrooms Town OF # U�.3 m a III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 0?& 1 6q 9. / 9. 1 © a 0 — , 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. p New 2. ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5_ ❑ Repair of an Syst E xisting System �q System Tank Only stem — - - ----- -------- -- ---------- 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 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 Reg yyfired (sq. ft.) Proposed (sq. ft.) (Gals/day /sA_ft.) (Min. /inch) Elevation ©� 46 '-112 . S'' t? r! - •arty 1 1 $ Feet f' -? Feet VII. TANK Capacity ,5 / �� h in lion Total # of r ti'S' Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturer s Name Concrete Con- Steel glass Plastic App New Existin structed Tanks Tanks Septic Tank or Holding Tank i s -C/4 0 ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ I ❑ I ❑ I. ❑ 1 ❑ ❑ VIII. 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 S na • (No mps) MP /MPRSW No.: Business Phone Number: 1 4 y Plum te Code 4 4f Cit� -3ya - �. f! sue►; w� D IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved gn itar Permit Fee (includes Groundwater D ate Issued Issu' g Agent Signature (No Stamps) \ ' y Approved []Owner Fee) Owner Given Initial ) � 8 Adverse Determination X. CONDITIONS OF APPROVAL! REASONS FOR DISAPPROVAL: B tA71�) OtSUM TION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber v� o � E Rl \10 T-1 1 I \ t O i a n �k S Q dR A /" /1 : 4 l ; � �j P R I -e- i rn(..r ,_ OF v SOIL TILL DIS1 iiIL%TI iI PIPE 2" of AGGRr(,A1E LL F_ V. OF FEE r - - --, ` �- 4✓ O �t< � u r iI — ki 1�k, A7 1 -E ^S1 A,k)(D A j L L A S 1 .2 1 A J,C 11 E.:. VP T k 1,0 M Q,r i t - 7, il I A N 1 7 I•IJ,( 13 l I O W F d rJ,!�L r ,r dyD,E mA ximm wr it or r- _)(cAvATiDo rKoM .OKI &*JAL bKADF WILL DL � IAJr.!JE Mi.�l1M�J1l� © ,E�'tl1 �`� EXC'AUAtl�1.1 �F�nM eI�,I(,I,Ngi GR�.V:� WILL �c Z/4' IN�:lar_ ; l IGEAIGr MIMBE I ?: J)ArE /Z � X -2.2— tt� i i cf I =fi r � I 0 .inn CD f! r t I � � I , �i t I rt r CD r � 1 f" I V 1 I t_ IJ r DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILOINUS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS 115 P.O. BOX 7969 j -HUMAN RELATIONS MADISON, WI 53707 (ILHR 83.09(1) & Chapter 145) L0CAT10 : SE CT ION: T LOT NO.:BLK. NO.: SUBDIVISION NAME: W w&- NW 1/ .SE 1/ 2 Ty9 N )9 E (or► W H u aso Pq / H (-tf Mt`A.b0C4s_jM_ COUNTY: MAILIN ADDRESS: s-+. 4 4VA9 0/0 co (JO Ty ?-o. A3 , tj U SO i w f s 5416 ' USE 3 -K, -"Z2 S DATES OBSERVATIONS MADE NO. BEDRMS : COMMERCIAL DESCRIPTION: fI Replace I �7U�£ {� ? {S I .TUti1f: I S 3 NESTS: Residence 3 opZ q- N, /., r xNew (� v P KG, >tRt2 T RATING: S= Site suitable fo system U= Site unsuitable for system • ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: S STEM -IN -FILL OLDING TANK: RECOMMENDED SYSTEM:loption Ox S DU DS ❑U CJS DU CAS (3U CAS ©U T(�FN�S k ) ( te, RO E A RATE: If Percolation Tests are NOT required If any portion of the tested area is in the ' under s. ILHR 83.09(5) (b), indicate: G (_ 1 S Floodplain, indicate Floodp el PROFILE DESCRIPTIONS BORING TOTAL QEPTH TO GROU NDWATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED EST. HIGME T TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) r 0- /0 " /0 y e 3/Z 1 m P IOWEV /0' - Z:2 '( / 0 yiP `/�� le-14-4.1 s- 12 7 � > /�d /•_ � U-91 ; Lz,._ 120 y/G ES � O -S'" 16 VR 4 14 5 /, PJo4.-� i P " -iy "moo y.P y ¢ 51 la, 5 bk,nw r e B- 2 115 1 2 -34 vb > (ly' Ly 3 �,. 7.5y 4 16 7 ,?40'44� 5/ IM,gR,n fe; 32 fl5 R 4 C5. 2 n 0 - 1)." iv VR 312- l6A-M, P Y/Y / Al, IN 56K, > M B- �/ ��$ Q �• Z �q � f {� FR I o' 1 5 7, S `l/� 4 /G 5!� 1A%je nnfQ i 3 0" - /l8 "' I O- " )OVA 31 1 . , plow -� ; 9 -1y "io yR 1' /fe /°fFti /,- sbk, B. 1 3 D 2rp > I Z ,e ; / v '- 2- 1. S �/c 51 /.t., 6h t , ,,,, )CX f"- i1�2_ E- L io y 3 Y� ¢/f- °4n, / P '3 /'- 1/Z JnH56k,iw l,e 1 ,? 36 "/o yR 4�ef s/� In. gR Q c �fRV�io.Js PERCOLATIONTESTS 36 " - !!1" /0 YR �/ /G .>M- , -'S TEST DEPTH. WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING NTERVAL -MIN. P R1o0 t PERIOD PER INCH P. 2 `/ 1�to y 1, 0 < a I P _ y o. a P- E PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION. — P ' Cj ` __ _ . _ I I I ;S &E _ L oT PA t:N i 1 i _ i I I , - I 1 1.. + M 1, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): TES WERE COMPLETED ON: _ HOMESITE S EPTIC & LO,__ -- T v A)E /7 11 ` ADDRESS: 6M5O'NE RD„ HUDSON WIS. 54016 CERTIFICATION NUMBER: PHONE NUMBER I ( o � tional): ROBERT UL3Rt6HT 2 y T 2 `� - C PLUMBER LIC. NO. 3307 M.P.R.S. CST SIGNATUR : � 7 f 4 HINN. INSTALLER & DESIGNER LIC. NO. 00663 �.i DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. o •- � < �- p 0 v I V ' L Q .� - W �jj LA I / 0 i M I � .a i I � I � I rA c��— •---- M �_ „ ? 1096 F J a- C.4 Gn J 0 J Qp O � • � u 2 ' xt;ZQ z z I �ma a wa It C ~ -,.e ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buycr _ L4( 1" I f; 1z / I Mailing Address 2 T /f d Property Address (Vuificatioa rcquimd from Maniac Dgm4ncat for acw coast uctioa) City/State /,7 p a ©? 4i i s Parcel Identification Number O 2 - G ' / - LEGAL DESCREMON Property Location r V d V" S� V, sec. 2 T N -R W To � v d . - _�2 To of cl s h Subdivision l� Certified SMTey Map # Volume . Page # Warranty Deed # S vZ D oZJ Volume Spec house ❑ yes P' no Lot lines identifiable l Yes ❑. no 6YETEM- MMUNANCE Iaspmperu9e =4 ofyuarscptiCq%6=Cod4 mi¢p ` . tohzr vrastcs.Propern=hd=mwe ofpm oat dr. i�c u* � � � oc woac4 if nea&d by � 1keasedpampM Wbtt you pu t.iat o tire em _ syst eaa iffoct 6m on of 6�e t�tamku.a,atm catmge isthevastedi-sposatsysbcm, 1 Pi owns agzecs to mbmix"to St: CM& Zwfi g Dvntmeat vL C on foam, signed by tha ewnw and by- a P 7mmcY=P ratrictodplumbcrorafi=sedpmmpervc fyiag6lat(I)theon�i �raAMatcrdsgMdsystC u mP�ap�gcoaditioaand/or(2) aftaias po�on�P�P�B.C¢rY),� �ptictanlcis icss��aa lf3 ofsludg�c. YWI"-. the 00cmigned hm =ad the above rvqui and ag= to do pdvatc =wage disposal system tai& W standa� at fO. herein. In set by the Dgatmeot of Comm= and the Dquft ed of N stur l Rte State of Wmo=n- Cc4ficahca $tl�OmtYOurzq)dctystcmhasbom=iaubodmtmtbe eomiplacd and retumod to the St. Croix County Zoniag within 30 days. f tin fi= year / expiration date. k A k3 W Ctt, S SIMM ITME OF APPLICANT DATE OWNER, C TWCATI<ON - Y (we) eerhfy that all statem«sts on $us form are hue to the best of my (our) knowledge. I (we) am (are) the owacr(s) of the P d=i'bcd above, by virtue of a warranty dcod woor dod in Register of Deeds Office. A `" 99 MNA MM OF APPLICANT / DATE «««««« Any information that is mis-rcprnxc dcdmay =* in the sanitary Permit beinS revoked by the Zoning Department. « « «ss «« Iadude frith this applicatloa: a stampod vmnmty flood from the Register of Doody office a Copy of the certified t=cy map if re(erc cc is made in the warranty dcod �o 0 » STATE SAR OF WISCONSIN FOR 3— IOU QUIT CLAIM DEED DOCCIiiEN1 NO. is ry REUTEEn CRVE St CR= MY, V Lvsala Bruce ilo�sita: „��`, - �IAiiBI4mIt chit- ct�iwa to .aatise tv;i Volake at left Foe 12r 15 T. dIe � &KIMed teal coo is >i t . C . SC Gas 9ploe of Wboansia. _ nalE nesalaEO soll wecrnlDae+s oAU► 114 t,. 3 at Y�sdaiib IXI to o* to of > wEa+ ADDAM aos; wro l�r� . St*- Ovot :COanty, i�fsc��►sfet`. tt:dy�e Porter 'Lundeen i Seguin i 110E Second Street P.O. Box .469 Budwoc, ill 94016 "- 26.29.19_1AL r x� r r- Y S r • Sot. �k a^ A •'� � e ap x 5 i Y FM hlth, pfd November ,19 s sE 11 r : (SEW (sl +U - mask Arli.cle, Al A. tSEAU LFD (SEA1J NOTMKOCATWN . ACXNOWGbWNT 1 Lyman Bruce iiolske, 'J*,. Same a! Wisconsin, SC ZI November- ; 4 t6 arc 6e6ore mc'tl s d r ' 19 the abm lensed " t Lrd l�ttCT . 1f. - Michael Waterman `. 111M' 1030M AN R SUn BAR OF W anlholized by i W SUM) al. be tl+e who ellvuW dw TM n 04SMACNY WU OPAFMn BY [ A. Michael Waterman • � � 1 P.O. Box 469, Hudson, iii 54016 _ awe ,, (Signatures may be audlenticated or wJm wkd&ed. Both sic not is ptr" .,nt. (If net, state expiration diat: 1 71 necessary.) _ � 14 s o ) Name s a MmOAS signing is anylppwitY shmW by Ifped or primed below their sipawrC. " - -- - — STATE BAR OF WISCOPAS + - - Wbwnm t"d q** Co.. vr- QUIT CL11Il DEED Fee No. 3 - IS= WhIftJac "L I - / cr v -n \ f �� ' c rn �g ( 1 tj . l x CD -` CL � CL CL - a ��� �• fD — ti Salk .r V► `1 0 ti V co C? O r- !2 Cl 3 X CL C7 O � N •�• CL w CD � O � _iG•J s. ._. _�� , >L , [ , t ,, c,t,t , �.. ..,. -.. -. ., -,a-, n, ., -,. -, -�., ,,u x ,.t ., r,�, rr ... .._.r r..l�, -