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HomeMy WebLinkAbout020-1333-70-000 • A ST. CROIX COUNTY TONING DEPAR'T'MENT AS BUILT SANITARY REPORT Owner _5!( /W 01 t L L-,F o"L Address - 2 Yd w /L ¢,QE,0 2 0,.q p City /State f 11.1 Legal Description: Lot /�_ Block — Subdivision/CSM # t /4 '/� ��Sec. � T N -RLTO Town of 4 bSor4 PIN # DZO - /333-70 SDOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer W E 1 S -E2 Size ST/PC Setback from: Housd " Well N d P/L T ? 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: Width 3 Length S • Number of Trenches Z- Setback from: House _y9 • Well N� P/L Vent to fresh air intake Sd' ELEVATIONS Description of benchmark 0. PV G k� = •�� C� 1 , �,, Elevation Description of alternate benchmark Sp P e g I p at /c "o p� H,T I p N 2 ,( 4 g Elevation / a . F Building Sewer ST/HT Inlet 7.fS2'- 8, z 3 : "" `P ST Outlet- PC Inlet PC Bottom ± _ Header/Manifold Top of ST/PC Manhole Cover Distribution Lines Q11) * 041 0 ` 98, Z ( ) Bottom of System ( ) 143, S S = 9 G, 6 s O Final Grade Date of installation / / Permit number -•� l State plan number Plumber's signature g ` � License number rf'/''iC'.S Date 7 lzv/ 98 Inspector complete plot plan r 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. PLAN VIEW l< A•L T F,c N A T is M ti o. F 9f - r qq-" x4 i P W XSd V � oe, /V DTE; AS e F 8 .20 -9b V T�l/STitl, v ALE INDICAT OR ARROW 'Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: Safety and Buildings Division INSPECTION REPORT ST. CROIX GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar Permit No -: Personal information y ou provice may be used for p urposes [ Privacy Law, s.15.04 ( 1) ( m) ]. 315967 Y Y secon P P [ y ()( ?1. Permit Holder's Name: ❑ City ❑ Village In Town of: State Plan ID No.: ILLER, SAM HUDSON CST BM Elev.:. Insp. BM Elev.: BM Description: Parcel Tax No.: 020 - 1333 -70 -000 TANK INFORMATION ELEVATION DATA A9800355 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Gie ..� ( -0 , t'. < fi j# ta... Benchmark -- -• Dosing off. 626 Aeration_ ..� Bldg. Sewer' Holding •-- w.. St /yt Inlet T, SETBACK INFORMATION St /yft Outlet `7�1�'.5/' TANK TO P/ L WELL BLDG_ Ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom - Dosing NA Headed, q3� Aeration ____.. _.__..._...._.__... _ ... -'NA Dist. Pipe Holding Bot. System y .ms's" /Osz' PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand "P 0 S. �• / Model Number -'"' "' " "_�_�_ GPM TDH I Lift L riction Syste Ft Fi Forcemafn I Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH width r Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 N I N _ __ -._ - M fufacturer: SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREAM "•- -� INFORMATION Type O nt,,u.�py;y, HAMBER " M0defN.U4 ber;_ System: `�� OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) ��_,_., x Hole Size x Hole Spacing Vent To Air Intake Length Dia, Length Di 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 ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON 27.29.19,SE,NW 740 WILFRED RD— BADLANDS PRAIRIE LOT 17 UX . f ^ � r Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Signature Cert. No Safety and Buildings Division SANITARY PERMIT APPLICATION 2 01 W. Washington Avenue NV Iscons i n I H P 0 Box 7302 Department of Commerce accord with IL HR 83.05, Wi Adm. Code Madison, WI 53707 - 7302 • Attach complete plans (to the county copy only) for the system, on paper not less County. -�- G Pe- t X than 8 112 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Number 3%S°I(a; Personal information you provide may be used for secondary purposes ❑ 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 Na a Property Location A ( L L X *t 5E 1/4 Q)1/4, S 7,7 T Z 9 , N, R )' E (o Pro erty Owner's Mailing Address Lot Number Block Number LK +'7 Cit Zip Code Phone Number Subdivision Name or CSM Number +dud .0 dus > 2 7 a .9 Atk bt-AND5 l�A�R1ic S + GIo� II. TYPE F B ILDING: (check one) ❑ State Owned 0 c ity Nearest Road Public 5k 1 or 2 Family Dwelling - No. of bedrooms 3 0 v o w a n OF .SZ?N LUILtf16d iiiaof III BUILDIN USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1❑ Apartment / Condo Q Z 0" 3 3? a 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 _ r'd New 2. E] Replacement 3_ ❑ Replacement of 4_ E] Reconnection of 5. E] Repair of an ---- System System Tank Only 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 TrenchS /L*_ wjgDE 2 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit K I IK F I L. nzAroa 2X � t Z S 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 se) op (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) , Elevation , S 3 S 7 1— ' Feet 100,0 Feet Ca aat VII. TANK in gall Total # of Site o INFORMATION Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. New Existin Gallons Tanks Concrete strutted glass App. Tanks Tanks pti oHioFAfi�Tmt l oco I Uj lF 1 J r__ rz_ ❑ ❑ ❑ 1 ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ 1 ❑ ❑ ❑ 1 ❑ 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 Signature: No St s) VMPLMPRSWNo.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued - Issuin A ent Signature (No Stamps) 5d Approved E] Owner Given Initial 18� Surcharge Fee) g Adverse Determi •O� 15 �� X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.11/97) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber 1-Ay - 1-5 3 3 -? Y O W/c L FrAP ROe} D �tLL �. F 3 � S j 's <sz 2 q r i 2d f o Lo'T t 2- TkFAIC-o yr 3 L1 , i AL T T- l2 Nd7 A B M' 7 1 F /_ 101,2 #� r CD C J ; S n CT Tj G � + c , co �ni m ✓ •n' An � Q A cn g n tD a• r r 1 ` t A. kA - TIM I ID < pJ ID w< b f O O �•6 a co PO ti Q � O O Cf) tA ID co S!.J - 67 V Wisconsin Department of Industry, SOIL AND SITE EVALUATION 1 3 Labor Ad Human Relations Page of N -ision of Safety and Buildings 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 St. Croix percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # APPLICANT INFORMATION - Please print all info , tion. Revie a by Date Personal information you provide may be used for condary purposes (Privacy.4 15.04 (1) (m)). Property Owner Property Location Richard Stout t` r-` Govt. Lot SE 1/4 NW 1/4,S 7 T29 N,R 19 A(or) W Property Owner's Mailing Address - -• ? , Lot # Block# Subd. Name or CSM# I_._ , r 1 353 Awatukee Tr 'i -' 1 7 Badlands Prairie City State Zip �4 s1: Ph f]tirlbe{.� jo E] [I [I Village ki Town Nearest Road Hudson WI 5 (Z�t1t�� Hudson State Hwy 1 2 ® New Construction Use: �] Residentia of o edrooms _ d Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow 6 0 0 g pd Recommended design loading rata 7 bed, gpclnt . 8 trench, gpd /ft Absorption area required 8 5 8 bed, ft2 750 trench, ft 2 Maximum design loading rate ' 7 bed, gpd /ft ' 8 trench, gpd /ft Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design /site considerations t- c) 1)_ix Q6 A b tre 959 Parent material G1 a . i a l d o o G it Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank = Unsuitable f r tem S❑ U S❑ U S❑ U El U ❑ S U U o sys tem S U SOIL DESCRIPTION REPORT Boring Horizon Depth Dominant Color Mottles Structure GPD /ft 9 Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 1 1 0-1E 7.5yr2.5 1 none L 2mabk mfr Cs 2f .5 .6 2 16-36 10yr3/4 none sil 2mabk mfl Cs 1f .5 .6 Ground 3 36-SO 10yr4/6 none Ms osg M1 CS - .7 .8 elev. Depth to limiting factor 9-0 ^ in. Remarks: Boring # 1 0 -1 7. 2 2 16-48 10yr3/4 none sil 2mabk fl s If .5 -.6 3 48-92 10yr4/6 none Ms osg 1 s - .7 .8 Ground elev. 9 6.4 (6t Depth to limiting factor 9 2--in. Remarks: CST Name (Please Print) Signature Telephone No. 2 _ / Address Date CST Number PRO P.Y OWNER Richard Stout SOIL DESCRIPTION REPORT Page of 3 PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Structure 2 in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed ,Trench 3 1 0 -1 7.5yr2.5 1 none L 2mabk mfr cs 2f .5 .6 ............... 2 14-- 10yr3/4 none sil 2mabk fl cs if Ground 3 36-S 0 10yr4/6 none ms osg M1 CS - . 7 .8 elev. 99.1©• Depth to limiting ; factor 9 4h. Remarks: Boring # 1 -14 7.5yr2.5/ none L 2mabk mfr C 2f 4 2 14-32 10yr3 /4 none sil 2mabk mfl CS if 3 2 -9 10yr4/6 none ms osq ml CS -- Ground 9 liev Depth to limiting factor m in. Remarks: Horizon Depth Dominant Color Mottles Structure GPD /ft in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed ,Trench Boring # 1 0-1 4 7. Yr2 2f .5 5 2 14 -6 10yr3/4 none sil 2mabk mfl CS if 1.5 ,.6 3 0 -1 0 10yr4/6 none ms osg ml CS -- .7 ;.8 Ground elev. 98 .30 ft. Depth to limiting factor 12 0 in. Remarks: Boring # Ground elev. ft. ' Depth to limiting factor in. Remarks: SBDW -8330 (R. 08/95) alL cdfs i°,i^, `Y DoT 17 � N a 0 V a v $ 64 p �3 I ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer S b4- Vv\ I*k\ I--`- E` ft.._,,,,,., Mailing Address Z c V '2t 1 „S 1 Property Address 7 '/ D W 1 L L /L t* Q tZ..a •4 t7 �II (Verification required from Planning Department for new construction) City /State k V 0- W4 W r Parcel Identification Number 0" 1 3 3 e 7 Q LEGAL DESCRIPTION Property Location '/4, Ill w y4, Sec. Z 7 , T_�LLN -R /f Q Town of /4 00 S D N Subdivision D L A (I- A k rL t CL , Lot # _ Certified Survey Map # s(e (Q ( to , Volume Page # / Warranty Deed # -`7 1 (U , Volume 'Z w T , Page # Gm y' / Spec house ayes ❑ no Lot lines identifiable X 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. 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 da of the three year expap on date. U CDA.- —��.4A AA 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 erty described above' by virtue of a warranty deed recorded in Register of Deeds Office. �VO `-' � - AA ` v-- 9169 - ATUR 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 STATE TMR OF WISC71N5!N FORM ? - 1952 U, 11 WARRANTY WARRANTY D� `ED 4 � ki JUN 0 2 19N ---- - - - - -- - ------------- - - - - -- - - - -- - -- 8:30 AM coneys and warrar:ts to -- - -' - -� - -"— - - - -— THIS SPACE RESERVED FOR RECORDING DATA _ NAME AND RETURN ADDRESS the [ollotiing described real estate in t.._CLi2 _ -- -- _Cooney, _ I "n State of Wsconsin: P o 00 /r/ Lots 17, 27, 28, 39 and 40, Plat of Badlands HlJDCaw 1,01 a �` Prairie, Town of Hudson, St. Croix County, Wisconsin. PARCEL. IDENTIFICATION NUMEER F EE This l�_AQ t� homestead property. (is) (is not) Exception to warranties: easements, restrictions, rights -of -way and covenants of record, if any. Dated this _- .� Qtil_- - - -- day of A.D., 19 -9-8.. Richard Q,_St-oslt- - - (SEAL) - - - -- (SEAL) (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s)- ___ _ State of Wisconsin, ss. - - - -- - - -- - - - - - -- - St. Croix County. Personally me before me this 20 th__ ___ day o aut}tenticar<d this _---day of - ___ -_. 19 —_. Y' ca Ma , 19_q$ -, the above named - R i d• ha r _ t — _.- TITLE: ME%IBER 5IAI E BAR OF WISCONSIN - - - -- (If not, ------ - - - - -- 11P Ii. u - - - - -- - - — - authorized by 4706.06, 'Nis. Sims.) to ax known to be the person —__ who executed the foregoing -= or In- vu and acknowledge the same. �(' 'r Af3Y jo • - - THIS INSTRUM._NT WAS DRAFTED ELY' Janet P. Stout i '°�"" — 1303 Awatu}:ee —Tr. - -- ; :- j�l r k ��° �irg:n::a R. - Gartman+ Hud _on, Wi_ 54016 St. Croix _ _— Nces -y Public — County; %;is l d d B arr zF " ?\h' Commission is permanent. (I( not, state expiration date. (SIgnat.lr. , rtra) be authenticated or a�kno, e he , [k. r pe [' January 30 2t10Q xx neces• ,,y) -- - - - - l -- - -- - -- ..) ..n: "n�n�+ and r �:j shou!•i'�. I; p;d r F- r:ted ^;loH thou s:pat.'^ 1, STA1F DAR OF %%1-;k O',51N Ws:orsn legal ElskCo.. "'C' R'A:RANT'i I-IA:0 Form Rio. 2 — 1•>k�2 M3r._3ee. Ws .� - .... a., .y 'der J'a . ��: . •iii. v . . .. '� � ,, t 3, .! .. T ., 1 ., „ -. .,. a '.1: e;sc?k:. 6- . �' : a. ► " {'`' 4' tr#' I 00 l k r I \ \ (I I N C1C' S1" W 358.18'. uj �a . ,LO•LST � � it J _ , sae 3.CO,UUXON C! //' N 00'02'51' 11 CD 7. 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