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HomeMy WebLinkAbout020-1334-00-000 - ST . CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT j >' Owner IoM � O u N Address City/State 3T CRC+I COUNTY ZONl��GOFFIC�: Legal Description: Lot a 0 Block Subdivision/ t. CSM # QA�� ptie f p- A P- S k '/, Sec. 1 , T � N -R W T own of ua.► PIN # - SEPTIC TANK - DOSE CHAMBER - HOLDING TANK INFORMATION: Tank manufacturer �� -�� k Size ST/PC / Setback from: House W >.S Pump manufacturer �"� 3U ell U p/I, ?SU I Model Alarm location - --- (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air 11 1 11ke Water Line Meter location Alarm location SOIL ABSORPTION SYS M: Type of system: L„t fiR u►• Width 3 g -'7� Number of Trenches C) Setback from: House _ 35— Well ?S U' p/L SO Vent to fresh air intake 7 S 6 ELEVATIONS Description of benchmark �1 V se it L c Description of alternate benchmark Elevation Elevation Building Sewer ST/HT Inlet O U . ST Outlet' U d PC Inlet PC Bottom Header/Manifold Top of ST/PC Manhole Cover �• 8 Distribution Lines W Q r S 1lao Bottom of System( Final Grade O U Date of installation 1 /� 1 �/ SPermit number _ -3 S g State plan number l� Plumber's signature (a. Q t- License number d 1/ Date Inspector I o A � S l w K Complete plot plan wr f 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 �0' 0 .�0 1 7 J out I�fi 13pi INDICATE NORTH OW w isconsi�r Department of Commerce PRIVATE SEWAGE SYSTEM County: S a 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)). 315925 Permit Holder's Name: ❑ City ❑ village 7jq Town of: State Plan ID No.: HOUMAN, TOM HUDSON CST BM Elev.:- Insp. BM Elev.: BM Description: Parcel Tax No.: 2 (�L 020 - 1334 -00 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV. Se tic Z Benchm r, rs & Irk(,.! /© Dosing }� �. 7•� /ef. Co Aeration �"' Bldg. Sewer S 75' 106.3 Holding ---�— St /}'Inlet &0 �pD. TANK SETBACK INFORMATION S t/ W Outlet �o a � 7 TANK TO P/ L WELL BLDG ir i ntake A to ROAD Dt Inlet ir Septic f 00 r l6/ NA Dt Bottom Dosing — _ NA Header /Man. (i•X7 Aeration NA Dist. Pipe G,�7 l� Z Holding Bot. System J-1-4 PUMP/ SIPHON INFORMATION Final Grade 4-02 . Manufacturer ---, Demand �b M 4.60 101- Model Number —" GPM TDH Lift --- Friction _ Syestem _ TDH —^ Ft oss Forcemain Length Dia. H Dist. To Well SOIL ABSORPTION SYSTEM BED kT Width Length i' No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIME N 3 y a DIMENSION SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: SETBACK CHAMBER INFORMATION Type �' , ��, Model Number. Syst OR UNIT DISTRIBUTION SYSTEM " ti a r �. Header /Manifold Distribution Pipe(s) / x Hole Size x Hole Spacing 4vent To Air Intake Length �r Dia. Length Dia. 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 E] Yes E] No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON 27.29.19,SE,NW 663 RED MAPLE L — BADL NDS LOT 0 o � - 7 Vi=a U 100 ( `f'te b uIC1+ Se kje--C -��M — V rnwo AiA TO �G 51 nr/ 3� F4 � C7�c7 1 CG S Plan revision required? ❑ Yes No Use other side for additional information. !J SBD 6710 (R.3/97) Date Inspector's Si nature =10 Vi s..ns i n Safety and Buildings Division SANITARY PERMIT APPLICATION 201 E. Washington Ave. 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 than 81/2 x 11 inches in size. 5f. CRc'u • See reverse side for instructions for completing this application State Sanitary Permit Number 0A The information you provide may be used by other government agency programs ❑ Chec 1 revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATI N Property Owner Name Property Location l 0 r" �GkM SE 1/4 N 1/4,S ;) T d ,N,R j E(or)W Property Owner's Mailing Address ry Lot Number Block Number yN� a �d e tacdb VtC, City, State Zip Code Phone Numb Subdivision Name or CSM N mber O qt600 1 J L. S9 ( llJWDS IZA R 11. TYPE OF BUILDING: (check one) ❑ State Owned !t Neare Road Public 1 or 2 Family Dwelling - No. of bedrooms A o row OF k Ao5ui / PH+� III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 Apartment/ Condo ::: 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, ja New em 2. ❑ Replacement 3_ E] Replacement of 4_ E3 Reconnection of 5. ❑ Repair of an ______Syst ________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 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 ed (sq. ft.) Pro osed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation (400 r7 U '. '7S U Feet Feet Ca ct VII. TANK in g allons Total # of Prefab. Site Fiber- INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con Steel glass Plastic Exper. New Existin App structed Tanks Tanks Septic Tank or Holding Tank U0 Q ❑ ❑ ❑ ❑ ❑ _L + Lift Pump Tank /Siphon Chamber 1 1 ❑ 1 ❑ 1 ❑ 1 ❑ ❑ Vlll. 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 Sig ture: (No Stamps) MP /MPRSW No.: Business Phone Numb ff� &4� eft - aaa g�v ���r3a�� vat Plumber's Address ress(SeW City, 3Ste,Zip Cod IX. CO i.(( VV UNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee pndudesGroundwater D ate I ssued Issuing Agent Signature (No Stamps) [(Approved []Owner Given Initial 5/ Surcharge Fee) 1 �_Ao Adverse Determination f X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-63N (R.11/96) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Pkwdw ' . I : t�. t_ . • • r� ( l L. �l { � I'I i < <.. ! � U � � `.7 l = 1, I I . ICI �r 1..N •.•. x...._ .WY.�� I ,. 'N AM am Un�ky"l,o .... I AM E O�AYV A Q L O C AT ( ._N .. »X?L:► a�5 1 2 P'!Zl� `_ I C I V ! WJ4-t W-kil I F pr4 tz f ,oN SU Fnur +fyr��n, { s = ��► � lr N, ,k e a ►' Pv e i Lb�� I /oo. 0 a X eve, Zl- ,c,LA ' 7U' _� z 0 • 11 � lylo� •B� Y �- -c-•- �ts', S5 3 ' y es» • �.- y 3 •• ', '' I U l o aS , w e y �IR'" 8 h;} o f• t 70' 1 y ' • *�,r V ;: N FRESH AIR INLETS AND OBSERVA ION PIVE CROSS SE CTION • __ Approved Vent Cap 4 r Minimum 12" Above Ei na 1 �e i���.__��_ ._ 4 Cast Iron Above Pipe Vent Pipe To Final Grader M Ilay O Synthetic Covering Min. 2" Aggreg';il • Over Pipe ' /..�r._.._ • • Distributio�� Tee • Pipe _........ �� q� Aggregate Perforated pipe Delow Beneath Pipe coupling Terminating r Bottom of System Wisconsin Department of Industry SOIL AND SITE EVALUATION i or and Human Relations Page 1 of 3 Division 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 locati to nearest road. Parcel I. D. # aa0 APPLICANT INFORMATION - Please ll inVm tion Reviewed by Date Personal information you provide may be used for secou �w, s. 15.jXj )). Property Owner sa r y Location Richard Stout -� ` tom? Gpvt_, of SE 1 /4NW 1 /4,s 27 T29 N,R XQ( or)w Property Owner's Mailing Address cY G r LL,btif Block# Subd. Name or CSM# P 1353 Awatukee Trail '\, ✓ `'�GO G � 2 Badlands Prairie City State Zip Code hors ,Nu er 0 V, City ❑Village] Town Nearest Road Hudson WI 54016 ( °56 y Hudson ill Farm Rd EkNew Construction Use: Residential/ Number of bedrooms 3-4 Addition to existing building ❑ Replacement ❑ Public or commercial - De=scribe: Code derived daily flo 0 0 gpd Recommended design loading rate _. 7___.bed, gpd /t _8 __trench, gpd/ft Absorption area required 8 5 8 bed, tt 750 trench, ft 2 Maximum design loading rate • 7 bed, gpd/ft - 8 trench, gpd /ft Recommended infiltration surface elevation(s) _._ 20 _ft (as referred to site plan benchmark) Additional design/site considerations Parent material Glacial de pos it — Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system [2 S❑ U ER S U � S El 1Z S ❑ U El ® U L I S � U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell ou. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench 1 0-48 10yr4/4 none lfs 1 fabk mvfr cs 2f - .5 : . 6 2 48-92 10yr4/6 none HIS osg ml cs -- .7 '.8 Ground elev. 101 . ft. Depth to limiting factor , 92 in. Remarks: Boring # 1 0 -4 10 r4 4 non lfs 1fabk mvfr cs 2f 2 46 -89 10yr4/6 n one ms osg ml cs - .7 ,.8 2 - — -- - - - -— -- -- - Ground e lev. 103 -0--ft. Depth to - — — — — limiting -e r r factor fP 89 in. Re marks: CST Name (Please Print) Jignature Telephone No. `l /.'.�. ,� S f a rn�,�1e y _ G•J,.��- ,�..»l� __ __7_ � S �3 �'� � 3�' a l Address —� Date CST Number IRiOPERTY OWNER Richard Stout SOIL DESCRIPTION REPORT Page of _ PARCEL I.D.# 3oring # Horizon Depth Dominant Color Mottles Structure 2 in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed .Trench 3 , 2 47- 1 10 r4 6 no ms osq ml cs -- ;. around 10 ),ev3 Qt. Z 5W 7, a,v,hY' ?epth to imiting act r Remarks: 3oring # 1 -49 10 r4/4 none lfs 1 fabk mvfr cs 2f 4 2 9 -9 10yr4/6 none ms os ml cs - .7 .8 Ground Aev. 101 -5-Oft . depth to imiting ach Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Boring # 1 -44 1 0 r4/4 none lfs 1 fabk mvfr cs 2 5 2 4 -9 10yr4/6 none ms osg ml s - .7 '.8 Ground Depth to limiting fac tor t in. Remarks: :3oring # .3round alev. ft. Depth to iimiting ' factor in. Remarks: SBDW -8330 (R. 08/95) l og 3 G 3 h�� d rnu e X GL IJ'C sue. � � z � • = r ye n e M e. J � mscon:rn uepanmeni or industry, SOIL AND SITE EVALUATION ibor atnd Homan Relations page 1 013 _ Diyisled of $afety..4nd Buildings in accordance with s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 Inches in size. Plan must County krclude, but not limited to: vertical and horizontal reference point (BM), direction and St . C r o i X percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. fi 0,0 - /07 S- 00 APPLICANT INFORMATION - Please pint all Information. Reviewed by Date Personal information you provide mey be used for secondary purposes (Privacy law. s. 15.04 (1) (m)1• Property O Property Location Richard Stout Govt. Lot SE t l4NW 1/4,5 27 T29 N,R 19 XI;IS(or) W Property Owners Mailing Address Lot N 8k cka Subd. Name or CSMf! 1353 Awatukee Trail 20 Ba dlands Prairie City State Zip Code Phone Number ` Hudson WI 54016 El City El Village �] Town Nearest Road (715)549 -6731 Hudson ill Farm Rd ER Now Construction Use: QResidential / Number of bedrooms __d Addition to existing building [] Replacement ❑ Public or commercial - Describe: Code derived daily no%.fQ __-. -- gpd Recommended design loading rate 9 9 -.bed, _._$ 5 gpolir? i $ .trench, gpd /Liz Absorption area required -15 — bed. ft ` 7 5 0 -- trench, ft 2 Maximum design loading rate • 7 bed, gpolh? — . 8 .— trench, gpd/11 gaersrltimwiltlwlrl lrillitibili�i ilwNiaa� al4rwlrNiin(al _II 144 filierifla to silo plan honchrnatk) Additional design/site considerations Parent material _Road plain elevation. it _— applicable _ -- • il S = Suitable for system Conv entional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable lot system (� s ❑ U CR S ❑ U 5D S O U CXl s O U. ❑ S ®U Os Q U SOIL DESCRIPTION REPORT goring # Horizon Depth Dominant Color . Mottles In, Munsell Qu. Sz. Cont. Color Texture Gr. Szt Sh. Consistence Boundary Roots GP0/tl 2 Bed . Trenr� 1 1 0-4E 10yr4/4 none ifs 1 fabk mv C 2f .5 :.6 2 48-92 10yr4/6 no ne ms osg ml Cs _ -- .7 -.8 Ground elev. i 60 - Depth to limiting factor _ Remarks: _ Boring M 1 0 - 4 10yr4 /4 none __ 1£s lfabk mvfr _ c 2 46-- 9 10y r4/6 none ms osg ml - Cs -- .7 ..8 2 -- Ground Depth to _ limiting lactor _ -B9_; Remarks: CST Name (Please Print) Signature Telephone No — _ (� 1'4L! I}± .? C..A F! L!~lel s"� -- "'"T a i.: L�+� Date - ...._ .. _ CST - t caber Address / r r . i i .ti /a7 s -1 h 7 a A .4, ?RpPSRTY OWNER _ .Bicfiard $tout SOIL DESCRIPTION REPORT Page �_ of T oARCEt. t.D.R ���iii///��� bring # Horizon Depth Dominant Color Mottles Texture Structure In. Consistence Boundary hoots 2 Munseo ou. Sz. Cont. Color Gr. Sz. Sh. Bed . Trench .3 ee _ L _ 47-91 10 r4 none s ots m , rte C s 0 2 V 31 )epth to inwiing ad Remarks: 3oring # 1 -49 10 r4/4 no lfs lfabk v 4 2 9 -9 3 10yr4/6 none MS os ml cs - .7 .8 around rlev. 01-50. )epth to uniting a Remarks: Horizon Depth Dominant Color Mottles Structure in. Munseil ou. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roofs QP Bed Trench Boring 1 -44 10 r4 4 none lfs 1fabk mvfX 5 2 4 -9 10yr4/6 no ms osg m1 CS _ .7 '.8 Ground , etev. 103 40. Depth to gmiling . in. Remarks: 3oring # ;round Depth to factor Remarks: SBDW- 8330(8. 08/95) — t oo ha Ike a° ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Boyer ` l &I Mailing Address (j/ Co Property Address 6 6 3 ,Q 444 i o L-e L W 2-o (Verification required from hanning Department for new construction) City/State Yu d s o vi LJ, „ Parcel Identification Number 6WO- 135 LEGAL DESCRIPTION Property Vocation S F— ' /a, NA) ' /a, Sec. 5 2-7 T Z�'_ -R, j_W, Town of f�d So tj Subdivision 5 A-J L S F( n i v , Lot # Z- Certified !Survey Map # , Volume . Page # Warranty Deed 4 5 c l 7 ° l7 , Volume 1,32- ( P , Page # 3 Spec house ❑ yes J( no Lot lines identifiable �'j 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 plumping 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. Th property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master plum�er, 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 }dour 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. SIGNA 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 property described above, by virtue of a warranty deed recorded in Register of Deeds Office. llqlf SIGNATURE, OF APPLICANT DATE * * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * ** ** Include t ith 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 I �y ry r� `9 ! 9 I STATE BAR OF WISCONSIN FORM 2 — 1982 5 WARRANTY DEED DOCUMENT NO. j Sam E. Miller, a single person, REGISTER A OFFICE : ST. CROIX Co.. WI c �a Inr !�g0erd it — jj conveys and warrants to Thomas Houman and Kimberly Houman, MAY 2 7 1998 ii husb and and!wife as survivor marital property. 9:30 A M Re !gter of Deeds I !! THIS SPACE RESERVED FOR RECORDING DATA NAME AND RETURN ADDRESS the following described real estate in St. Croix C.-Y. F Fl. i State of Wisconsin: j it ;i i 020- 1334 -00 jl PARCEL IDENTIFICATION NUMBER ! s i it li Lot 20, Plat of Badlands Prairie j jj in the Town of Hudson, St. Croix I 11 County, W$consin. T APSFER II li j' This is not homestead property (is) (►s riot) J Exception qo warranties: ✓ , Subject to easements, reservations and restrictions of record. I � 4 da of May A.D., 19 -9,8 . I Dated this Y 4 (SEAL) ___1` f ,`Tr , F ►i8f��t��' « • SA.M E. MILLER I (SEAL) (SEAL) 'I AUTHENTICATION ACKNOWLEDGMENT ! + i Signature(s) State of Wisconsin, Peres ss St_ Croix County day of J Larne before me this authenticated this day of , 19_ �at1} May 19 , the above named i Saar E. Miller '+ TITLE: MEMBER STATE BAR OF WISCONSIN — — I (If not, 1 authorized'by §706.06, Wis. Slats.) to the kn�ia to be the persor. who executed the foregoing irstru zd xk wled saW. Y I I THIS INSTRUMENT WAS DRAFTED BY __ t ! STEPHEN J. DUNLAP i nAty I f /�Q r .I.rO Hud on, Wisconsin Naarv k. . St. Croi County,Wis. s !I (Signatures may be authenticated or acknowledged. Both are not !•1y c�b � sr#isicrtt is permanent. If not, state expiration date. r. necessary.) • Names of persons signing In any capacity should by typed or printed below their signatures I STATE BAR OF \YISCJ%SIS WwonsrI Leg Stank Co . Inc h �d WARRANTY DEED Form No. 2 — 1982 •tl"�`�. 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