HomeMy WebLinkAbout020-1339-00-000 f -
STR
OIX DEPARTMENT,/.
C C
O
U
NTY
ZONING
AS BUILT SANITARY REPORT
Owner la -s-old
Address �Q3 l,.�,i s' 1 �s -', sr CROIx i
COUNTY
City /State .&.- ,d g, ZONINGOFFICE
Legal Description:
Lot Block Subdivision/CSM # eSm
'/.!TAZ %, ,$';'Sec..`" , T, 2�N -RZW, Town of Ada,✓ PIN #
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION
Tank manufacturer Size ST/PC 4oW1w Setback from: House 1c' Well .6 PAL, 35
Pump manufacturer - Model �oe1,!
Alarm location _ 14/ A , e , qe
(HOLDING TANKS ONLY)
Setbacks: Service road Vent to fresh air intake Water Line
Meter location
Alarm location
SOIL ABSORPTION SYSTEM
Type of system: G�,rJ Width L 5 - Length 3 Number of Trenches 2
Setback from: house 13d Well Sa P/L ID , Vent to fresh air intake 1,?d
ELEVATIONS
Description of benchmark _ 5'5v ,—e_ A _5 Elevation X46
Description of alternate benchmark Elevation
Building Sewer ST/HT Inlet ZIF, 79 ST Outlet- PC Inlet
PC Bottom Header/Manifold 94 Top of ST/PC Manhole Cover !F fd'
Distribution Lines
Bottom of System(
Final Grade O O ( )
Date of installation 6 /3 /0 ' Permit number State plan number
Plumber's signature // - License number yr'd' Date
Inspector n ld
complete plot plan a
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
I"
I
A
J
INDICATE NORTH ARROW
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM y
Safety and Buildings Division Count
ST . CROIX
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) SanitarxPle�rr�iIM:
Personal information you provice may be used for secondary purposes [Privacy L s.15.04 (1)(m)]. 3 �5i2ii UU 44
�erp�it olde ', 'J%'9ON f]_Lit�t Y�llage Town of: State Plan ID No.:
CST BM Elev.: JA Insp. BM Elev.: BM Description`:F1VU1177 1V Parcel Tax No.:
00 I 4� o , - ; ;+ - 0 P - l33 -�c
TANK INFORMATION ELEVATION DATA A9800193
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic �Aw� Tee ot`i I QUO Benchma
Dosing
Aeration Bldg. Sewer p S �0
Holding ( ' t i u Inlet
TANK SETBACK INFORMATION 6 DO111 outlet
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic -7 NA Dt Bottom
Dosing t' �jv' NA Header /Man. .(� �a V9
Aeration NA Dist. Pipe
Holding `e °� Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer
45 vv (':45 Demand o w
Model Number 'po 3 GPM
TDH Lift ,_ Friction3 System_— TDH�, 7 Ft
Forcemain Length' W Dia. H am'' Dist. To Well
SOIL ABSORPTION SYSTEM
BED / E Width Length i No. Of Trenches PIT No. Of Pits Inside Dia. Liquid D th
DIME �PO .P I DIMENSION
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEAC G Manufacturer:
SETBACK HA BER
INFORMATION TypeO L f Q � Mo a Num �.
System < TID'f I V OR U
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
1
Length 1Z , Dia. Length Dia. `-/ Spacing f , — (oV 5< V7
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: H UDSON 33.29.19,SW,S 603 HIGHWAY 35 S _
`
1 1 Cit `tD 6c-- C"W f -10 w� to , 1(„ w Z i vt C C Q vG� C�
J / v
Plan revision r6cli d? [ �l No � t q
Use other side for additional information. h ( b] l or l 61 7
SBD -6710 (R.3/97) Date Inspect Signature ert. No.
Vi sco ns iSANITARY PERMIT APPLICATION 210 e E Washin�9�Ave lion
n In d with act o r Wis. Adm. Code P.O. Box 7969
Department of Commerce t h ILHR 83 O5, 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.
• See reverse side for instructions for completing this application State sanitary Permit Numb r
31 -Fd7
The information you provide may be used by other government agency programs [_1 Check if revi:on to previ ous application
[Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION
Property Owner Name Property Location
a r SW 114 114, S33 T a , N, R�9 E (or
Property Owner's Mailing Address Lot Number Block Number
lo D.p // s r S e. �� 'Y
City, State Zip Code Phone Number Subdivision Name or CSM Number
Ha s ,rl A): 1 (7 / 5- > - C S m a 2 23�
II. TYPE BUILDING: (check one) ❑ State Owned ❑ it Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms ❑ village
Town OF �' i✓ ��
III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) �� 15 0'4
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 onIv one box on line A. Check box on line B, if applicable)
A) 1�_Ww 2. A Replacement 3 E] Replacementof 4. ❑ Reconnection of 5. E] Repair of an
System_ __System____ _______TankOnly______________ Existing System Existing System
B) ❑ A Sanitary Permit w ously 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 E] In- Ground Pressure f f 42 ❑Pit privy
13 E] Seepage Pit c� X 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/day /sq. ft.) (Min. /inch) Elevation
Slv 3 S 70 Gc. 91 1 7 1 10 Feet fy. 0 ,0 Feet
VII. TANK Capacity g allon s g Total # of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
New Existing strutted
Tanks Tanks
Sep is ank Q ® ❑ ❑ ❑ ❑ ❑
Pump Tan e I Y 1 1 1 Irk! ❑ 1 ❑ 1 ❑ I ❑ ❑
Vitt SIBILITY 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) MPRSW No.: Business Phone Number:
< a S a T-< le 1 a2
Plumber's Address (Street, City, State, Zip Code):
/ 4 7G , &e—,l _v f D
IX. COUNTY/ DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fe (Inc ludesGroundwater ate slue Issuing nt Si nature (No Stamps)
k Approved El Owner Given Initial surcharge fee)
Adverse Determination �
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBDZM (R 1/96) DISTRIBUTION: Original to county. One copy To: Safety & Buildings Division, Owner, Plumber
I
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• aSa,lJ �va,.d5 d,� S"1rJ� S 33 DE'q�f /Q!J � s"� � y1 o �'
t l vFcvice aS%
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f 5; s i d a(
all g _�X$� Tre uGhss
fX�s ?�Y9 �ew�o`nbc T a�� i GC
BL.�R�d.'Li /Bd�'GSd
�UAx
I 'W
I
1
M
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C
PAGi ___ Gr _
PUMP CHAtA6ER CROSS SECT10tJ AMC, SPECIF ICATIOKJS
—VEWT CAP
`i" C.I. VEIJT PIPE
WEATHERPROOF APPROVED LOCKIK ►G
> FROM DOOR, JUKICTIOU BOX MAIJHOLE COVER
- 25�
WIMDOW OR FRESH 12'MIU.
AIR IMTAKE
GRADE
I
COIJQUIT ______
18'MIKI. - - - - - -- --
�1
INLET PROVIDE
AIRTIGHT SEAL i I
4 A
� ICI
ALARM
� 1
c *APPROVED om
JOINTS WITH I
ELEV. FT. APPROVED PIPE - -�
3' ONTO PUMP - --- OFF
D SOLID SOIL
COKICRETE BLOCK
RISER EXIT PERMITTED OIJLH IF TAUK MAIJUFACTURI`R HAS SUCH APPROVAL
SEPTIC £ SPEC.IFICATIOUS
DOSE
TANKS MANUFACTURER: G> Eke..,r/ (JUMBER OF DOSES: — --_ PER DAU
TANK SIZE : �!� CALLOUS DOSE VOLUME
ALARM MAUUFACTURER: _ / /,n IMCLUDI►JG BACKFLOW: lyT...s'O GALLONS
Y MODEL ►DUMBER: Z d CAPACITIES: A= AU IUCHES OR _ GALLUS
SWITCH TYPE: _ " �-e
!} = x IIKICHES OR y GALLOWS
PUMP MAKI UFACTURER: C = ` S �IKICHES OR GALL01J5
MODEL MUMBER: _ f 04 7 D- INCHES OR ALLOMS
SWITCH TYPE: -_ c°vY MOTE: PUMP AUD ALARM ARE TO BE
MIr111MUM DISCHARGE RATE - 3l, GpM INSTALLED OW SEPARATE CIRCUITS
VERTICAL DIFFERENCE BETWEEN PUMP OFF AUD DISTRIBUTION PIPE_ L_ FEET
+ M A(ETWORK SUPPLY
PRESSURT,E �. , , , , . , , , , , FEET
- � ._ FEET OF FORCE MAIM X 2 O� F / o o rtFKICTIOkI FACTOR 6 1 FEET
{
° TOTAL 09JAMIC. HEAD FEET
I i
IMTERUAL DIMEWSIOu[ OF TAKJK: LEU&TH ;Wip7" ►{ LIQUID DEPTH
I
Wisconsin Department of Commerce SOIL AND SITE EVALUATION
Division of Safety and Buildings Page of
Bureau of Integrated Services 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 3- C r
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
APPLICANT INFORMATION - Please pri i fQe a Re ed by Date
Personal informatan you provide may be used for seco ry u s (Privacy f ; 1 (1) (m)). �+(/ et e'L Z ( i
Property Owner P �� ' � P perty Location /;�
`
0. a (1 k 7 y , .Lot l� 1/4� 1/4,S `f) T aq ,N,R E (°'v
Property Owners Mailing Address G i °tot Block# Subd. Name or CSM#
City State Zip Code , Phone Road _
�s F , y City El Village ®Town
N
4 S c>vi W �0 A .,l N C U-S4 W _
F New Construction Use: CgResidential / ° s Addition to existing building
(� Replacement ❑ Public or commercial - Describe:
Code derived daily flo gpd / Recommended design loading rate bed, gpd/ff gpdt*
Absorption area required y bed, ft �L� 3 trench, ft 2 Maximum design loading rate _Z bed, gpdJfl� trench, gpd*
Recommended infiltration surface elevation(s) y� ft (as referred to site plan benchmark)
Additional design/site considerations ,, t—
Parent material �P laGi 4 t t r / 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 Ea S❑ U � S ❑ U NS ❑ U PIS 0 U I [Is I U ❑ S Q U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
/sY S -- S�G� ma r1 eLl
Ground )0vr L 1 1 6 i rn C 1
q.�
Depth to
limiting
factor
in.
Remarks:
Boring # mad -fir CS
Y ? 1 Jo f wt l C,
Ground
elev.
i 96�t
Depth to
limiting
4 factor
S Remarks:
CST Name (Please Print) Signature Telephone No.
7/ 3 6 3/z/
Address Date CST Number
/0 Sc //vWSC v" 6" 1 q aZ �
SOIL DESCRIPTION REPORT
PROPERTY OWNER Page .,-2-- of
PARCEL f.D.#
Boring Horizon Depth Dominant Color Mottles Structure 2
9 Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
0-8 0 3/i �' S,` lmc�b Vnl r- C %S 14- - .l
G� S
Y/v `� S rG I C3
Ground y4 "�� l0 �� S VYl C, 7
elev.
Flo -
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in.
Remarks:
Horizon Depth Dominant Color Mottles Structure PD /ft
Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Boring # ;
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
' Remarks:
SBD -8330 (R. 07/96)
zas
Sc O r Sul vq
lie ne r
S .e/.eu, '
w e �l
N Y�o 2
3 icAr 6 1 83s
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer 'Vev,
Mailing Address
yr it tr
Property Address
(Verification required from Planning Department for new construction)
City/State Parcel Identification Number
LEGAL DESCRIPTION
Property Location 9W ' /4, 945 ' /4, Sec. .9--? , T N -RLW, Town of ZL" 1;
i
Subdivision t 7' ly , -e-IV , Lot # _ .
Certified Survey Map # , Volume 2 , Page # 3r"
Warranty Deed # .5 77:2 3 91 , Volume (.? IS , Page # f 4�7
Spec house ❑ yes 9 no Lot lines identifiable K 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, restrictedplumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal 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 year expiration date.
SIU&A 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.
S ATURE 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
• 57`7 STATE BAR OF WISCONSIN FORM 2 - 1982
WARRANTY DEED
DOCUMENT NO.
RICHARD O. STOUT
I �ic
eZ
conveys and warrants to JASON R. BRANSON
AF-R 1 4 1998
4; 30 PM
THIS SPACE RESERVED FOR RECORDING DATA
NAME AND RETURN ADDRFSS
the following described real estate in St Croix Richard 0. Stout
1353 Awatukee Tr.
Su, cifWisconsiw Hudson, Wi. 54016
Lot 4, Plat of Summerfield, Town of Hudson,
St. Croix County, Wisconoin.
PIRCEL 7: ENTIFCATION NUMBER
T FER
F
i
This -- is ho^nestead property.
its) (i not)
Exception .o warranties: easemenf-.;, restrictions, rights and
covenants of record, if any.
Dated this day of April A.D-
Ricjiard O. Stout (SEAL) (SEAL)
R
(SEAL) (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
State of Wisconsin, ss,
St. Croix County
illy
authenticated this day of 19 persona: v 3me before me this day of
April J!
19 tLe above named
ichar 0. Stout
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not,
authorized by 9706.06, Wis. Stats) Notary Public no�7' o 1 the person --,, who executed the fore go
!ng
State of Wiscongfif k - ' -tkriowledge the same.
THIS INSTRUMENT WAS DRAFTED BY Diane M Barron
Janet P. Stout —A
— 13 - 53 - Awa - tukee --- Tr - -
Hudson, Wi. 54016 _ZAJ�— County, Wis
(Sigo.awres may be authenticated or acknowledged. & are not My corvrn—z�" Pci (if riol state cxf W1 1,11 Ioni'll e
necessary)
SFATF BAR OF
%%ARR-\ \I[N DLI 0 form No. 2