HomeMy WebLinkAbout030-1066-30-000 (2)sTc 10 4
AS BUTLT SANTTARY SYSTEM REPORT
I
OWNER
A KADDRESS
r/trJ*,r,4/ort
suBDrvrsroN z CSl,t#
sEcrrow--@ rt%'*-olL *,Town of 5r
sT. cRolx couNTY, wIScoNSIN
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover-
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PIJAN VTETY
SHOW EVERYTHING hIITHIN ].OO FEET OF SYSTEM
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ALTERNATE BM:
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SEPTIC TANK / PUMP CHAMBER / EOLDING TANK INFORMATION
Manufacturer: //,Jorrt frcCAyJ Liguid capacity:
setback from: werr P 5p House fO' other
Pump : Manufacturer Model #-Size
Float seperation GaIIon s/ cycl.e:
A1arm Location
. SOIL ABSORPTTON SYSTEI.T
width , { 'Length 3o'Number of trenches 2
Setback from: well: House Other
ELEVATIONS
Building
PC inlet
Sewer ST Inlet:ST outlet
PC bottom Purnp O f f
stemHeader /l{an ifold Bottom of sy
Existing Grade Final grade
DATE OF INSTALI,ATIO 1
PLUMBER ON JOB:
LICENSE NUMBER:3t3I
TNSPECTOR:
3/93:1X
BENCHMARK:
J
Distance & Direction to nearest prop. Iine:
. lffiTJeffi r.Eft 6r r,ilg$FPH
Labor and HLman Relationi
Satqty and Buildings Division
GENERAL INFORMATION
2 5 . 3 o .ifi vtrltttffitE *&ffi srREEr
, . INSPECTION REPORT
(ATTACH TO PERMIT)
TANK INFORMATION
TANK SETBACK INFORMATION
PUMP / STPHON INFORMATION
ELEVATION DATA A9300085
Permit Holder'r Name:
MT(.HAT.SKI . A}ITHONY
D City D village q{own of
ST. JOSEPH
CST 8M Elev : - 'r
,//d, o levlnsp. BM_E
//).
BM Deicription: :, , -,'5)[ os 2L{ /L-
ounty
ry Permn
Stata Plan lD No
ParcelTar No-:
o3()-1066-3()-OOO
TYPE MANUFACTURER CAPACITY
septic W.t/ ur<s/ /e aa s1-t rl0cal
Dosingr---
Aeration
Holding
F5 ELEVSTATIONB5HI
Benchmark /7_2)n2,/a).a)
o'oz'//L. 3y' 'azt/,r1,,
Bldg. Sewer f ?/./o7.rz'
5t I y< lnlet 0rL /a6.5O'
St / ltf Outlet //z fia,o(/
Dt lnlet
Dt Bottom
HeaderlJc6l ,ffi:
Dist. Pipe or.3I
'9rW"t'rouffiBot. system
Final Grade
/?'t)2,tlL'*p ar <..7
.7tu-1, /, (ca;r
f;"qoill?"./ L",/ ?.o{'
TANK TO PIL WELL BLDG.Ventto
Air lntake ROAD
Septic > )tD @ Gd@ t|*NA
Dosing----NA
Aeration NA
Holding
--IIII
Manufacturer
Model Number
Demand
GPM
TDH Lift ffi?ftfi TDH Ft
Forcemain Length Dia -..-;t.n"*.q-_
M
SOILABSORPTION SYSTEM 6'3
DISTRIBUTION SYSTEM
BED / TREtiICH
DIMENSIONS 5wadth Lenoth '/- o0'No. Ol Trenches
DlMEilSlOlrlS
PIT -Dlo. O{ Pits lnside Dia Liquid Depth
sYsTEM TO ManufacturerPILBLDGWELLLAKE / STREAMSETBACKINFORMATIONype
-.10L
TEACHING\
CHAMBER
OR UltllT-Et @ //4
Header*l*d
tenstt /6t oia y' | "*'','"'il;''E2' ,,. 4' ,ou,.,nn /
x Hole Size x HoleSpacing Vent To Air lntake
sort covER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over
Bed /Trenah Center u:10'Depth Over
8ed /Trench Edges /d xx Depth Of
Topsoi OYer DNo fl Yes E No
COMMENTS: (lnclude code discrepancies, persons present, etc.)
LOCATIO : ST. JOSEPH 25.3O.1-9.2438,NW,SW,L3 2ND STREET
.rr',,{-:*,{ J.{ c,'t tti 7,
d/2" *,"4 6''"n 1 ilu,'(,;+z' ''/ /o;'
@ Dd-@4e?n44r/-c-{zd "/ Lt-"
@,6.--/rL74t')o'1 'w b{""> 7.d'a
Plan revision required? E Yes
Use other side for additional information.
SBD-6710 (R 05/9t)
G o?6T\/I 7
Date lnSpector'! Srgnat
tf
Cert No
o a.( 3 ,
I<:trTILHFIIrffitI-Eil.-ul;.-
--I
SANITARY PERMIT APPLICATION
ln accord with ILHR 83.05, Wis. Adm. Code
-Attach complete plans (to the county copy only) for the system, on paper not less thanSlLx 11 inches in size.
-See reverse side for instructions for completing this application.
I. APPLICANT INFORMATIOil - PLEASE PRIilT ALL INFORIIATION.
'S$ . Cr(/ td
STATE SANITARY PERMIT #
" J?,#,,H,n,?"us appr icati on
STATE PLAN I.D. NUMBER
I PROPERW LOCATIONi[;;fd},; ,< r3o,N,R /? eor6)
PRoPERw owNERs ilru(lxa ADDRESs/50? fiheu-"oA ltt *l LOT #
----
BLOCK #
"ffii'o U''4il7/PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
O E Medical Facility/Nursing Home
z E Merchandise: Sales/RepairsI E Mobile Home Parkg E Office/Factory
3e
O Ea-/o
9+
all6
trtr
o
10 Outdoor Recreational Faci I ity
11 RestauranUBar/Dining
12 Service Station/Gar Wash
Other: Specify13
lll. BUILDING USE: (lf building type is public, check attthat appty)
il. wPE
llin
1
2
3
4
5
ApUCondo
Assembly Hall
Campground
Church/School
Hotel/Motel
OF BUILDING: (Check one)
Public E] t or 2 Fam. Dwe
State Owned
9-# of bedroom " 3
lV. TYPE OF PERtllT: (Check only one in line A. Check line B if applicable)
4 5.
B Date Issued
Repair of an
Existing System
A)1E Reconnection of
Existing System
A Sanitary Permit was previously issued. Permit #
Replacement of
Tank Only
Replacement 3.
System
New
System
2.
Other
41 tr42[]€E
V. TYPE OF SYSTEM: (Check only one)
Experimental
30 E Specify Type Holding Tank
Pit Privy
Vault Privy
Non-Pressurized Distribution Pressurized Distribution
21 n Mound
22 Z ln-Ground
Pressure
11
12
13
14
Seepage Bed
Seepage trench)-f,1'
Seepage Pit
System-ln-Fill
5. PERC. RATE
(Min./inch)1/D
7. FINAL GRADE
ELEVATION
Feet
6.ELEV
ROPOSED
<Q6 Feet
ED (sq.ft.)P (Gals/daylsq. ft.))h
VI. ABSORPTION SYSTEM INFORMATION:
4. LOADING RATE2. ABSORP. AREA 3. ABSORP. AREA
(sq.ft.)
CAPACITY
in gallons PrefabVll. TAltlK
IilFORMATIOil NewTanks
Total
Gallons #otTanks Manulacturer's Name
Site
Con-
structed
Steel Fiber-
glass Plastic Exper
App.
Septic Tank or Holdino Tank X ',b6 O I V(ir ,1,$f fte$gl
Lift Pump TanUSiphon Chamber I
VIII. RESPONSIBILITY STATEiIENT
l, the undersigned, assume responsibility for insfallation of the onsite sewage system shown on_lhrurched plans.
Plu6ber's Name (Print):
Tlnnas I [ta 1/
Signatu MStamps)Business Phone Number:({6t//tr
'u er 5 29
tx.ARTMENT USE ONLY
Approved
Disapproved
Owner Given lnitial
(r
Surcharge Fee)
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
EWH
SBD{398 (formerly Plb€7) (R. 11/88) DISTRIBUTION: Originalto County, One CopyTo: Safety & Buildings Division, Owner, Plumber
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' DEPARTMENT OF
IN.DUSTRY,
LABOR AND
HUI\NAN RELATIONS
REPORT ON SOIL BORINGS AND
PERCOLATION TESTS (115 )
(ILHR 83.09(1) & Chapter 145)
SAFETY & BUILDINGS
DIVISION
P.O. BOX 7969
MADISON, WI 53707
BLK. NO.U BDIVISION NAMELITY
se
NIC
t'.tAsA
IIttt \
c
ffiru.* EReplace
-
lKResidence
DATES OBSE RVATIONS MADEUSE
RATING: S= Site suitable for system U= Site unsuitable for system
t
S
lf Percolation Tests are NOT required
under s. ILHR 83.09(5)(b), indicate:
DESIGN RATE
PROF!LE DESCRIPTIONS
/(
HOLDING TANK
uDS
RECOMMENDED SYSTEM:tltttehes S f$ff:h. 3^ boi,*ngSDU
N-FIL
s U
M
Us
NVENT
utrS i
BORING
NUIVIBER
TOTAL
DEPTH IN ELEVATION R U H CHARACTER ITH THICKNESS, COLOR, TEXTURE, AND DEPTH
TO BEDROCK IF OBSERVED (SEE ABBRV. ON BAC K.)
B-I )ru l1s.*Alou E ,7t"a-J!'8 is;l.tv-iD" 6nsrl go-V"6n S 16n
,-))$"/ct, o 1t'i 3 A 6n{sil 3d{ ge " P nf sA4?% I eil-qb"- ,t'6n e3
e-3 78"/ r,L,a 1t fs)3a"*7t"
'{)&."/aKa -3D"3o'^3 t)a 3 t':lt
S S
s-J )&"/NA,S o^36"!s6 tt OB tl n6s
B-
I
PERCOLATION TESTS
TEST
NUIVBER
DEPTH
I NCHES
WATER IN HOLE
AFTER SY}'ELLING
TEST TIMEINTERVA L-M IN
DROP IN.WAT-ER TEVEL-INCHES RATE MINUTESPER INCHPERIOD 1 PERIOD 2
p-I 4$,'A I 3 s 5 I
P-9 j)"3 9'/t t/4 /
P- ?,rtE ,.j ilq Y?/Q o sir I
P-
P
P
PLOTPLAN: Show locations of p€rcoletion tests, soil borings and the dimension3 of suitable soil ar€as. lndicste scal6 or distanc€s. Describe what aro the hori_
zontal €nd vertical elevation referenca points and show.th€ir locstion on the plot plan. Show the surlace elevation at all borings and the direction and percent
of rand srope. 'treac\t' I -i6<J. 5 A S' na.€
SYSTEM ELEVATION {J 3-l03.9 ?t qBS6Y
B+t. Top s ta [e Nex t to 16!' o'e"D' i N;l, ri \-'Pir.
-,^"r,ktd uf ribbon
N\ttrr [.tS
6= fe,^e ll, ie s
t&
e%
t,a Ol-
BI
Sec.ri 8.h1. ilo'o
Top slqke
u Do' l{orunqCn. Ib fia'
ttt
t, the undersigned, hereby certify that the soir tests reported on this ,"rrn #JfrI'R rnH$g*.| 30n
with the pro
lu€
cedures and methods specif ied th tsconsl n
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief B0
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ERE COMP TE
ionalER
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MNPHON
ON())
tpts
ERTIFICA T o
CST S
Dt LHR-SBD6395 (R. 10/83)_ OVER _
st
ff
t
lf any portion of the tested area is in the
Floodplain, indicate Floodplain elevation :
OBSEF VFD ES I. HI(H EST
{ve
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
NAME (print): /
%on4na I L)ana
oHt{
ROU
h
TE/BOX NUI{BER
src r05
SEPTI C TAI.IK HAI NTETIANCE AGREE}IENT
Crolx CountY
a I
I
7,lPCITT/STATE tSott t
ill^t,rt SlD -trt, s rron 9< , 7 3C tt, * ,4 ,,
Town of SC St. Crolx CountY,
Lot No.2'
),' .
PROPERTI LOCATI ON:
Improper use and malntenance of your septlc system could result in its Premdture
[allure to handle yastes. proper malntenance conslsts of pumping out-the septic
tank every three years or roon.r, tf needed, by a LICEI|SED ttBPttc Tttlx PUXPER'
That you put into the system can attect the function of the septlc tank as a
treatmlnt stage in the uaste disposal system.
ty Resldents XAI be eIlg[ble to recelve a grant for a XIIIXT'X of
ost of replacement of a falllng system, wnicn Yas ln operatlon
, l9?8. St. Crolx County """.[t.a tf,tt program ln August of
requlrement tlrat ouners of ILL xgu sIsTEl{S-agree to keep thelr
malntalned.
-73
St. Crolx Coun
53000 of the c
pr lor to Jul
1980, ulth
systens prope
The property oyner agrees to submit to st. crolx county zonlng a certlflcatlon
f orm, s lgned by the oYner and by a naster plumber, journerruln plumber 'restrrcted prumber or a r.rcensed pumper verliylng !hat (1) the on-stte
vasteyater dlsposal system is ln proper operattng iondltion and (2) after
lnspectton and pumplng ( if necesuary)l tn" slptic tink ls less than L/3 fulr of
sludge and s"u*. i:er[itlcatlon form vlII be sent approxlmately 30 days prlor to
three year explratlon.
l/ttr,, the underslgned, have read the above requlrements and agree to malntaln
the private seyage dlsposal system tn accordance wlth the standards set forth,
hereln, as set by the Ulsconsln Department of Natural Resources. certlflcatlon
form must be "o^ileted and returned to the st.crolx county zonlng otflce vlthin
30 days of the three year expiration date.(
SIGN
Subdlvislon
St. Crolx CountY Zonlng Offlce
St. Crolx CountY Courthouse
911 lth Street
Hudson, UI 54016
( 7I5 ) 385-1680
Slgn, Date, and Return to above address
yl
therIy
DAT
t
,-.q!#ad-tr'
STC lOO
This appr ication f orm is to b.e .completed in f urr and signed bythe oh'ller (s ) of tho property b:.tnq -J.-*toped.
Any inadequacies
Yi I I
-
onry resurt in deriy" trr the permit issuance . shourd thisdeveropment be intended f or rg:a.ie by qwn et /contractor, ( specItouse ) , then a second f orm shourd be retain"a- ilJ compreted whenthe property is sord and submitted - lo thls office wlth theappropriate deed recording.
-------------__
Owner of property
Location
Township
llailing
of propert L/4 J,L/4, Section 9<
s1.
,r&-n*/Lw
address
Adclress of site /
Subdivision name .Lot no.
es K o
Previous owner of property R/n Tt 4
Total size of parcel v
Date parcel was created
Are al I cornerg ancl 1ot lines identi f i able?Yes
-No
( spec house ) ?_yes X Xo
recorded. with thE Register
Is this property being developed for
vgr y" =fr l-and Pase Number /, ? asof Deedil-
I NCLUDE WITII TIII S APPLICATION THE TOLLOWING :A WAIIRAI{TY DEED whic}r inclucles a Docu}tENT NUHBER, V9LUHE A}tD pAGEl{uHBtrR & TIIE SEAL otr TllE nncrsriun- oF DEEDs. rn addition r Elcertified survey, if avairablr;-.;;;il; helpfur so as to avoidderays of the-reri.o.*-r.r,g_ prlocess, rf t,h; deed descriptionrefer€ncoB to a certlfrea burvey Mapl the cer[tit"a snin;y Hapsltarr arso be rgquirgd. - -i ' u"e \'sr' t'4r .
PROPERTY OWIIER CERTII?ICATION
I(we) cerLif y that all statements on this form are true to thebest of ny (our ) knowleclge that I (we) am ( are ) the owner ( s )ofthe property described in this inf ormation form, by virtue ofawarranty deed recorded office of th e county Register ofDeeds as Document No., and that I (we) presentl vown the proposecl site for the sew age disp osal system or I (we)obtained an e a s ement to run the above describeclthe construcLion of said system,and the Bame h aB been dulyr eco Ltre offic e of, County Register of deeds aa DocumentNo.
gnature apP can Co-appI cant,
=J -'?3 5-7/-=Date of Signature Date of Signature
Other homes on property?
I property, for
(
ia?uiN lo
txrl a"A(l icsEnvID 701 nt'co,rolf.,: DArADOCU!,IENT NO WARRJT.HTY DT:D
STATE BAB OF UTISCONSIN FOEJ{ T-18-4s}.141,3 Slln*139rril.
conveys and wrrrrnte ib ..-....enthony..Edward-.lllchalskl..and
-.... Ann. uar le. lli cha I skl r. -husband-. ard .wl f e.r - . a !r-.. - -.. - -. - ..
. -. . . -eurv.l-v-or sh lp . -nar i ta 1 . .prop e r ty r. .. ... - -. -.
the followlng dererlb+d rcrt otatc tn .----..-.S.tt-.Coonty,
Stetc of 'Wiaconsln
i ruGiS I LR s oiFicE
sT. cRotx c0., vd
Rcc'd for Rcccrd
JAN 2 7 1993
lfhe South 519.51 feet of the tteet 427.63 feet of the
Range 19 Westl St. Ctolx County, lllgconsLn.
Thie ls t houateed propcrty,(b) (ls mtl
,
Ereeptlor. to rrrrentlcr:
SubJect to easerenta, resenratLons and restrLctlons of record.
Dated this rh ....-.., r9 93 ..
(sEAL)
a
(r:EAL)
ID
mthcaHcetal ttlr ------. tby of-------------- -.---.- -, 1r--.---
a
TITIJ: UEUBEB STATE BAB Ol trISCONEIN
t^t-"#=\h (sEAL)
a
ACElrOWLIDOUENI
SIATE OP WISCONSIN
?HIT IX3TRUXENT U'At DNATTEO IY
DI'NIAP
Budsori lilsconsLn
(8t3arhrc nry !r tuttcnHcrtad or rAuostcirstl Bothrr not amerlz)datc:
?!Jlr d D-m. rbilla ta rry arr,cltl rf,ool{ D. Epef c arlatr{ uor tf,clr rhnltserrr-
;r1tf r11 rJrrD tlA"t ttt O? WErCOrsrrtOl^I lgG t- lE
St. Ctol.x rt.
County
Pcrrondly crrnc before
---- rlantrary-,-- - - -- --- - -- -. - - - - - - -,
me thir .2rth-...---dry ot
19-9.3---- thc ebovc aened
--- --llt lll aD.- J-.-- Itlllrnan - -and.Charlene Hlllnran,
b rno luoru to be tle p€rroa --s---------- ;ho tleeuted thc
forcgr'-n3 lDchtment and eclnowledgc thc tlme.
----.S-t --Crok
intto*at by t 706.0C. .Fb. Strtal r ''.t. '.
(Il not,
Wircontin Lcg t ELnt Co.. lrr
lllkauhac, Wirconrln
.----.Couuty, WL
::,rcflT
,l
.. . lti..I. L I e$. .L...Wl I Inei n ..and. .Qh er I e n e..lt I ltlirtr . . . -.....
.. .. hus.band ..and . .u.t E e - .g s -.na r l ta 1.. glrrvlYgr plrlp. PrgP?lt-lY.r.. .....
H
ler Puccl No: -.--.----
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