HomeMy WebLinkAbout030-2081-70-000 (3)6TC - 10{
AS BUTLT SANITARY AYATEM REPORT
OWNER
ADDRESS /-<lA -4:u //,-., *
//,^/.oJ.t /
suBDrvISroN / csM#r-pr * /7
Town of
sT. cRolx coIrNTY, WISCONSIN
Provide setback and elevation information on reverse of this form'
Provide 2 dinensions to center of septic tank manhole cover'
)i
PI,AN VTEW
SHOW EVERYTHING WITHIN 1OO FEET OF SYSTEM
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TNDICATE NORTH ARROW
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/BENCIO,TARK:
ALTERNATE B},I:
AEPTIC TANK / PUMP CIIAMBER ,/ I{OIJDING TANK INFORI'IATION
Manufacturer: tr)p*zs
Pump : Manufacturer Model #Size
Liquid capacity:
setback fron: weII -?3 Horuse //. other-
Float seperation callons,/cycIe: _
Alarrn Iocation
..8OII. ABSORP:TION 6Y6[EU
width:T,enSEt-
-;!{--Number
o f t renches
Distance & Direction to nearest prop. Iine:
setback from'. weIL: /r' House--z3- other
EI,EITATIONS
sT r.n]-ext qq,-r4 sT outlet q./3eBuilding
Pc inlet
Sewer
Header/l,tani fold_ Bottom of system
PC botton Pump off
ade Cl? (Existinq Grade ,/,/ll. / _ Final gr
DATE OF INSTALI,ATION:
PLUMBER ON JOB:
LICENSE NUMBER: -3C.5'Z
rNS PECTOR:
3/e3:)t
Loq<b,r'roE$;"'suiluJlHafiBc - 2s , 13o* pftfr,A\d SrflAdf Bflsffifir" )
. Labor and Human Relations
suiety unl aurJnst Division INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT)
TANK INFORMATION
TYPE MAN U FACTU RE R CAPACITY
Septic lDae,tk G',c-. A.<-/, (AAql
Dosing /
Aeration
Holding
TANK SETBACK INFORMATION
TANK TO PIL WE LL BLDG Vent to
Arr lntake ROAD
Septic )/fr)'y'o//J.b /1,+NA
Dosing <NA
Aeration NA
Holding \
PUMP / SIPHON INFORMATION
SOIL ABSORPTION SYSTEM
ELEVATION DATA A9 3 00L42
Permit Holder's Name:
CDTNI{T,ER - KIIRT
! City ! Village QlTown of
ST. JOSEPH-6T-EMEIe-v l-'
( D ,(Pl
lnsp. BM Elev.: ,/n.(D BM Description:s,,-a".s PMfl*
u nty
anitary Permit No
State P nlDNo
Tax No
ELEV.BS HI
a
F5STATION
Benchmark / FE'/a,D ',
Bldg. Sewer
{.r'y''9.sy''St ty1" lnlet
-/s,5/?9 -z/'St ty't Outlet
Dt lnlet
Dt Bottom
Headerll4aa-a)I ?6,fr'
s.zd ?6.73'Dist. Pipe
8,ry''2s.2/Bot. System
Final Grade @
3,15'/&,83bP a{ F7nfi*,/rO GrrManufactr-Eef Demand
GPMModel Number
TDH Lift Friction
Loss
SvstemHead h(Ft
Forcemain Length Dia Drst To Well
BED / TNEilCf+
DIMENSIONS
Wrdth1J,,_"nn,btr,No Of rynches PIT
DIM 7ENSIONS
lnsrde Dra Liqurd Depth
SETBACK
INFORMATION
SYSTEM TO PIL BLDG WELL LAKE / STREAM LEACHING
CHAMBER
OR UNIT
i"-nufacturer
Tvpe Ot n!& ,svit"r, fud-)/0'?y'LI,A*Model NumbeH--
DISTRIBUTION SYSTEM
Header 7fr1i{6ft
Length -U Dra /:
Drstrrbutron Prpe(s) ,
/"6'Length ,?S Dra Spacrng
x Hole Srze x Hole Spacing Vent To Arr lntake
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over
Bed / Tcrd center
Depth Over
Bed /kceeh Edges
xx Depth Of
Topsorl
xx Seeded /Sodded
fl Yes E No
xx Mulched
!Yes ENo
COMMENTS: (lnclude code discrepancies, persons present, etc.)
L)
6 .rr*;"fu- /"rl *x . <Orry f
Plan revision required? fl Yes tstr
Use other side for additional information.
sBD-6710 (R 05/91)
2{7 ^nH /
Date lnspector's Srgnatur Cert No
\--
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-
trtc Of Prts - _
LOCATION: NWTNETSEC .25,T30N-R2
O 3'AFru*
oua4@E
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tr
--
trIILHFI SANITARY PERMIT APPLICATION
ln accord with ILHR 8ii1.05, Wis. Adm. Code
-Attach complete plans (to the county copy only) for the system, on paper not less than
8%x 11 inches in size.
-See reverse side for instructions for completing this application.
I. APPLICANT INFORMATIOil - PLEASE PRII{T ALL INFORIIATION.
COUNTY
- 3/ /h,t
[:i?x?H:",sappca,.n
STATE PLAN I.D. NUMBER
OWNER PROPERW LOCATION
tA) % lr %,fis' \EO,N,R2fi dor@
PROPERW OWNER'S MAILING ADDRESS/377 f:-,, t/,';u 7<.
LOT#/7 ***1/
ClTYz STATE
A, //^.,,),
ZlPCODE
<y'nxQ
PHONE NUMBER(V.r L<+9<tzs
SU B D IVISIO; Y,:"'Yru"'"
!1. TYPE OF BUILDING: (Check one) E St"," Owned
E prOti" E , or, 2Fam.Dwelling-f ol bedroomd
VILLAGE:
!ll. BUILDING USE: (lf building type is public, check allthat apply)OsceoSr- 7or E Aoucondo
2 a Assemblv Hat!
3 E campground
4 U Church/School
s E Hotet/Motet
6
7II
Medical Faci I ity/Nursing Home
Merchandise: Sales/Repairs
Mobile Home Park
Office/Factory
10 fl Outdoor Recreational Facility
11 E RestauranUBar/Dining
12n13E Service Station/Car Wash
Other: Specify
lV. TYPE OF PERtllT: (Check only one in line A. Check line B if applicable)
A) 1.8 New
System
2 Replacement 3.
System
Replacement of
Tank Only
4.Reconnection of
Existing System
5. E Repair of an
Existing System
B) E n Sanitary Permit was previousty issued. Permit #Date lssued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental
30 E Specify Type
Other
41 E
42Ii€E
11
12
13
14
atrtrtr
Seepage Bed
Seepage Trench
Seepage Pit
System-ln-Fil!
21 tr222 Mound
!n-Ground
Pressure
Holding Tank
Pit Privy
Vault Privy
VI. ABSORPTION SYSTEM INFORMATION:
2. ABSORP. AREA I g. EESONP. AREA IRE%;D(sq ft)
f"y3eorsa
tt)
|
4. LOADING RATE
(Gals/day/sq. ft.),a
5. PERC. RATE
' ,'I""n'
6. SYSTEM ELEV.
k t Feet
7. FINAL GRADE
ELEVATION
n/ Feet
VII. TANK
!]{FORmATtON
CAPACITY
in gallons Total
Gallons #ofTanks Manufacturer's Name
,I
Prefab.
Concrete
Site
Con-
structed
Steel Fiber-
glass Plastic Exper
AppNew
Tanks
Existing
Tanks
Seotic Tank or Holdino Tank J..tn /ac'a I tr
Lift Pump Tank/Siphon Chamber f
VIII. RESPONSIBILITY STATE]IIENT
l, the undersigned, assume responsibility for installption of the onsite sewage system shown on the attached plans.
"2Z''Y"W)-,^.//Plu MP/MPRSW No.:Business Phone Number:
tZr \J/P-.?J9/
, State, Zip
n,qpproveo
EE Disapproved
Owner Given lnitial
Adverse Determination
sanitary Permit F"" ($HflSS.p::f*","'( -2 c'?)
Stamps)
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
S8D.6398 (formerly Plb€7) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
RORD
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IX. COUNW'DEPARTTIENT USE ONLY
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Wisconsin Department of lndustry,
Labor ard Human Relations
Division of Safety & Buildings
SOIL AN D SITE EVALU ATION R E PORT
in accord with ILHR 83.05, Wis. Adm. Code
Y-r-
Attach complete site plan on paper not less than 8 112x 11 inches in size. Plan must include, but
not limited to vertical and horizontal reference point (BM), direction and"h ol slope, scale or
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION
PARCEL D.#
REVIEWED BY DATE
PROPERW OWNER:Z-r -\'A1r)ttF
PROPERTY LOCATION
GOW. LoI tr1out 1t4N[Ja Eto'@1/4,s ,N,RT
LOT #/7 'u^o,ffu 'ii)::i: ::*)J /,pRopERTY owNER' $ i\,14i tt ttc ADD RESSt:t7z z/:tz /),o,.t #
CITY. 9TATE \ ZIP CODE
lttrt<ai /, )f -q4c /
PHONE NUMBER
VA.s4-.{zz3 troIY EV|L[-AGE EIoWN '
<Y -lnc;rl
NEAREST ROADA, rJ,,, *
[{ New Construction Use lyl Residential/ Number ol bedrooms ,4 t I Addition to existing building
[ ] Replacement
Code derived daily now . Vtn gpd Recommended design loading late 7 bed, gulllz-;?_ttench, gpdft2
Absorption area requird ./-ag b(r', ftz -" t-<' ten$,ftz iraximum design loading rate . 7 bed, g$lfi2-z? .tench, gpdtlt?
Recommended infi ltration surface elevation(s)ft (as relened to site plan benchmark)
I I Public or commercial describe
Additionaldesign /site co si erations
Parent material Flood plain elevation, il applicable fr
S = Suitable for svstem
U = Unsuitable foi system
CONVENIIONALES DU
MOUNDES trU IN-GROUND PRESSURE8s Uu AT.GRADEEs Uu
SYSTEM IN FILLtrS EU
HOLDING TANKtrS EU
SOIL DESCRIPTION REPORT
Boring #
Ground
elev,
/@Ltt.
Depth to
limiting
factor7{
Remarks:
Horizon Depth
in.
Dominant Color
Munsell
Motfles
Qu. Sz. Cont. Color Texture Structure
Gr. Sz. Sh Consistence Bqrdry Roots G P D/ftz
Bed Trendr
I n -.Q nql -e/t ,/o s-//n////'1 S .3 3
3 9:.?/< qla//"/./-2,.,JJ C 11 t.1 3€c
1-/
??/-4.r LtYlz././-/5 fl r, n,'t) rl /,, {7 ,q
4 4<--/ar /nHsl ,r/,cu)rtl<)n<-l/ / r,' r.,'7 R)
Boring #
Ground
elev.
/oo,-8-tt.
Depth to
limiting
factor>///_
D=J.2 ,</r r/,rr/./.J,rr*/1 (-l.s _?-_{/
9.?-44 /2r/-/-
/ n'K r-/<
,r/^\2 .rr.., .'f)i(7i,*
?4/-ttr ,/s
Remarks
,q /-,.'t,/ f..<
PhoneName:-Please Print
ress
Signature: /Date CST Number:. z">'-.'//
,,
)
PROPEFITY OWI{EB soll DEscRtPTloN EEPORT eaeulu -?'
PARCEL I.D.n
Boring #
s{F#dscEffi
Gound
eler/.
//aefi.
Deph to
limilirE
hcb.>-raL
Horizon Depth
in.
Dominant Color
Munsell
lloues
Or. Sz.Pont Color Texture Stru'ctu re
Gr. Sz. Sh.Consis-tence hrday Boots cPD/itz
Bed lTrsdl
," yl-r/,-a...././?.--,/
!)t,tt4t'<-/t :>i.t/^.c ?^<.I
?Y..ut ,//,,/.2-.1
/?-L1al
Boring #
M</ffiffisdffi
Ground
elet/.
///ZtL
Depfr b
limitirE
lacbr>343
Remarks:
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3
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1
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,rol.J",./.a x
Boring #/
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,rr1L/4
Romarks
ffi*ffiffi.-' $sW
Ground
elev.
/4LLtt.
Deph b
limiting
fachr>.t?l
Boring #
Grcund
elE/._ ft.
Deph h
limiting
lachr
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s T c 105
SEPTIC TANK MAINTENANCE AGREEHENTSt. Croix County
owNER/BUY
ADDRESS
crTY/STAT
)IRE NU|TBER ,1'?77
P2I
PROPERT
TOWN OP
Y LOCATroNz//tLt/4,,t- L/4,
,//
sEcrroH2t_, t-ulN-niz_w
,, Se. Crolx County , '
CroLx Co. Zoning of f J-cer withinonda
, LoT NUt{BER_lz_.
Improper use and maintenance of your septic system couldresult in its premature failure to handle wastei. propermaintenance consists of pumping out the septic tank every threeyears or sooneT , i f needed by a licensed sept,ic tank p.r*p"t'. Whatyou puE into the system can af f ect the f unction of the slpt,ic tankas a treatment stage in the waste disposal system. iSt. Croix County residents nay be eligiUfe to receive a grantfor a maximum of 6ot of the cost of replacement of a failingsyst'em, which was in. operation prior to .fuf y I , 19Zg . St. Croixcounly accepted this program in August of 1980, with therequirement that owners of all new syitems agree to keep theirsyFtem properly maintained.
. . Tf. pfopqrty owner agrees to submit, to st,. croix zoning acert'i f ication 'f orm, s igned - by the owner and by a mater plumber ,journeyman plumber, .restricted plutnber or a Iicensed' pumperverifying Lhat ( 1 ). the on-site wastewater disposal system - is- inproper operating condition and (2) after inspection and'pumping (ifnecessarY ) , the septic tank is less than i/l f uII of sf riAge andscum.
T /lte, the unders igned have read the above requirements andagree to maintain the p rivate sewage disposal system in accordancewith the standards set forth herein, as set by the Wisconsin DNR.Certification stating that,your septic has been maintained must becomp 1e t,ed a nd re turned, to
SUBDIVI S ION
30 days of the three year the St.expJ-rati
SIGNED:
DATE:
St. Croix co. Zoning Office911 4th St.
Hudson, tll 54016
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LANDS
U RVEY MAP
PAGE IBB
24
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'This apprication forn is to b.e .completecl in fulI and signed byith" owner ( s ) of the property
^
b:ing 'J*"loped . Any inadequacies
1111 - only result ln aqtny* 'ot, ilin'pennlt i**u.n.n . , should thlsdevelopment be intended for resare by gwn er /contractor, ( specItouse ) , then r a second f orm shor.rra rr" f6tained lna completed whenthe propqrty-' is sold and submitted to this office with theappropriate deed recording.
)Owner of property
Loca tion of ' pro perEyrlLLl/ 4 ,il t / 4 ,s ecti on.:Zi-, T_?_N-Wt_w
Town sh i p
Mailing address
Address of site
subdivision nam t no.
other hones on property? ves d No
PrevlouE owner of property
Total s ize of parcel
Date parce I .was ereated
Are arr corners and rot rlnes identlflabre?Yes
-No
rs this property pelng deveroped f or ( spec house ) ?_yes ./ No
:;,32"#andPageNumber{S;Sz!SJasrecordedw1ththeRegister
)
<).2'2 +
INCLUDE WITI{ THTS APPLICATION THE FOLLOWING:A WARRANTY DEED which incrudes a Doc[mENT NITHBER, voLUHE AND pAGEHUHBEIT & TIIE strAL oF TI{E REGISTBR oF DBEDS. ,ID addition, acertified survey, if availabre, would be herpfur so as to avoidderays of the revi.1ll"q process. rf th; deed descriptionreferences to a certifted 3urv"y Map, the certifled survey }lapshaIl also be required.
PROPERTY OWNtrR CERTIFICATION
e ) cert,if y that aI I statement,s o n thls form are true to thet of my ( our ) knowled ge that I (we ) am ( are ) the owner ( s ) ofpropert,y dbscrl"bed t n t,hls lnfo rmatlon form, by vj.rtue of aranty deed recorded the ottr ce of the County Register ofds as Document No., and that I ( we ) presentlythe proposed site for the sewage dlsposal s ystem or I ( we )dined an easement I to run the above describ ed property, forconstruction o f sald system, and the Eiame has been dul Yorded ln the of flce of County RegLster of deede as Docurnen
nat of applLcant Co-appI icant
r(w
besthe
war
Dee
ownobttherec
No.
Date of Slgnature Dat e of Signature
e
q/^1r.
7
a
j
I
I
t Ioi 100?"., 55
OOCUMENT NO.STATE BAR OF WISCONSIN FOR}.I 1I - 1E]2. .LAND CONTRACThdlvldoel rnd CorgorrtoBE USED FOB ALL TBI'}TTIACT'CN8 WEERE O1/E}3OOO Ig FINANCED AND IN OlrEER' NOX.CONSI'UABAgI TRANSACTIONS)
Contract, by rnd bctweo ----Tro P. Hurd
('Vendorr,
vhether ono or more) rnd Kur t inkle
Vcudor eellr aad I,gloc. to couvey to hrchaser, ulpn the prompt aad full per-
fotaence qf ihl coutrrct by hrchaaer, the following progcrty, togrtbc vlth thc
routq prof,tq 0rturc end other egporteornt lutsr€lt! (dl c.lled thc'hoperf),h------------gt-'---Cf-Oi:S- --- County, Strtr ol Wbcoarln:
(,.hrcha^eef, rhdlrcr ono ot norc).
",
t
Tar Parcel No.
t.
Tti. .---l-g -.n-o--t- homestaad property. . '' (ir) (ir not)
hrchaser sgle* to purcha.sc the Property ead to Dst to Vcndor st P-LA9--e---Y.gn-d-g-f----C-lf--g-g-!-g!!--.-------,
tbr mu of l---------4-4r-5-0-Q-'-A-Q---------- -- in thc foUowing nanner: (c) f---.4r-50-Q-.-Q0-
of the caecution of this Contract; aad (b) the bslanc€ of l-----4Or-O0O-^O-O---.--------, together with intcrest from date
hereof oa the balancs outstanding lrom tume to time at the rate ot--.----B*--aftgf--f-1f-qt-- fC:oE3 per annum
uutil peid ttr full, u followr: , 6 paynenta
Comnenclng May 9,1993 and on the nlnth day of each and every Bonth
thereafterr egual nonthly lnstallmente of $335.0O1 the first slx
lnstallmenta shal1 be prlnclpal palrments only; beglnnlng ulth the
seventh lnstallment, aald paynents sha11 be prlnclpal and lntereat
computed at 8S per annun untll thls Contract lE paid ln full.
kovided, horever, tho entire outrtending balance rh.ll bc peid ia full on or beforc the----nlnth---------- dty of
----AprLl- -e-----, 19---96- ( thc mahrity drte). ',
Fo[owing any default ia peymenf lntcrct shall eccrue at tlre rate ol.---l0---* Der snnun on trhc entire amount
itr dc(rdt (wbich ebdl iuclude, without limitrtion, delinquent interest eod, r1p66 scceleretion or maturity, the entirepriacigalbdancc)._.- .-. : . .:t ' - :
petad aanurl tlrea, rpecld asrecrureatq firc ud rcqulrod inrurenco premiumr whcn duc. To tle extent received by Vendor'
Yador l3re- to rpply pr5nueutr to thc.. obli3ationr rhcn dus. Such emouatr reccived by the Vendor for plyment of
terc+'uscarmeutr end lnsurEnce rill bc dcpoeited into ea elcrot fuad or trurtee rccounf but ahdl not biar interest
ualcer otl€crlse rcqulred by l,rw-
Pegucote &rll b. rpplied iret to iata€lt on thc unpaid brtanee at thc rrte epeciied and tho to principal. Any
euount mey be prcprld without premium or fc upon priucipel et a.ny tlme {GEl)
Ia thc cisat of aoy prcp8)'mcnq thit eontract ftall not be treated as in ddault with respect to pryment so long
ar tho onpeid balencc of princlpal, eud intereat (aud iu such cgro accruing interest from month to month rhall bc heated
re unprid priucipal) ir leer tban the amount that said indebtedness would hsve beeu had thc monthly pa5rmeate been
made ar fint rpeciied gbovc; grovidcd that monthly paymcntr rhdl be continued in the event ol credit of any prtceeds
of inrunncc or eondcmnation, tle condcmned preniret bGins thereefter ercluded herefrom.
hrcbeser ctsha that hrrcharer te satieied with thc title ar showu by the title svidenca rubmittcd to Purchase:
lor ra-'in^atior ccc;lt:
' hrchue rgrc6 to prt tfic cort ol futnre titlc cvldcucc. If titlc cvidcncc ir ln thc fora ol an abrtract, tt shall
bc rctrincd by Ycador until the lull purchese prtcc ir pdd-
hrchuet rhrll bccatittdto trlc poescssion ol tbe Property on-------ciay---of,--closJ.og------.--------., r0--------.tCru Ont Olc
IAltD COII?BAGI- tndHCurl udCorponrr TATE BAX O? WISCONSINIOB{ liq tl - ItCt-,Wlxonsio Lcrrl Btant Co. Inc.ILlrrukcc. Wir
txrt ar^ca irsrtYlD 701 tfcoRolxo oAtA
NEGISIER'S OF.FICE
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