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HomeMy WebLinkAbout040-1199-40-000 (2)STC - 10 4 AS BUILT SANITARY SYSTEM REPORT OWNER r ADDRESS 7 SUBDIVISION CSMf LOT SECTION —T N-R- -W Town of ST. CROIX COUNTY, WISCONSIN Provide setback and elevation information on -reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. 13ENCHMARK* D �� QSaSC��I,t ALTERNATE BM: 00 0 2K/s�-Tck T I C T A_N PUMP CHAMBER HOLDING -TANK INFbRMATION Manufacturer: LAj Liquid Capacity: iOjO �.��,j„ Setback from: Well A)a",P— House Other Pump: n ac u er_ Float tser4iiun Alarm Location Model V size- Gallons/cycle: -.,SOIL ABSORPTION SYSTEM Width: L5 Length ? Number of trenches Distance & Direction to nearest prop. line: 6 j- Setback from: well: House Other ELEVATTONS Building Sewe ST Inlet, (!>Z') ST outlet PC ini- h -PC bottom Pump Off Header/Mani fold (14ey Bottom of syste��Q`� Existing Grade ('19 Final grade(/j84() DATE OF INSTALLATION: 1/2.19 /Q 3 PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/93 :jt L "lloUp "rtT rM IQSVY2Q w 17 * 71.1 VAN]@ SEWAG4 Labor and Human Relations INSPECTION RE Safety and Buildings Division (ATTACH TO PE GENERAL INFORMATION Permit Holder's Name: ` ❑ City ❑ Villz 1 lnsp. BM EIev.. BM Description.&"' J, TANK INFORMATION TYPE RER MANUFACTURER CAPACITY STATION BS H1 FS ELEV. Septic Benchmark ' Dosi ng Aeration Bldg. Sewer St 1 H Inlet Holding TANK SETBACK INFORMATION St 1 Outlet TANK TO P 1 L WELL BLDG. Went to Air intake ROAD Dt Inlet Septic N A Dt Bottom Dosing NA Header tf%iaR� �, .(Z Aeration IAA Dist. Pipe p , Holding Bat. System PUMP/ SIPHON INFORMATION Final Grade M a n u fac-t)a ref- -4 Demand C r .. Model Number GPM TDH Lift Friction System Ft L e. Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED 1 TRENCH Width. Len th ' No. of Trenches PST No. Of Pits inside Dia. Liquid Depth DIMEN I N _ `� ,�". DIMENSION5�_._.. LEACHING Manufadurer: SETBACK SYSTEM TO P L BLDG WELL LAKE 1 STREAM CHAMBER Model'NUr;ber: INFORMATION Type .�. yp System: OR UNIT DISTRIBUTION SYSTEM x Hole Size x Hole Spacing Vent To Air intake Mani old Header / Ma / Distribution Pipe(s) , ws / Length % Dia. Length F Dia. Spacing SOIL COVER x Pressure Systems y Onl xx Mound Or At -Grade Systems Only Depth Over p Depth Over �� �''` � / Trench Edges �* '"" xx Depth Of Topsoil xx Seeded iSodded ❑Yes ❑ No xx Mulched ❑ Yes El No /Trench Center .Sod COMMENTS: (Include code discrepancies, persons present, etc.) -LOCATION: TROY 2 .28a19-911,SE! NE, LOT 4,SYKORA LANE Ria T 'r f yl_ 17 it /' r' _ � �,, • ..`-Y �/d ` f, � - Yet � t�-1n ,6,..� "" r. Plan revision required? Yes Qo�o Use other side for additional information. SBD-6710 (R 05191) Date Z�, Inspector's Signa ure Cert. No. 100 � Lu, — QILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, 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 INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION pe'i� ko rc;t SE Y4 tJa Y49 S Zt PROMRTY OWNER'S MA ADDRESS LOT # J3*ey,- vie..d �!. C)TY, STATE ZIP CODE PHONE NUMBER LA); (47 46*& 11. TYPE OF BUILDING: (Check one) State Owned E]Public X 1 or2Fam. Dwelling4of bedrooms COUNTY " ?ell, j STATE SANITARY PERMIT ❑ C/eck f revision to pr ious application STATE PLAN I.D. NUMBER TZ8 , N, R BLOCK fi SUBDIVISION NAME OR CSM NUMBER -S �O�d�+J i �� � ITY VILLAGE TOWN OF: NEAREST ROAD 3 U44,0,, E (o 111111. BUILDING USE: (if building type is public, check all that apply) 1 ❑ Apt/Condo 2 Assembly Hall 6 Medical Facility/Nursing Home 10 ❑Outdoor Recreational Facility 30 Campground 7 ❑ Merchandise: Sales/Repairs 11 1-1 Restaurant/Bar/Dining 40 Church/School 8 El Mobile Home Park 12 1:1 Service Station/Car Wash 5 1:1 Hotel/Motel 90 Office/Facto ry 13 ❑Other. Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. [f.,A' New 2. 0 Replacement 3. EJ Replacement of System System Tank Only aB) El A Sanitary Permit was previously issued. Permit# _, - V. TYPE OF SYSTEM: (Check only one) Non -Pressurized Distribution Pressurized Distribution 11 ❑ Seepage Bed 21 FlMound 12 '['&"*_lj Seepage Trench 22 0 In -Ground 13 Seepage Pit Pressure 14 ❑ System -In -Fill 4. ❑Reconnection of Existing System Date Issued Experimental 30 ❑Specify Type 5. 1:1 Repair of an Existing System Other 41 ❑Holding Tank 420 Pit Privy 43 ❑Vault Privy V1. 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 OiYC570 REQUIRED (sq. ft.) C?Y5 PROPOSED (sq. ft.) 1?y (Gals/day/sq. ft.) (Min./inch) ELEVATION 6om 1 A, xod V11. TANK CAPACITY INFORMATION in gallons New xisting Total Gallons # of Tanks Manufacturer's Name Prefab Concrete Site Con- Steel Fiber- glass Plastic Exper. App. Tanks Tanks strutted Se tic Tank or Holding Tank LJ El 0 0 11 Lift Purne Tank/Siphon Chamber, 7 1 Ljmmmnmi�110. El Lj Ll El V111. RESPONSIBILITY STATEMENT 1, 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) mpaPRSVv Business Phone Number: F_ 2, -7157 )5-6�� - q Plumber's Address (Stre ity, State, Zip Code)( J�kj I qw- `7 N IX COUNTY/DEPARTMENT USE ONLY E] Approved [:] Disapproved ] Owner Given Initial Sanitary Permit Fee (includes Groundwater Surcharge Fee) Date I ue Issuing Agent ' atur Adverse Determination X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11188) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. t 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. fi. if you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings- Division, 608-266-3815. A 8 To be complete and accurate this sanitary;permit application must include: t 1. Property r e owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. YP II. Type of building being served. Check only one and complete ## of bedrooms if 1 or 2 Family Dwelling. Ill. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1-7. Vll. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. Vlll. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use only. X. County/Department Use only. Complete plans and specifications not smaller than 8'/ x 11 inches must be submitted to the county. The - plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells, water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if , - --� required by the county; E) soi•l- t*st data on a 115. form; and F) all size information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11 /88) „2 , ?6 -2 ,'S s ��(� �r�s p POl - 9c:4 S -NO va-N HS Ql .00 11 tye -lp � � a���5 SSG1.11� 4i'b/c:�2/L z i z�'. �S�II� o -" 9 -Vnr/(/ End Cop) �i, r Last Hole Should Be , Next To End Cap End Cap Per ipe Detail Distribute ipe Layout 1 � � r Page 0 r s End View Holes Locatod on Bot tom$ �S Are Equally Spaced R mep Mnin A ...` _ Alternate Pb5ition Of Force Main j P Ft, R S Hole Diameter Inch S i gned : fs Lateral Inches) License Number: Manifold Inches Date: Force Main Inches # of hol es) pi p�-�--_ w Invert Elevation of Laterals Ft DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY &BUILDINGS INDUSTRY, DIVISION LABOR HUMAN RELATIONS PERCOLATION TESTS (115) MADISON WI 53707 I LH R 83.090) & Chapter 145) _OCATION: SECTION: WNSHIP UNICIPALITY: LOT NO.:BLK. NO,: SUBDIVISION NAME: 5E 1/4 NE V z8 /TZ8H/R 19 E (o) iF, --� CA&4 c dw dillS -OUNTY: MAIL G ADDRESS: Grolx Pte' stj�Kof%q' a ' er5 `i e-A 7 �-, e. -d J6r p4mSit-J),`,5�m' ISF1t A Trf/1F1r.r A• • w Tf\w./1 ■■ w 1\r &# L % voa�nvra i �vema Jv1r-%vF_ NO. BEDRMS.: COMMERCIAL DESCRIPTION: n t 1 PROFILE DESCRIPTIONS: PERCOLATION TESTS: Residence 1 /A K� New Replace ~7 2-1 / 9 S 7/Z4 193 RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN -GROUND -PRESSURE: SYSTEM -IN -FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) . S EIU US EA XSEU 1E1Sr-=U EIS[ZU -�rth If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: /V/A Floodplain, indicate Fioodplain elevation: 1V/A PROFILE DESCRIPTIONS BORING NUMBER TOTAL DEPTH IN, ELEVATIGN DEPTH TO GROUNDWATER OBSERVED -INCHES EST. HIGHEST CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 3 9� D T` 3 S c.l 3 Z rI- G Z. " {�' I Z � =- L7' SN / �/ I r/y� r/ yr` ^� E/". ij & � �r f so 1 �, i/� t�`r_..._3i� 2.d �'— ij 3� N fir/ 99 1Qrr B- ts�' t7 �G 'r`�� / g r� S l� •'� (v `r �. rs � Y' a rs PERCOLATION TESTS TEST NUMBER DEPTH INCHES WATER IN HOLE AFTER SWELLING TEST TIME INTERVAL -MIN. DROP IN WATER LEVEL -INCHES RATE MINUTES PER INCH PERIOD 1 PERIOD 2 PERIODPERIODY P- / —J.% n O H Q' _.-N U 4� G P- 2 20 r,0 i P- P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATIC) �$k'kre' 9c,0 �- ,c�»i841a r ti E G 97. i'_t� s'e ay. a� d Vic. !`G► O' T� L� I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): TESTS WERE COMPLETED ON: ADDRESS: _ CERTIFICATION NUMBER: PHONE NUMBER (optional): K-41"Z 6a `% io a LDS' � 4 -1 Z r71 5 "` CST SIGNATURE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) — OVER — S T C — 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER: BUYER -� %�-r- -S L)*�a ADDRESS- q\ FIRE NUMBER CITY/STATE �0-ctev­ Tcv� S L.�! Z I P 0 'Z'Z— I If PROPERTY LOCATION: -SE.— 1/4 , NIC 1/4 , SECTION Oce?> T Z<8 N—R _W TOWN OF_:-�&q St. Croix County, SUBDIVISION L LOT NUMBER 40 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 septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 600 of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a water plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and ( 2 ) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and SCUM. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St, Croix Coo Zoning officer within 30 days of the three year expiration dat'e. SIGNED. V' DATE: St. Croix co. Zoning Office 911 4th St. Hudson, WI 54016 S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor,(spec house), then a second form should be retained and completed when the property' is sold and submitted to this office with the appropriate deed recordirt(�. ---------------------- --�77---------------------------------------- - Owner of property Location of property ,7>E. 1/4 1/4, Section , T 26.N-R W Township Mailing address N W-Z JAM eAP Faj"t'r- , LA,)_'._ 15 Y-6 r 4 Address of site Subdivision name Lot no. Other homes on property? yes X No Previous owner of property Eovlr C Q-Ap Total size of parcel -2 -a -4?, CO�C' Date parcel was created A/ILL� 2-- A --" / 0/ 7'� Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes No Volume -SI/ - and Page Number as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLU14E AND PAGE NUMBER & THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I(we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the office of the County Register of Deeds as Document No._:3*2ZjnS-() . and that I (we) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system., and th-.-.--, same has been duly recorded he office of County Register of deeds as Document No. Date of Signature Co -applicant Date of Signature f DOCUMENT NO. ,.2VO0 THIS DEED, made between earl Ce_rnohous Bernard Cernohous , Rosella Cernoh©us Hendrickson Mar aret Certxvhous AhrensLilliam Cernohous Blake __ and S kora Lar:�d Com Grantor - ---y - P �F, Inc . , a Wis consin Co ration — Grantee, Wit n e s a e t h , That the said Grantor for a valuable cons ideratiorl~"�" iE:llt►g■- One Thousand and N_ 1006.. --- 1, 000._00 ----Dollars conveys to Grantee the following described real estate in_ 5' County, State of Wisconsin: The Southeast Quarter of the Northeast Quarter (SEJW.�) of Section 28, Township 28 North, Range Nineteen West, 1 STATE BAR OF WISCONSIN-FORM 1 WARRANTY DEED 7HIS SPACE RESERVED FOR RECORDING DATA REGISTERS OFFICE 5T. CROIX Co., WIS. Rec'd for Record this_ _ 2$th day Of}(_("_Ay------- A.D.197L at_,•s_ts3—Q-__ As, Me _ RegtstW of Dee s RETURN TO Tax Key a This is not homestead property. TRANSFER $IL - FEE Together with all and singular the hereditaments and appurtenances thereunto belonging or in any wise appertaining; And said five grantors and each of them warrantor that the title is good, indefeasible in fee simple and free and clear of encumbrances except -of cord and will warrant and defend the some. Executed at _. bV@r F SCQM- _ th•s 2nd day of Ma 19 7�} t. Paul, Minnesota► _ ,�sL->.Ste} SIGNED AND SEALED IN PRESENCE OF �O Ro erAa O en C 4n �� (SEAL) - „ Bernard Cerriohous Lillian Cernohous Blake jSL) ,� t Cernohous Ahrens Signatures of Earl Cernohous, and Rosella Cernohous Hendrickson auther}tieiifed' day of _ May 19 r '• �� Title: Minnesota Other Party Authorized under Sec. 706.06 STATE OF viz. Notary Public , State of Wisconsin -- __ --County. S. My commission expires: 6/6/76 Personally came before me, this _i3th day of May 19 7% the above named Ber and Cerri©bausz�Lillian �vernohous Blake, and �argare�- Cerna�ious �.�s ' to me\knpwn to be the person S who executed the foregoing instrument and acknowledged the same. �+'• � it ,Thk itrumpnt was drafted by Earl H. Plante •��R�,l E�_Senn MN Notary Public— amsey County, Is• --. H;Lve Fa11s , wis c onsin The'Use of witnesses is optional. l H. PI.AtiTE Ir My Commission (ExpiresW) NrrtclC� Nl�r 1.. , Names of persons signing in any capacity shauld he typed or printed below their t es. - --__._ -__.�_ ,_ --� BOOK UQUIl p�l` _ H.G..... W... p ny M IA WARRANTY DEED -STATE BAR OF WISCONSIN, FORM NO. 1 -- 1971 """" "'"`°"""