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HomeMy WebLinkAbout032-1007-20-000FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER 4- C-7 TOWNSHIP 4- SECTION ADDRESS Y,� ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM INDICATE NORTH ARROW BENCHMARK : Elevation and description: 7 Alternate benchmark- .0 f- Fo L-e A d 0" ZZ <' SEPTIC TANK: Manuf acturer: L-jj j ' e _5- c - V- Liquid cap. 7 E b Rings used:_Q Manhole cover elev: Final grade elev: Tank inlet elev.: Tank outlet elev.: No. of feet from nearest road :Front Side. Rear Ft. From nearest prop. line:Front Side_, Rear Ft. No. of feet from: Well A)A Building: /,.z (Include this information in the above plot plan) (2 reference dimensions t© septic tank) SEE REVERSE SIDE PUMP CiiAMBffi2 Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufact.: Pump Size Elevation of inlet: Bottom of tank elevation Pump on elev.: Pump off elev.:,Gallons/cycle: Alarm: Man.: Switch Type: Location Distance from nearest prop. line: Front , Side_, Rear Ft. Distance from: Well Building SOIL ABSORPTION SYSTEM Bed: V"'� Trench: Seepage Pit: Width: Length S Number of Lines: -Area Built Exist. Grade Elev. Proposed Final Grade Elev. Fill depth to top of pipe: No. feet from nearest prop. line:Front J. Side, Rear Ft. No. fcct from well: Aj No. feet from building 3 HOLDING TANK Manufacturer: Capacity: No. of rings used* Elevation of bottom tank: Elevation of inlet: No. feet from nearest prop. line:Front_, Side-1 Rear Ft. No. feet from: Well , building , nearest road Alarm Manufacturer: INSPECTOR: DATE:/ PLUMBER ON JOB: LICENSE NUMBER: 6/90:cj 13ILH 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 th 8% x 11 inches in size. an -See reverse side for instructions for completing this application. I. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER K6� � -/?I- PROPERTY LOCATION P(rP:RT1Yj.OWNER'S MAILING ADDRESS Or Y4 .5 CAJ14 S /to!5I LOT IP 0ex .5 ACITY, STAT&i CO Z1.0.1 ZIP CO E PHONE NUMBER L v4v) C, TYPE OF BUILDING: -L.Check one) State Owned E]Public Poll or 2 Fam. Dwelling-# of bedrooms 000=000� III. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo COUNTY STATE SANITARY PERMIT q 96J,0_7 ❑ Check if revision to previous application STATE PLAN I.D. NUMBER T?/ 9 N, R E (o LOCK # SUBDIVISION NAME OR CSM NUMBER C NEAREST ROAD E )F: '51AA7&esa 7 2J osz— iao�—�� 2 _j Assembly Hall 3 ❑Campground 60 Medical Facility/Nursing Home 7 ❑Merchandise: 4 ❑Church/School 5 ❑Hotel/Motel Sales/Repairs 8 ❑Mobile Home Park 9 ❑Office/Factory IV. TYPE 0 ERMIT: (Check only one in line A. Check line B if applicable) A) 1. TYPE w2. ❑F-1 Replacement 3. ❑ El Replacement of System System Tank Only B) ❑ A Sanitary Permit was previously issued. Permit# V. TYPE OF SYSTEM: (Check only one) Non-Pres ized Distribution 11 ZSeepage Bed 12 0 Seepage Trench 130 Seepage Pit 14 0 System -In -Fill Pressurized Distribution 21 EJ Mound 22 0 In -Ground Pressure VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA REQUIRED (sq. ft.) PROPOSED (sq. ft., It-110 VII. TANK CAPACITY INFORMATION in galIons Total # of New JExistin Gallons Tanks Tanks I Tanks1 10 El Outdoor Recreational Facility 11 El Restaurant/Bar/Dining 12 F] Service Station/Car Wash 130 Other: Specify - 4.E1 Reconnection of Existing System Date Issued Experimental 30 ❑Specify Type 4. LOADING RATE (Gals/day/sq. ft.) 19, -7 Jt-- Manufacturer's Name 5.PERC.RATE (Min./inch) 3 5.0 Repair of an Existing System Other 41 0 Holding Tank 42 El Pit Privy 43 El Vault Privy 6. SYSTEM ELEV. 7. FINAL GRADE ELEVATION �! �7� I Feet a-Z5.Z) Feet ._ / -D Prefab. Site Con- Steel Fiber- Exper. ','oncrete structed glass Plastic App. I Septic Tank or Holding Tank 75b Z/ 1 4 _P1 Lift Pump Tank/Siphon Chamberl Vill. 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 $Ig ture MP/MPRSW NO.: Business Phone Number: /b Plumber's Address (Street, City, State, Zip Code): 7 J 3 4 c% A-F ry _J T COUNTY/DEPARTMENT USE ONLY wm� [--I Disapproved I Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature No Stamps) Approved ED Owner Given initial Surcharge Fee) Adverse Determination rr / # X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: 777 SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber 0 DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR LABOR & HUMAN RELATIONS P.0- BOX 79,69 ON -SITE SEWAGE SYSTEMS MADISON, WI 53707 STD -VIST0411-sec. 10 9 T31 - R1 9 040 Town CONVENTIONAL Of Sometset r-� 7 ALTF DOSING CHAMBER: I IN k SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing or excavation. (If soil can be rolled into a wire, construction shall cease until the soil Is dry enough to continue.) CONVENTIONAL SYSTEM: COMM TS: j- C�w Jtr'*' — X y cj-:�; ,P C)rr 4eC,,4t�� J tvice��v-ie ic-c(o_.tz tom,-eel--�,,�joec�_ 0 Sketch System on Reverse Side. SBD-6710 (R. 06/88) SAFETY & BUILDING DIVISION OFFICE OF DIVISION CODES & APPLICATION AMICATIOH FOR 8AIIITXRY PERMIT g T C w 100 T h I s application form In to ba ComploLad in full and tlgnad by the ovntl;(a) of kht property being developed, luny 111�doquacIEI u111 only result In dtlays of tI�R pzrnI t taauUnce, • Should th15 davelopment be intended for rtzalt by owner/contractot,IxpQc h o u a i I I than a sacond Lorin should be rataIn:d and ca■platid when t118 prOpartY 111 sold and submltte-d to this offIce with t h a appropriate deed recordlny, w r w - r w r w w..r r w -- r r ww w w w,w w.! wwrM wr r r.syr iwrrrlrwr wrr+r r.0 .+w r'�rY w �.:r w �+Yr rr.. r.� � �r•�i-w# �i-y 0xn7r of property Location a prape tky 1IV �114 .5Z' lf�, 8•ctlon R � V hIp Ha13lnq address ':':;'�' r Lill address of .lt. � 7" Iutd IYls Ion no" r Lot hualbe t: Ptevlous otimer a( proprrLy Total slsa of parcel F_5 , Date parcel was created —A/C ,/ Are All C01nits and lot l.ln!■ ldentlfl•bl•? Ye• � o In this pcapetty being developed for renal; s e © �` i p c house)? , ,..�Yts X Ko Yalnr.a end Page Humber -"I as recorded With the A471st•r of Deeds. - r e - r w r w r w� r r r w w w w w r wrw w r y r M r r. w r w r r r. tls r r .w w w w .. r i rr A w e- •... w r er w r a w r r w r �1 r r1 w r a i .� - - w w w r w I11CLUD9 WITH T>•Ild ,APPLICATION TIIQ PDLLOWIHCl A VKAP"Tr DZID which Includes a DOCUHxHT HLrHnVR, t h t 6IKL OT Till R90I8THR OF DRRDS. In ndc] 1 t!on YOLUNZ AND PAC[ RLNjrR, and •vetlable, would be helptul ao as to avoid delays 0t to c a r t I I I v d survey. IC the deed deacrlptlon tetearencas to a Cs>rtltled gurYe he reviewing process. tC Nsp shall also be tequlred, Y Map► the Cettltlad futvoy r r w • r ... w .. w r w - w .+ r "-w--w w - w ewe.---- r v:. y w .� •.II w w a e+ w ew w w - r w r w w w rt PROPIRTY 01�'?IER CKRTIPICAT10H ;....iw----.-w-__-__-_--- iIV•? rorkity that all skatementa on this [azrn are knovl�elge! khat I (") am (are} the owner(• of true to the best of �.y (our ) �hla !n(ntrr.atltin torm b r } the property deactlbtd In lhw Counk � Y V•zkue oC a �•�z�ar-sty dyed recorded in the oillc�r at Y Rtglaker ©E Dee�ls as Document Ha, S",/ Prieantly own Ole proposed elta fur tho newage did oaa and that I Ival obta Ined an easement, . to run with ti}ie above dP 1 nyal;em (or I {ere) hara conettuctilan at sold nybtem, end khe frame hoer a d0aun d llbed property,, for t.ha of the eoVnty Aagtater of Deeds, as Document No. recorded In the orri s • rlgnaat Own_'sc 8lgnatut� of Co-©vner it A 1 PP1tcab1al Date at dlgnaLuz a Data of Signature SEPTIC TANK MAINTENANCE AGREEIIENT St. Croix County Z OWNER/ BUYER -. 1 Fire Numbe, /,J6 7- 11-551CIYE 21 7- ROUTE/BOX NUMBER 5_ ZIP`' C . CITY/IqTATE f7 Section N T_ 5 PROPERTY LOCATION: 2"' 4St. Croix Countyt 4- -' - * ------- Town of, Lot number Subdivision Improper use and maintenance of your septic system could result in .V its premature failure to handle wastese. Prover maintenance con- sists of pumping out the. . septic tank every three years or sooner, 'ept'ic tank tic er. What you put into if needed, by a licens-ed s the system can alTe-c-t the function of the -aeptic tank as a treat ment-stage in the waste disposal system. St. Croix County resim��Z dents ­ be eligible to recieve a grant for a maximum of 60% of the cost .of replacement of a failing eystern , in 0 oration prior to- July 1, 1978. St. Croix County wh'i-ch was pe in August of 1980, with the requirement that accepted this program owners of all new 'Sys't'ems agree to keep their system properly maintained. The property Owner agrees to. submit to St. Croix County Zoning a I certificat'on for-m, signed by the owner and by a. ma ter plumber, journeyman plumber, restricted plumber or. -a licensed pumper veri- fying that (�.� the on -site wastewater disposal system is in proper I operat-ing condition and .(2)-after inspection and pumping (if nec- essary) , I. -he septic .tan is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. I/1-TE, 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 Depart - me -lit of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning office within 30 days of the three year expiration -date. SIGNED 1,�51xe DATE 4'0� St. Croix County Zoning office 911 4th St. iludson, WI 54016 386-4680 Sign, date and return to the above address& �J 0 -d CERTIFIED SURVEY MAP Located in part of the SW4 of the SE4 and in part of the SEA- of the SW4, all in Section 3, T31N, R19W, Town of Somerset, St. Croix County, Wisconsin. I/ OWNER 11 a r o I d r E, ZW. 56-8-2-32ird at-r"+- NE, 5+e -7 61[ 5 NJ Corner of Section 3 C_; N -mr1,111 Iron Pipe Found /FIC-111�ljl,54 41 CV0 a) = 1 -1 V) 00 Lot I U-) W 0 C3 Lot 2 L) WCD C v_4 --------- C: cu 0 C e r t i f i e d Sur v ey Map jCertified Survey Map -4 - - - - - - - - - - - - - - - - - - CD volume 8, Page 2155 (U --t I- ------ -- ---- ---- Volume 8 Page 2156 A-- N8901310111E 634.831 S0102011011W Q V) a 601.811 Ln 33.021- 4-J V) (U 0 co 4- 33 33 3 • as rc) r_ — LC 01 0 (N - Ln 4 LUL LOT 3 cyl C� -It Area Including R/W- CD 4-J 397,777 Sq. Ft. 9.13 Acres- C3 0 C:) Area Excluding R/W: Of CD a CL� 373,844 Sq. Ft. 8.58 Acres *40"KE D 398.831 E 6 S890 16 1 44"WIf 636.541 S� Corner of South line of the SW� Section 3 + of Section 3 1 tj Aluminum Cap in Concrete ipo" Found 0 \ �Temporary cul-de-sac to be removed upon Unplatted La6ds extension of roadway. SCALE, I FEE 0 100 200 300 N Y H P, G% HUD%, Found Section Corner I" Iron Pipe Found © 1" x 2411 Iron Pipe Set, weighing 1.68 lbs. per linear foot. t P .DF-PANTMENT OF SAFETY & BUILDINGS INDUSfR"�, REPORT ON SOIL BORINGS AND DIVISION LABOR AND P.O. BOX 7969 HUMAN RELATIONS PERCOLATION TESTS (115) MADISONWI 53707 (H63.090) & Chapter 145.045) , LOCATION: SECTION: 1/4 T 0 W l�qS H I Pj6b6d066tkV: iLOT NO.: BLK_ 0,: SUBDIVISION NAME: 1/fw -SE 10 /T31 N/R 19fx.,r) W Somerset n/a n/a n/a = COUNTY: y§ftV4k5ffq/BUYER'S NAME: MAILING ADDRESS: St. Croix Kurt Sroka IR.R.#3, Box 328, New Richmond, Wi. 54017 USE DATES OBSERVATIONS MADE �BEDRMS, PROFILEDESCRIPTIONS: PERCOLATION TESTS: !esi:dence 0. BEDRMS.: COMMERCIAL DESCRIPTION: baN e w Replace 3 n/a 10-12-89 10-12-89 RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: N GROUND -PRE RE: SYSTEM-1 N-FI ILL HOLDI NG TANK RECOMMENDED SYSTEM: (optional) S HS [_]U 0 Qu IXF?LIS QUT r17 S DU [AxLj U conventional If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5) (b), indicate: n/a Floodplain, indicate Floodplain elevation- n/a decimal' PROFILE DESCRIPTIONS page 2 OnC2 BORINGI TOTAL DEPTH TO GROUNDWATER -INCHES F-CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTI)MI, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 1 6.84 100-23 none >6.84 .67bl.1. 2.50bn.sil. .42bn.l.s. 3.25bn.cs. B- 2 6.75 100.34 none >6.75 067bl.1. 2.00bn.sil. .50bn.1.s. 3.58bn.c.s. 3 7.08 100-39 none B- >7.08 83bl.l. 2.33bn.isl. .42bn.l.s. 3.50bn.c.s. B- 4 1 7.29 100.14 none >7.29 1.00bl.1. 1.92bn.sil. 1.75bn.c.s. .42bn.l.s. B- 5 7.17 99.92 none >7.17 .50bl.1. 2.00bn.sil. .42bn.l.s. 4.25bn.c.s. decimal' PERCOLATION TESTS 777-r r-01 NUMBER ULF I H VVIA I tH I IN MULE AFTERSWELLING TEST TIME INTERVAL -MIN. DROP IN WATER LEVEL -INCHES RATE MINUTES PER INCH PERIOD 1 PER 101D 2 PERIOD 3 P_1 3.50-- none 3 6 P_ 2 - none 3 6 6 6 <3 P_J 3.69 none 3 6 6 6 <3 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 ELEVATION 96.73 c + �y _� 9, Aj 1, 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): Gary L. Steel ADDRESS: 988 N. Shore dr., New Richmond, Wi. 54017 TESTS WERE COMPLETED ON: 10-12-89 CERTIFICATION NUMBER: PHONE NUMBER (optional): 229814 71g-246-6200 CST S I G N AlLM E: y I DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02182) -- OVER — 01 4 1 /�o 0 �e r , 5� /u s w /� s i� �� � Ai/2 t 9 w S .4 _�T. N/Zcix k)j'/ TURTLE LADE PLUMBING & HEATING P.O. Box 93 Turtle Lake, Wl 54889 715.986-4138 Turtle Lake 54889 V/ I