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HomeMy WebLinkAbout180307 030-1048-10-130CORRECTED PARCEL INFO: 22.30.19.179A-30 030-1048-10-130 682 North Bay RD Town of St. Joseph STC AS BUILT SANITARY SYSTEM REPORT 2 . 30• l`'1• � OWNER ADDRESS,�0 �fttS'tAr�� lo� morn 'vs SUBDIVISION / CSM# Z.,k - ,Zorrl� G s In �S'roT 3 SECTION. a- T 3 d' N-R /7 W, Town of fie s gyp! ST. CROIX COUNTY, WISCONSIN Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: _7Aote ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING..TANK INFORMATION Manufacturer: ModalesLiquid Capacity: /110d Setback from: Well House. Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location :SOIL ABSORPTION SYSTEM Width: 5� Length ?9 Number of trenches Z Distance & Direction to nearest prop. line: west 36- Setback from: well: House SDI Other ELEVATIONS Building Sewer ST Inlet: ST outlet PC inlet PC bottom Pump Off Header/Manifold Bottom of system Existing Grade Final grade DATE OF INSTALLATION: /2� PLUMBER ON JOB: LICENSE NUMBER:3 INSPECTOR: 3/93:jt M�qATrY QK;tn,§76f I49,§FPH, 22 . 30 •PRIVA E SEWAGE3$�(STEM H BAY Labor and Human Relations INSPECTION REPORT Safety and Buildings Division GCNERAL INFORMATION (ATTACH TO PERMIT) Permit Holder's Name: ❑ City ❑ Village ❑Down of: ST. JOSEPH CST BM Elev.: A Insp. BM Elev.: BM Description: TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic Q/ r�!'CaSZ, Dosi �Q Aeration Holding. TANK SETBACK INFORMATION TANK TO P/ L WELL BLDG. Air Air Intake ROAD Septic A NA Dosing ---._NA Aeration Holding PUMP / SIPHON INFORMATION Manufa Demand Model Number GPM TDH Lift Friction Ft oss Forcemain Length ia. Dist. o ' 1 SOIL ABSORPV60N SYSTEM ©A SOD -1A.O RE .- County: ST- QROTX Sanitary Permit No.: f� 180307 State Plan ID No.: Parcel Tax No.: ELEVATION DATA A9200390 i0zl9-7 STATION BS HI FS ELEV. Benchmark Bldg. Sewer St/114Inlet St/ I e Outlet Dt Inlet Dt Bottom Headers .3/ Dist. Pipe Bot. System v' M BED /TRENCH width / Length , No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONSDIMENSIONS SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREAM LEACHING urer: INFORMATION CH Type Of r � I O Mode Number: System: 4 OR UNIT DISTRIBUTION SYSTEM Header / Mm ffl'd / Length / 2 Dia. Distribution Pipe() Length2L:5� Dia. le Size x Hole Spacing Vent To Air Intake Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems O7rI•� Depth Over 9'' — Depth Over „ 18ed/TrenchEdges 3� _ xx Depth Of ed / Sodded xx ed Bed /Trench Center 30 " cy Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: ST. JOSEPH,22.30. 9,NE,NE,LOT 3,;O�R,H BAY)�,' •`'���/i:%//J°'t.i ar.,�� ���/' f Plan revision required? ❑ Yes 01`4_0 / Use other side for additional information SBD-6710(R 05/91Date Inspector's Signature Cert No. SANITARY PERMIT APPLICATION COUNTY 5T OILHR In accord with ILHR 83.05, Wis. Adm. Code S I PE �� MEMOSTATE less than —Attach complete plans (to the county copy only) for the system, on paper not 8% x 11 inches in size. � c ec if rev sion to previous application —See reverse side for instructions for completing thi n. STATE PLAN I.D. NUMBER I. APPLICANT INFORMATION — PLEASE PRINT A ATION. PROPERTY OWNER PROPERTY LOCATION ? '/a C Y4, S .2 �2 T go, N, R / r! E (o� PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # � GL CITY, STATE ZIP CODE SUBDIVISION NAME OR CSM NUMBER yo/ C : NEAREST ROAD II. TYPE OF BUILDING: (Check one) ed Li CITY J�Li o ff�� ❑ Public [X 1 or 2 Fam. Dwellin o droc,ms-:?- PARCEL TAX NUMBEHISI 111. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 104 ❑ 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 only one in line A. Check line B if applicable) A) 1. New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) A Sanitary Permit was previously issued. Permit # 1(� 30 Date Issued V. TYPE OF SYSTEM: (Check only one) Non -Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ SpecifyType 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In -Ground 42 ❑ Pit Privy 13 Seepage Pit Pressure 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 ft.) (Min./inch) ELEVATION REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. I 2Feet f?' d YSD rA T '1r, Feet VII. TANK INFORMATION CAPACITY in allons Total Gallons # of Tanks Manufacturer's Name Prefab. oncret Site Con- Steel Fiber- glace Plastic Exper. App New istin Tanks Tanks structed Septic Tank or Holding Tank +E'11 El I L1 LI-1 El 1:1 Lift Pump Tank/Siphon Chamber . VIII. RESPONSIBILITY 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) 89MPRSW No.: Business Phone Number: :7' Jii 2. / S �� •/Z Plumber's Address (Street, City, State, Zip Code): IX. COUNTY/DEPARTMENT USE ONLY Approved ❑ Disapproved JE30wrier Given Initial SanitaryPermit Fee (In ludes Groundwater) �yrcharge Fee Date IssuedIssuing Agent Signature (No Stamps) Adverse Determination ��5j" X. CONDITIONS OF APPROVAL/REASON FOR DISAPPROVAL: SBD-6M (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, owner, rwmoef .vortk. 03,.E REPORT ON SOIL BOKINUb ANU DIVISION X 76 PERCOLATION TESTS (115) MADIS P.O. W 53707 TIONS (ILHR 83.090) & Chapter 145) 0 SECT! TOWNSHIP1NXX}@ xY LOT NO.:BLK. NO.: SUBDIVISION NAME: 3 N. Bay 1/4 NE 1/4 22 /T 30 N/R19jaor) W St. Joseph n/a • OUNTY: t. Croix OWNER' ME: MAI LINU A DRES Richard Stout R.R.#2, Box 340, Hudson, Wi. 54016 DATES OBSERVATIONS MADE USE NO.BMS EDR.: LPS: I N TESTS: COMMER IAL ESCRIPTION: R FI��y iaNew ❑Replace 11-1_90 n/a OReside.ce 3 n/a RATING: S- Site suitable for system CONVENTI NAL: MOUND: U- Site unsuitable for system IN -GROUND -PRESSURE: S S-IN-FILLHOLDINGTANK:REC SYSTEM: (optional) ®COMMENDED S o u [as u �u ❑ S �1 S EjU conventional If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the 2 Floodplain, indicate Floodplain elevation: n/a under s. ILHR 83.091511b), indicate: C1a58 PROFILE DESCRIPTIONS page 34 OnC2 dPciaml' ^^ ^o TCYTIIRF AAI r1 r7FPTH BORING NUMBER B- 1 DEPTH TOT.ELEVATION 6.74 99.05 B_ 2 7.17 98.50 6.75 99.00 B- 3 B 4 6.75 99.30 B_ 5 6.84 98.49 B- T DEPTH NUMBER INCHES P- P- P. P- P- P- none >6.74 .83bl.1. .83bn.sil. .75bn.S.1.&8r. 4.33bn.l.s. none >7.17 .75bl.1. 1.17bn.l.s. &gr. 1.50bn.l.s. 3.75bn.c.s. none >6.75 .75bl.1. 1.25bn.sil. 3.00bn.1-s.&8r. 1.75bn.f.s. none >6.75 00b1.1. .75bn.sil. 1.25bn.1.s.&gr. 3.75bn.l.s. 1�117bl.l. none >6.84 1.67bn.sil. 2.00bn.1-s.&gr. 2.00bn.f.s. 000 Al ATIMU TFRTS WATER IN HOLE AFTER SWELLING TEST TIME INTERVAL -MIN. D Pl W TER L V -IN H S RATE MINUHTES PER INC P D1 P a D 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 _ 95.25-T-_--T--,-__T ---- r r r r -1 -_i TN I, the undersigned, hereby certify that the soiltests 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. DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHRSBD-6395 (R. 10/83) — OVER — SANITARY PERMIT CO - DILHR TRANSFER/RENEWAL UNIFORM PERMIT #!� (PLB 67-T) 0 So % PERMIT RENEWAL DATE: PERMIT TRANSFER DATE: ORIGINAL PERMIT ISSUANCE DATE: STATE PLAN I.D. NUMBER: 93 � PROPERTY LOCATION: CITY: '/a it/ _ '/a,Sgaj3d N,R /y' E (or Vow LOT NUMBER: BLOCK NUMBER: SUBDIVISION NAME: NEAREST ROAD, LAKE OR LANDMARK: D PREVIOUS SANITARY PERMIT HOLDER (IF CHANGED): SANITARY PERMIT TRANSFERRED TO: NAME: SIGNATURE: NAME: PHONE NUMBER: GZ O w ADD ESS: PHONE NUMBER: ADDRESS: r,,, ' I, the undersigned, hereby assume responsibility for installation of the private sewage system that has previously been approved for this property. PLUMBER'S SIGNATUR : PREVIOUS PLUMBER'S NAME (IF CHANGED): //9Al O a PLUMBER'S ADDRESS: PREVIOUS PLUM ER'S ADDRESS: .S G a y� e / z G� f,� d�S'i.,/ ? X m � r , /MPRSW NUMBER: PHONE NUMBER: RS UMBER: PHONE NUMBER: TUBE O~qG AGENT: - DILHR-SEM609 M. 5/82) DISTRIBUTION: Original - County Copy - Bureau of Plumbing Copy - Owner Copy - Plumber CARIITARV DFRIUIT ADDI I['-ATIAN �3,o1LMR------------ --------- --- ----------- In accord with ILHR 83.05, Wis. Adm. Code Co STA S 1 PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ 8% x 11 inches in size. Check f revision to vious application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER I. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION /06: Y4 NC Y4, S ZZ T 74 , N, R 19 E (o PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # t/ !A R# z Bo a-%o CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER o Sin l6 7�S X -6'�31 II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD State Owned ❑VILLAGE S-� lTOWN OF: G �ar.�/120.4 ; y ❑ Public X 1 or 2 Fam. Dwelling- # of bedrooms 3 PAR X UM ER( III. BUILDING USE: (If building type is public, check all that apply) 10AP; _ io 11 1 ❑ Apt/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 Howie Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. X New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit ## — 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 N Seepage Trench 22 ElIn-Ground 42 ❑ Pit Privy 13 Seepage Pit Pressure 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 sO REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) eELEVATION ZS g �� S� L Z. 9.5. ZS' • Feet Feet VII. TANK INFORMATION CAPACITY in allons Total Gallons # of Tanks Manufacturer's Name Prefab. Concrete Site Con- strutted Steel Fiber- glass Plastic Exper. App. New istin Tanks Tanks Septic Tank or Holdina Tank ID001 /0w I UIL&L&$ Lift Pump Tank/Siphon Chamber VIII. RESPONSIBILITY 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) M MPRSW No.: Business Phone Number: s,- Plumber's Address (Stfett, City, State, Zip Code): LNJL IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Surcharge Fee) ate Issued u ng Agent Sig (No Stamps) Approved ❑ Owner Given Initial % Adverse Determination !/ . CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber STC-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/coptractor,(spec house), thenia second form should be retained and completed when the property' is sold and submitted to this office with the appropriate deed recording. ------------------------------------------------------------- Owner of property pick" S � Location of, property )E1/4 WE 1/4, Section Z2 , T N-R IkW Township `J7� sP_C) Mailing address 2 166K 2 -� Q Wu eau l``�,, 7111�6 / (,o Address of site _ /U�s l�G�v rA, 0)i _ c�oz� subdivision name_L),),t ; �s+ Lot no. other homes on property? _yes�_No Previous owner of property Total size of parcel Date parcel -was created l�Q. Z3 ! ! 94 1 Are all corners and lot lines identifiable? __Yes No Is this property being developed for (spec house)?-4 Yes _No Volume P and, Page Number -03;G as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME 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. �!y 9� z z , 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 the same has been duly recorded in the office of County Register of deeds as Docujkent Sig Lure of appIALcant Co-ap licant t . Q'Z-- Date of signature Date o Signature S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER_-SY-awt ADDRESS /l`2 13o1C 3`f0 FIRE NUMBER CITY/STATE -j41 ,A &e'C,a . C, i_ :jt4n l 6 ZIG PROPERTY LOCATION: aE 1/4,9_1/4, c SECTION 22 , T a0 N-R,�WW TOWN OF_ -f, �p S.e t� (,. , St. Croix County, SUBDIVISION NdV`tL gar j ' LOT NUMBER 3 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 60% 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 mater 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 Co. Zoning Cifficer w=Q, 30 days of the three year expiration date SIGNED: DATE: 10'�--- St. Croix co. Zoning Office 911 4th St. Hudson, WI 54016 DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY &BUILDINGS DIVISION INDUSTRY, P.O. BOX 7969 LABOR AND PERCOLATION TESTS (115) MADISON,WI 53707 HUMAN RELATIONS III mn u2 n9f11 E. Chanter 145) OCATION:q1/4,CTION: TOWNSHIP/Y: LOT NO.:BLK.NO.:SUBDIVISION NAME: NE �� NE /T30 N/R19or)W St. Joseph 3 n/a N. Ba;OUNTY:NER'S ME: MAIL N7,RESS: t. Croix Richard Stout R.R.412, Box 340, Hudson, Wi. 54016 DATES OBSERVATIONS MADE USE IPRO ILEDES IPTIONS: PERCULAIIVI'J It7IJ: NO.BEDRMS.: COMM RCIALDES RIPTION: IResidence 3 n/a :UNew ❑Replace 11_1_90 n/a RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN -GROUND -PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SVSTEM: (optional) as �U ElS EU C� ❑U ❑ S CCU EEI S E90 conventional If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the under s. ILHR 83.091511b), indicate: ClaSS 2 Floodplain indicate Floodplain elevation: n/a oQnFrl F nFcrRIPTIONS '11L nnr.9. BORING aeciam-L' TOTAL-. DEPTH TO GROUNDWATER -INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH IF OBSERVED ISEE ABBRV. ON BACK.) OBSERVED NUMBER DEPTH ELEVATION EST. HEST TO BEDROCK B- 1 6.74 99.05 none >6.74 .83b1.1. .83bn.sil. .75bn.s.1.&gr. 4.33bn.l.s. 2 7.17 98.50 none >7.17 .75bl.1. 1.17bn.l.s. &gr. 1.50bn.l.s. 3.75bn.c.s. g- 3 6.75 99.00 none >6.75 .75bl.1. 1.25bn.sil. 3.00bn.1.s.&gr. 1.75bn.f.s. g B 4 6.75 99.30 none >6.75 1.00b1.1. .75bn.sil. 1.25bn.1.s.&gr. 3.75bn.l.s. 6.84 98.49 none >6.84 1.17bl.1. 1.67bn.sil. 2.00bn.l.s.&gr. 2.00bn.f.s. B. 5 B PFRrnLAIIUN ItA1J DEPTH INCHES WATER IN HOLE AFTER SWELLING TEST TIME INTERVAL -MIN. DROP IN WATER LEVEL -INCHES RATE MINUTES PERINCH TEST NUMBER PERI D1 PERIOD P R P- P- P- P- P- P- g' PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or aisiamza. tee..., .._ ••� •••� •••- - 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 95.25 • ._.7 __ TN 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. DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) —OVER — 6-t 0o z A 1 1 � 1 I g.3 1 1 I 2�e tl ; 1 8•�1�t�" 3r�,cX; e 1 1 1 1 1 � A r04 Nip.'S 8m t b (Ol-4zI 4Z MpRs�-3ua -'A IS , (w 6 LEG.a-N P �' �/il i i faro at vlita /Cr* S'ta�n aas--"-- .d,lao�oa f J /, C4 ,r` t ¢..i" jdO ,So�r �� �.s+.G. Se�r'�►�c 3-i e_ld CRa S s SEc�-ro+J -- p vim" �- 2 55 1