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HomeMy WebLinkAbout002-1010-10-000 STC - 104 AS BUILT SANITARY SYSTEM REPORT f ,J REEEK OWNER ~Q - _ Q~er 1997 ADDRESS 5 rK,)Ix f 'oLj"Ty SUBDIVISION / C-SMI LOT SECTION `7T 2Qi -R_16 W, Town of ~,6t Z ST. CROIX COUNTY, WISCONSIN PLAN. VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM gCk,10 ~~R7 Y~ ~o Q(6-11 I o INDI ATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. r 'BENCHMARK: /000,0Z, ~~I~ ALTERNATE BM: + ,*1► TIC / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: man ez Liquid Capacity: ~ X 'd Setback from: Well 46V House Other Pump: Manufacturer ;Model# Size Float seperation` Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: Length Number of trenches Distance & Direction to nearest prop. line: Setback from: well: House Other ELEVATIONS Building Sewer ST Inlet: / 0 2 3~? ST outlet: la --+p Off Header/Manifold Bottom of system Si Cf ~6 ,.Sy Existing Grade %q 9JFinal grade T- DATE OF INSTALLATION: 2 PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: r, 3/93:jt Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County Safety and Buildings Division INSPECTION REPORT ST. CROIX GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Pgy 44 njth-: Personal information you provice may be used for secondary purposes [Privacy L , s.15.04 (1)(m)]. 3s P.aresit HOlc11,6)Yfff, & KAREN 7111111 TRge ❑ Town of: State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Th"!F 1010-10-000 /1,1/0 60 TANK INFORMATION ELEVATION DATA A9700239 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic ,-v C Benchmark 2 d~ c0~ Dosi Aeration Bldg. Sewer Holdin St / W Inlet "z 0~ TANK SETBACK INFORMATION St/aft Outlet 1v2 • /J~ TANK TO P/ L WELL BLDG. Airi to ntake ROAD Dt Inlet t/( Ar I / Septic NA Dt Bottom Dosin NA Headed Aeration NA Dist. Pipe Holding" Bot. System 9cS ` 7 PUMP / SIPHON INFORMATION Final Grade Manufacturer Demand o3 7c/Model Number GPM TDH Li Lrictio System TDH Ft oss Forcemain Length Dia. H Dist. o e SOIL ABSORPTION SYSTEM No. Of Pits Inside Dia. Liquid Depth BED/TRENCH Width Lent i No. Of Trenches g DIMEN I N DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACH Manufa SETBACK CHAMBE INFORMATION Type Of X a - Mode r. System: OR UNF DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Ho t jo Air Intake Length ~ Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or -Grade Syste my Depth Over Depth Over xx Depth xx Seeded /Sodded xx Bed /Trench Center Bed /Trench Edges Tops ❑ Yes ❑ No ❑ Yes ❑ N. COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: BALDWIN 05.29.16.71B,SW,NW 2208 115TH AVENU ,l 1Plan revision required? ❑ Yes 2 /No Use other side for additional information. SBD-6710 (R.3/97) Date Inspector's Signat re Cert No. 1 ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: t 17 oc;2 63 i Safety and Buildings Division SANITARY PERMIT APPLICATION Bureau of Building Water Systems 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O- Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County ~~tn©~ than 8 112 x 11 inches in size. miitNu • See reverse side for instructions for completing this application State SThe information you provide may be used by other government agency programs Cheevious application [Privacy Law, s. 15.04 (1) (m)). State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Prop Owner Name Property Location ert e 1/4 S S' T N, R /9 E (or) Property Owner's Mailing Address Lot Number Block Number City, S e , . Zip Code Phone Number Subdivision Name or CSM Number 9~ "rv~~ U/5 S Oo (7~S) 684 r~~ 11. TYPE OF BUILDING: (check one) ❑ State Owned ❑ E] City Lein Nearest Road 74 Village .7 ❑ Public , 1 or 2 Family Dwelling - No. of bedrooms_ Town of III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) j to l l b 1 ❑ Apartment/ 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 Home Park 12 ❑ Service Station / Car Wash 5 ❑ Hotel/ Motel 9 ❑ Office / Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. ❑ New 2. fA Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an _____System System- _______TankOnly Existing System _________ExistingSystem B) ❑ A Sanitary Permit was previously issued. Permit Number 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 Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 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 Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) 7910 EIevatit~lj~' 600 A©© AIAI- f.% eet c!9 9 eet VII. TANK Capacity gallons Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App. New Existing strutted Tanks Tanks Septic Tank or Holding Tank V rtes e ❑ El ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ VI11. 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 St mps) MP/MPRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Feg (Includes Groundwater ate Issued Issuing A ent S ps) Approved F] Owner Given Initial Surcharge f ee) Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SRD-6398 (R. 05/94) DISTRIBUTION: Original. to County, One copy To: Safety s Ruildings Divrion, Owner, Plumber i INSTRUCTIONS 1. A sanitary permit is valid.#or two (2) years. 2. Your sanitary permit maybe renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved b 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 systenis must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on 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 for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new/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. VIII. 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 1/2 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; frictionloss; pump performance (urve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing 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 contamination investigations and establishment of standards. Pa of ~`►r PLOT PLAN 9e SCALE 1"= PAD ~i• aoZ_ 1010 - ) 0 tL°t85 • B-3 lL a'1 S 5 5 o ~ SJ 8.2 b b SPII+~ B z, P>130U~ y C-M'N"Qt) IN 3 0" ! O1 A . 1Zt~.ti, . ~ o, ~ R'8ouc ~iR.auti/'u Pooh tR too s ~ G tY~G ~ M I N , N 4 BuaM so' t tlo~se N Wr Ze s c~ i Vs > l p' Soy 3T of er ej • I,p J r S •Tl PNe. RIP W$sconsin Npartment of Industry, SOIL AND SITE EVALUATION REPORT Page of 3 Lahr and Human Relabor ss Division of Safety a Bindings in accord with ILHR 83.05, Wis. Adm. Code ' COUNTY Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but ST~ G~EX not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. OO Z - •I O 1 13 - APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION _Zz"a 10 - r n )Q\-3 Gew. Le-- Ski IN 'Nw1N,S S T Z°1 N,R I 6 E (dij~) PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # SUED. NAME OR CSM # CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE ®fOWN NEAREST ROAD 3 ~~►-vt ti yv I S V o o Z (-)19 W/- Z Zil PS ~ w 1N 1\ S `TAI- PruN' New Construction Use Residential / Number of bedrooms L4 [ [ Additign to existing building [~Q Replacement [ ] Public or commercial describe Code derived daffy flow ~-Oo gpd Recommended design loading rate - bed, gpd1ft2 ' S trench, gpolft2 Absorption area required - bed, ft2 1Z0U _ trench, ft2 Maximum design loading rate _ - y bed, gpd$ ' S trench, gpdtft2 Recommended infiltration surface elevation(s) S ~ V->" e 3 ft (as referred to site plan benchmark) Additional design / site considerations'.) M )'I &\jb 3 `r-~ C_ [I-es - O_A L4 s 'x. &'o ' Parent material STb lm ~ T- O Q~'R '[L \,L Rood plain elevation, if applicable Yy • R - It S = Suitable for Sf CONVENTIONAL MOUND IN GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK ern U=Unsuitable for tem S ❑U ❑U ❑U ❑U ❑S ®U [~U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Botnd3y Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed mach 1 0-o ~o~tZ z1z s L'1 -L S - . s Z l0-n ►o ~1 (4- V13 ~ s 1 Z ~S~k vn'FH CS Ground 3 -Zq l0 `1 IZ 31 elev. \oo.S ft z9-y S 3 Y - s 1 e s bk M chi l c g b~ >n Depth to S t4643 S /L _ s `s o s - I - • Ll , S limiting factor > B3'' Remarks: Boring # o~ l 0`1 R- 2- L 2 , S 13 Ground 3 t6-3) 3)y - tit- ~S 1~q SD1"L hMU`F, CIA.) elev. 3)-SI -)-s Lift y/6 - S o Sg wt - `.8 Ons It. 9 199 Depth to limiting CE V E factor > Shy Remarks:' ' CST Name:-Please Print Phone: Arthur L. We erer 715-425-0165 eg rer Soil Testing & Design Service-P.O. Box 74 River Falls,-WI 54022 c. vt -t - 3 Date: H ~..Z [ 0, l')q 7 CSTNumbar M0057'6 PROPERTY OWNER e-Pch'LP SOIL DESCRIPTION REPORT Page Z of PARCEL I.D.# OO Z - l~til~- l0 Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bomrxiary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 3 0-10 Le\-I2 31~ s' Z `F y, . h~ cS . s :b Z 1z-1f l0`-/IZ 3lL S Z T-S~h MCS .S .L Ground z Yo -S`IR 3!y - S~►6t o.S9 wt C~,o elev. qB. S ft. tf yu-S~f `~.S y~ X16 _ `FS o s M I - , s b Depth to <!,uw S `f fi-- 3` `s %tcn ~ - 1 u limiting factor '4 y i i Remarks: Boring # 's i Ground elev. ft. Depth to limiting factor Remarks: Boring # 3- Ground elev. i ft. Depth to limiting b factor I Remarks: Boring # 13 Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) Page . 3 of 3 y PLOT PLAN SCALE 1"= HID ' P\U Me apZ- 1010 - 10 L'L0185 B-3 8 . Z `D~ e 5 b - Q:L. ~oo.o' aN SPIhg 3Z~Pr~OV~ D~ 47 G~uvtrl~j IN 30" v. ,o ~Ola F'BovE <QWSUNv Pool co'`rc°`'~t g8 fl-LZO s GCE t ~ ~i STS n/ 6 \-Z/7t,, N 4 B~~ i so' t s~ I I~ S `Rt m1l . C-Lt ty1~ l (715 ) 425-01 65 M00576 " CST Signature Date Sign Telephone No. CST # 8 T C 100 .n This application form is to be completed in full aha ai2ff 6d by the owner(s) of the property being developed. Any inadequacies rill only result in delays of the permit issuance. Should 'his development be intended for resale by owner/contractor,, .(:pec house), then a-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 C 13(- /~,;j Location of property Ld 1/4 X1/4, Section _ k-g 16, Township_ o Mailing address Address of site ~O / 5- 7fj z° Subdivision name Lot no. _ Other homes on property? Yes No Previous owner of property Total size of property Total size of parcel Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house) ? Yes No Volume and Page Number 2o,:~ as recorded with the Register 6 'f Deeds.. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND P73E NUMBER AND 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 Yap 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 the office of the County Register of Deeds as Document No. , and that I (we) presently own the proposed site for-the' or 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 the County Register of Deeds as Document No. 4in t ure A icantp Co-A licant a ig D nature Date of Signature STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER dlkd MAHMG ADDRESS PROPERTY ADDRESS Az)o Z~~ /Mo' G L,::7 (location of septic system) Please obtain from the Planning Dept. CITY/STATE _~EA I/LJ,'.o U PROPERTY LOCATION 1/4, 1/4, Section T_ a ° N-R TOWN OF _E4 ~/ULrI ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER CERTIFIED SURVEY MAP 2 VOLUME , PAGE , LOT NUMBER 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 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 conditioq and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Me, 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 County Zoning Officer within 30 days of the three year expiration date. SIGNE v ` /L'Y\ DATE: 7 c 7-3-/ St. Croix County "honing Office Government Ccntcr 1101 Carmichael Road (Hudson, W1 54016 11/93 ~~~SPACE~~6 !7p0~ VOL STATE BAR Of WISCONSIN FORM ? - I432 j' 556161 WARRANTY DEED DOCUMENT NO. REGISTER'S CU ICE ST. CROIX CTY, Wt -Alice Trahms, a/k/a Alice DeMotts, in her Mt11i►tMoflO can right and as sure v ng o nt enan o John DeMotts, a k a John Mar on DeMotts LIAR _3 1991 a it 30 A. ' Ro ert amp an m conveys and warrar s to Camp, husband an w fe k - i>ayistar ut Das;:a ,h t , THIS SPACE RESERVED foR nEc, DATA the following described teal estate in St . Croix NAME AND RETURN A~pgESS _ - State of Wisconsin: ~7t "d:. S O 1- I 3 01 Svc ~ Part of the Southwest Quarter Of the Northwest Quarter (SWljc of NWT) of Section Five (5), Towrnshi p Twenty-ni>ee,~ W~ North (T29N), Range Sixteen West (1116W), described as foiloI Comitencing at the Intersection of the North- - - i South and the East-West Roads in the Sovithvest 0orner _ II of said Southwest Quarter of the Northwest Quarter PARCEL OENTIFICATM Nt1MM (SW% of MA) of said Section Five (5), as the point of beginning; thence North Four Hundred Twenty-three (4231) feet; thence Fast sI Hundred Eighteen (618') feet; thence South Four Hundred Twenty-three (423') feet; thence West Six Hundred Eightil (6181) feet to the point of beginning. This deed is given In fulfillment of that certain land contract between the above parties dated January 27, 1984, and recorded in the office of the Register of Deeds for St. Croix County, Wisconsin, an January 30, 1984, in Volume 681 of Records, at Page 293, as Document No. 390845. MAO: This is not homestead property (is not) Exception to warranties: Easements and restrictions of recotrd, and except any liens or encunebrances created or s=uffered to be created by the acts and defaults of the grantees, their heirs, successors, or assigns. Dated this day of January 97 , A.D., 19 (SEAL) abzae (SEAL) ' Alice Trahms (SEAL) . (SEAL) i AUTHENTICATION ACKNOWLEDGMENT _ Signature(s) State of Wisconsin, Sl Croix authenticated this Cou day of 19came before me this day of 19 97 , the above named Alice Tr*mfg TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by §706.06, Wis. Stats.) to me 1ram® a be i the foregoing ~d , f. THIS INSTRUMENT WAS DRAFTED BY (a Thomas A. McCormack M&C OF r 5 S r I u 0 a Fr96A Au 1041916 And OAeer.•llon pipe 1~ Approved Vonl Cep MM1wMw It' AM.• - riw91 Or91• 20 • 42' Above Pipe _ *'Call koo 19 Final Grede vast live Mash Nor Or Synthetic Covering win 2' Aggrogele O.or Pipe Olrlrl•ollen iN 6 Pipe o R9IN6i11eO p9 • PNlereled Pope •elow J4 3 • 'Cowling forlnln•ling At U sell•1. Of $16190 U ~Y. ya 4 r 40 14 `IcJr.~ 1904 /~,//J/\~i K~r SOIL FILL. O DISTRIBUTIp1.I PIPE X 2"0FAGGRE(,AlE ILLF V. OFeE 30" ~ 3~f . 3d~f L)IS'TRJ.a;;T1,7A1 r1rc TO. At AT LERST -E %9c4E BXL0w O 1&1W2 c.A A,.Dc ANM, nj ~~nsrzo!,J4CftF~sur kI,o *f~AW 42 yalcll,ES sE.LOw F+AWhL ' I MNc. OAp ni or EXCAVArI00 FROM ,PRI& U 69Aor= WILL BE 3 Q Mcw-C•s M.OMM., f1EF" Or- FACAXATIOM FROM 0~14W#NL Cjg4,9l€ WILL BE ~ INCNES 1 91G1~1[b: ell LIGEMSE UUM13ER: d7 Ito