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HomeMy WebLinkAbout014-1072-40-000 s ` STC - 104 AS BUILT SANITARY SYSTEM REPORT jZ s OWNER ADDRESS_ J ? (f SUBDIVISION / . CSM# LOT _ SECTION_29 'T 9j N_R_Z,.3-W, Town of- e~8-~ ST. CROIX COUNTY, WISCONSIN PLAN. VIEW, SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Cp S' gM /0D',-~jCq A© 1 f INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. 1 `aENCHMARR: ALTERNATE BM: <1w► :SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: Setback from: Well House b Other Pump: Manufacturer Modell Size Float seperation_ Gallons/cycle: Alarm Location r SOIL ABSORPTION SYSTEM Width Length / Number of trenches Distance & Direction to nearest prop. line: ~ w,&e f 9Z Setback from: well: House Other ELEVATIONS Building Sewer - ST Inlet: 9 ST outlet: PC inlet PC bottom Pump Off Header/Manifold 4. - Bottom of systemA p-~ Existing Grade Final grade DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: hl p 6 9 INSPECTOR: ad~ 3/93:jt Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count Safety and Buildings Division INSPECTION REPORT bT. CROIX GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar2ft9tihlio.: Personal gilnffoorrmation you provice may be used for secondary purposes [Privacy L , s.15.04 (1)(m)]. SIrmit H ;N LVIN !kyEg,~1(illage ❑Town of: State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description: vK Parcel x'1°-:1072-40-000 TANK INFORMATION EL VATION DATA A9700257 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark y6 ' ~V' Dosing O Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St / Ht Outlet 3 ,G'I TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic ray NA Dt Bottom Dosing NA Header/Man. Aeration NA Dist. Pipe B cry, ~f..4,7 q0. Holding Bot. System Q ga 9/• G ,:V'~ PUMP/ SIPHON INFORMATION Final Grade Manufacturer and z-+.1t+ <o rr~r 1 4'), y Model Number GPM TDH Lift Friction stem TDH Ft Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSION 5 2 S S I DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK _ INFORMATION Type Of CHAMBER Mode Number: System:', OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed/ Trench Edges -36 " Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: FOREST SW SW 33.31.15.537 2840 CTY RD S Plan revision required? ❑ Yes EJ/No Use other side for additional information. o 197J 1 SBD-6710 (R.3/97) Date Inspk or's Signature Cert No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: 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 than 8 112 x 11 inches in size. Sf e • See reverse side for instructions for completing this application State Sanitary Permit Number a ~9 All The information you provide may be used by other government agency programs ❑ Check it revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Property Owner Name If Property Location / A4 e Z lk id 5-1- M0 Al 5i&1/4.S'Lv 1/4, S ~3 Tj/ r N, R 4-E (or) W Property Owner's Mailing Address Lot Number Block Number r7f co d City, State Zip Code Phone Number Subdivision Name or CSM Number ,FMC 1,4 Ze, i I I( 71-r) -2 4q4.2 11. TYPE OF BUILDING: (check one) ❑ State Owned ❑ city Nearest Road ❑ Village Public 1 or 2 Family Dwelling - No. of bedrooms _ Town OF e° f ~O al Ill. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) ~j3 1 . 1 S 5 1 ❑ Apartment/ Condo A0 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 Q Merchandise: Sales/ Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church / School 8 ❑ Mobile Home Park 12 Q 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. jX 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 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) 9/. d8 ' Elevation ✓ - to 7 O Feet 'j-= .3 Feet VII. TANK Ca in gallons Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App New Existing structed Tanks Tanks Septic Tank or Holding Tank C? El n 1:1 1:1 0 Lift Pump Tank /Siphon Chamber ~ E] ❑ 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) MP/PAIfiY No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): O O~ D ~3 3('a 94-X /170 IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issue Issuing A ent Si nature ( tam ) Surcharge Fee) Approved ❑ Owner Given initial ~ffD j~ 10 Adverse Determination v X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: - SOD-6398 (R. 05/94) DISTRIBUTION: Original to Counly, One copy To: Safety & Ruildings Divi ion, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for 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 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. 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; friction loss; pump performance curve; 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. 44 _ -1 /V le 5-7 <QIA O I I ~ r I X~N`N- - - - - 1 i - ~1o I s , . - s' ' 7.S'_ - - - - - -1 _ a rwf - - - twenr _(.7 Nes - I .10 Vyibconsin Department of Industry, SOIL AND SITE EVALUATION Labor and Human Relations Page of Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and C percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I. D. # APPLICANT INFORMATION - Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location .~G Govt. Lot S ~t! 1/4S4/1/4,S3 T3 N,R 13 fir) W Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# City State Zip Code Phone Number Nearest Road O.2 1 (7/~..) El City ❑ Village Town ❑ New Construction Use: 6Residential / Number of bedrooms Addition to existing building X Replacement Public or commercial - Describe: Code derived daily flow - gpd Recommended design loading rate _ -bed, gpd/ft2-4~-trench, gpd/ft2 Absorption area required O O bed, ft2 2-!r4a trench, ft2 Maximum design loading rate ^ bed, gpd/ft2 trench, gpd/ft2 Recommended infiltration surface elevation(s) 74 8 `t . &.2 ft (as referred to site plan benchmark) Additional design/site considerations j Parent material 6~AA C /A L / L Flood plain elevation, if applicable A ft S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank U = Unsuitable for system ® S ❑ U ® S ❑ u ® S ❑ U [XS ❑ U ❑ S ®U ❑ s U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/fl2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench 1 - /e YS j?& 4 2SdkM Alf -R 5 a r 6 7.. -/6 o s' h16 /4 G S d Ground tii21 7,-,5rYffl x1A 56 J, 24 h h M G S V -S elev. Aft. -80 56 k V F~7 - - ,S' 6 Depth to limiting factor Remarks: Boring # 2- d-f - L r 67 s F 1s ,.s" S& Al X G rF Ground S'7! F /A V F p elev. 7Xft. Depth to limiting factor 72.`-in. Remarks: CST Name (Please Print) Signature Telephone No. &A Lri .SaM! ~`i1 71-47-.240-- Address Date CST Number ~.?2 o GLerywooo/ ~i7`' lL I~ ~ oI3 7 ~ - 99 / PROPERTY OWNER 1 dAl iN SiMcA;£e~y SOIL DESCRIPTION REPORT ~ Page 2 of +3 PARCEL I.D.# "0/ D 7,Z - y O Boring # Horizon Depth Dominant Color Mottles Structure 2 Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench o F GS l 5'; 6 Ground aJr 5,6A Ao t~T V~ .S 9elev. ? l" ft . -~Z 614 e -5 8 Depth to limiting factor Remarks: Boring # Ground elev. ft. , Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # Ground elev. ft. ' Depth to limiting factor 'n. Remarks: Boring # Ground elev. ft. Depth to limiting factor 'n. Remarks: SBDW-8330 (R. 08/95) l I 419 f I 'Ald i FJ 1 e I _ -L-- i - - _ - - - - - _ _ - - - c,* Isk ANN I - - - - d f- dos I ' i ~ I I - - - - r - - - F , i I ~ I i ~ I i - 4 -J - - - 1 - - - - - I I I ~ I I ~ _ I L ~ I I I r-- i I I I ~ i . 17 - ~ r - I 1-4 I- I y I ; I i l_ I , r ! { I 8 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 recording. Owner of property Mel tll"l/ ,Sj/1ijGs/VSON Location of property5'4) 1/4 SLR/ 1/4, Section , T Y/ N-R_W Townships _ FOY'~4'Mailing address Address of site .2 ro& Subdivision name Lot no. Other homes on property? Yes X_No Previous owner of property Le /F Total size of property Z/O A C'e Total size of parcel /l!1 y c d e, Date parcel was created /54.2 Are all corners and lot lines identifiable? Yes _,X No Is this property being developed for (spec house)? Yes ( No Volume and Page Number 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 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 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. 2 l7 and that I (we) presently own the proposed site Eor 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. ~2U4~ Signature of Applicant Co-Applicant Date of Signature Date of Signature STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNERMAIM / YI V /V Si M e N /Qd MAILING ADDRESS f 7<f l Ca PROPERTY ADDRESS o2 F C y C (location o septic system) Please obtain from the Planning Dept. CITY/STATE "E::~ /y e /l / a Zc" / PROPERTY LOCATION 5W 1/4, -5- 1V 1/4, Section 3,, T N-R~W TOWN OF ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER CERTIFIED SURVEY MAP , 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 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 County Zoning Officer within 30 days of the three year expiration date. SIGNED: DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 t DOCUMENT NO. WARRANTY DEED 2711 4 STATE OF WISCONSIN-FORM 9 TIiIS SPACE RESERVED FOR RECORDING DATA THIS INDLNTURF,, made by_..... Pale ...Ra..... Fa ferliek.- anc3_•--,.-..--- ---Wanda.-Taiferli.ck-,....husband. a.~d...w~fe., R~ c:~ I . t , V t ..tenants----- . - I. r;tlolx c~~.°~~~. Recd tl~cenh rUiis. grantor_-.-5_... of.-......._... ............County. Wisconsin, hereby conveys and warrants day t?f to...Mel.vizl...~T.._.-.. 7.II14X1 s-. ~ Qn....a_rid....L..auxa.__.$1-m4.n.s.o..n.,....h.us.kaxld.... and...[ai£.e_,-... s -Joint -Tana.nth...................................................................... k1-Fr~.t ✓,I,I/l: - of..-•----.....---._..._...._St. ~X Q.l X ...........................................County. Wisconsin, for the sum of RETURN TO ........Se.ven._Thogs.and-.-and n.4/_)-00_..-(.~7.0-00- 00)- Richard P Rivard - - - - - - - - Dell<3rs Glenwood City, WI ,con:,in the following tract of land in -St . CT O 1 X . , County, State of Wisconsin; I 1 II South West Quarter (SW 1/4) of Section 33, Township 31. North, Range 15 West. I I M I i 1 1 1 N 1 1: i II r( r}: t (r cy~ 4' ~jf1 IGll~ta 1..L'1~~I I i I r , IN \1'I'I"c:I'SS WHEREOF, the. said grantor-s ha.. ve---hereunto set.----their ........hand day of November 7 A. I)., I')_- 6 SIGNED AND 8 . Ff) IN PI217 ENCE OF A~ ~ I 1 S. IA R F a i f~r, l i p J~ 1 a.lP Dale Richard P. Rivard l l` l - - . ~ to , (l 1 ad.c~... F.c X a c k - - SEAL) !I P[o W - e-~ In....._...u I - .I r1 S•I'ATl OF WISCONSIN, 15_ I ±YA °---.._..._-County. J i _ _ . 1 ~ -4.13