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HomeMy WebLinkAbout018-1022-30-000 . r V - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ~~y~a ~//~J .o ► / ADDRESS SUBDIVISION / CSM# LOT SECTION - , TAN-R17 W, Town o ST. CROIX COUNTY, WISCONSIN SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM e~ S ~ ,CIO 9 INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. ~t BENCHMARK: ,j n,--e ALTERNATE BM: I SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: /,,fC) 0 Setback from: Well ,S"'Q House Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: Length ?S Number of trenches ;~7 Distance & Direction to nearest prop. line: -t Setback from: well: ff'Q House SW r- 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: PLUMBER ON JOB: 2 7 Q~d LICENSE NUMBER: INSPECTOR: 3/93:jt i f Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 284273 Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.: ANDERSON, NOLAN E & RUTH ANN HA4MOND CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: oo f 018-1022-30- TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic s Benchmark Dosing a Aeration Bldg. Sewer </3 S q'91 3 Holding St/ Ht Inlet 3~ TANK SETBACK INFORMATION St/ Ht Outlet 6y' Vent irito ntake ROAD Dt Inlet TANKTO P/L WELL BLDG. A Septic ra 7S0 NA Dt Bottom Dosing NA Header / Man. s~.ss fl Aeration NA Dist. Pipe i3,y6 FrS-?.;2 , Holding Bot. System a. 6 e6), J? 2- PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand el gS_ 4 Model Number GPM TDH Lift Lrictio System TDH Ft oss Forcemain Leng Dia. H Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length _ No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS J DIMENSIONS LEACHING Manu acturer: SYSTEM TO P / L BLDG WELL LAKE /STREAM SETBACK INFORMATION Type Of CHAMBER Mode Number: System: 5 f = 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 Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HAMMOND 11.29.17.165, NE,NW 110TH AVE 1.~ ~D4 /dam Cn ell Plan revision required? ❑ Yes ~o Use other side for additional information. 1-9d SBD-6710 (R 05/91) Date s or's Signature Cert. No. r ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: Water tems SANITARY PERMIT APPLICATION BureaSafetyu o oand ff BuiluildinWater 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 81/2 x 11 inches in size. $TCs~c~ • See reverse side for instructions for completing this application State Sanitary Permit Number The information you provide may be used b other government agency / Y Y Y programs Check if 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 Property Location u f'h AA14te r SV .J F 114 1/4,S it T 19' , N, R E (or)do- Property Owner's Mailing Address Lot Number Block Number 143 d V City, State Zip Code Phone Number Subdivision Name or CSM Number I. TYPE F BUILDING: (check one) E] State Owned ❑ ~t~r Nearest Road ❑ VII age ❑ Public 1 or 2 Family Dwelling - No. of bedrooms 3! El Town of d ® TA III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo I l . 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- g 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 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 ISO Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) 8T qd' Elev ton O -76"D c G a- Feet 2 Feet VII. TANK Capacity in gallons Total # of Prefab. Site Fiber- Ex er. INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel Plastic p glass App. New Existin structed Tanks Tanks Septic Tank or Holding Tank k ./V d40 1( 2, ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) LPIumber's Signature Stamps) P/ PRSW No.: Business Phone Number: I 4 Sc a c tr ^ 2 C 41 3 6- 3 .Z Plumber's Address (Street, City, State, Zip Code): IX. COUNTY / DEPARTMENT USE ONLY XApproved ❑ Disapproved San ary Permit Fee (Includes Groundwater ate ssue Issuing Agent Signature (No Stamps) ❑OwnerGivenInitial Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05/94) DISTRIBUTION: Original to couniy, One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. Al: 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 comp"ete # 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. l vas sT lla 7I a i i F l ' ~ ' /3~ ` ° C~ Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page I of Ldbor and Rumen Relations Division of safety & Buildings 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 Cro ' 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. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION GOVT. LOT 1/4 114,S T 2/ N,R or W Wotayl ktkut~ p PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUED. NAME OR CSM # VCNJ © 110o) CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE OWN NEAREST ROAD M t 5'0 l-(1157 - 5' IID [ New Construction Use K] Residential / Number of bedrooms 3 [ ] Addition to existing building Replacement [ ] Public or commercial describe 100Ittgvi+cd M~ Code derived dally flow SQ gpd oh #I*h recommended design loading rate o J bed, gpd/ft2 (j 6 trench, gpd/ft2 TQ W Absorption area required bed, ft2 75'0 trench, ft2 Ma)amum design loading rate Q , i bed, gpd/ft2EO~,trench, gpd/ft2 A ll ~ z Recommended-infiltration surface elevation(s) 89,1 0.1 ft (as referred to site plan benchmark) 1I Additional design/ site considerations r v c s r a q /f rt Parent material La e5se S Flood plain elevation, if applicable At IA: ft S = Suitable for System CONVENTIONAL MOUND IN -GROUND PRESSURE AT-GRADE 7 SYSTEM N FILL HOLDING TANK U = Unsuitable fors stem 'S ❑ U ;'S ❑ U S ❑ U 'KS ❑ U ❑ S ON ❑ S SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD/ft Boring Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Tw& ,w :1- 0-5 0 A 3 13 o, 6-6 ~ ~ q ~G 2 r r f 10 3 t b m tr C 0,7 ©►6 Ground 3 22-3 i0 si) 2 s~k ~r' C W elev: 10.4t. lov S44 so .7- .Depth to 11 r? limiting fact Ay' Remarks: Boring # TY cou 4 0-ID 102 1 tNG ~r s 2 O.S r~ 2 2 O"3 I 2 a~k ~r 0, s O,b 10 YR ?J 31-V io ye 4 1q M 2 r C S 015 -:014 Ground ele~v.~ 2-63 10 n c~ J'5 C -S 0-710,S O 10 Depth to S 63' ! k ',S 10,7 D. $ limiting factor Remarks: CST Name:-Please Print Phoned y 30 V Address: N 3 5'9 1 W It 5q61 Signature: Date: CST Number: 6 CSTM 5'n 1 0 PROPEMYOWNER. N61010 Rufh gh~evSihrSO[L, D.ES'GRIPTION REPORT::. Page of~ u PARCELLD,# Boring # Horizon Depth Dominant Color Mottles, Ft;b- Structure Consistence Borr~r Roots GPD/ft in. Munsell Qu. Sz Cont Color Gr. Sz. Sh. Bed Trench , Is :1 0- o Y 3/3 3 ~s6 2 0.3- 0.6 -L 16' 10 YR V3 24- O'S' 0-of Ground. 3 IF-3 o s Falk o.s 0 6 eW. ft. 3q io sqn d 0.~ Q$ Depth to limihn9 factor Remarks:* 6 Y a i r Boring # a- ~oYR.1 s`1 3 6' w 2~ a.s 0.6 6.22 , o bk c o,s 0,6 `Ground 3 2Z-35,* 0 I ~~'1 Yh Ir' C r Q 6 elev. o- 710,9 ~$-I ft. ILL Depth to imitlng "facto ,Remarks: N I I Lie -t 4A r Boring . ~_6 Io s ; 2 6-► s z ~Sbk FY cf s z~ a.6 3 14 1571 0 ~ ~ 5C oa 2 f bk ~ c s ~ d.s~ 6 6 Ground 2 O_ 0,.1- wF. 36` p 5 6 M :2 6 ~r 47, M 1 , y :0.5 Depth to C 0 limiting 6 , . H~5s 0 5-~ N S sa 7 9 factor joy S/ Is Remarks: Boring s 1 0.5 0 Ground 13-al 10 ,R S 0,6 4 . elev. -~2 CD S b. Scan s c' 0.1 d • ft. Depth to limiting....: , fact 71 Remarks: sa Na ondr~ S8D-P;o(Rn4 2).:: t f t y.` N t7~ r, t venue r4 0 50 100 150 ~0~ } SCALE in Feet Plot P a.nanal Soil Evaluation for Nolan and Ruth Anderson 1930 110th Avenue Hammond Wisconsin Nor°^the a,st 1/4 of Northwest 1/4 Section 11 T29N R17W town of Hammond St, Croix County i F ',h 4 M 4, $ TH h, SIM 14 ~ Noun Md=5an g~ I/ 4. NO Plan cnd Sal bb 9 G4 i N I~f/' ` Evnlungon aT,a IIJJ~~ j lrt C5 C5 C3 ,I- co NJ- > Oti CN 011 CJ`s 0i d- 117 +~p 1 s as a o fi'7 0 ago C J o 0 -Y a) .4 1) V L d: } ~ ~ V~ ~ C ~ 0 - 0 o 0 LL- 0i C. x -P C C C - c -~o © CC'~ov~ OJ- 0.~ 0- d C 3 cD U p z a.. W ~ a al ~ ~ z • ~t Pqj ov trees trees open area Ope c~~ ado)s i9G STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER IVO /cz- x- 4wo(ers a MAILING ADDRESS ( a S-~, 1d41 tt L~, S'V, 2 - / PROPERTY ADDRESS /!v l//~ /~a 1d w ,'K ~,1 S7Cili 2- (location of septic system) Please obtain from the Planning Dept. CITY/STATE PROPERTY LOCATION X),5 1/4, 1/4, Section T__2 9 N-R__2_j W TOWN OF ~a.w. woo v~~ 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: -7 - 5 7 - St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 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 recording. Owner of property 1t)61-.- Location of property .IJF--_1/4A)lJ 1/4, Section ),T gf N-RAW Township s v»o,~ Mailing address /:Gr d.-k s, 41q-, 4 5 72- Address of site/~~rj/o AUK Subdivision name Lot no. Other homes on property? Yes5_No Previous owner of property ,C1a~,r~n rt,yG~-e r S'c3~ Total size of property Stp Total size of parcel 7CZ PSl Date parcel was created <TuG/ 3 Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house) ? Yes )_No Volume 42Ie,' and Page Number Z~ 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. ,L6 y4f7-;;, , 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 the County Register of Deeds as Document No. Signature of Applicant Co-Applicant 3--7-97 Date of Signature Date of Signature DOCU,4ENT NO. WARRANTY DEED 5540'77 YO11~16PAGES$ ft'd'or Rocca THIS DEED, made between Norma Anderson, Grantor, and Nolan JAN 3 1997 E. Anderson and Ruth Ann Anderson, husband and wife, as survivorship It 3:20 P. (.i; marl, Grantee, WITNESSETH, That the said Grantor, for a valuable consideration of `Yjt.t.. 'i* u Al, one d.,llar and other valuable consideration conveys to Grantee the following Haysmr ct tom, . described real estate in ST. CROIX County, State of Wisconsin: RECORDING INFORMATION SEE ATTACHED DESCRIPTION . NAME AND RETURN ADDRESS This deed is given in satisfaction of that certain land contract dated April 12, Bakke Norman, S.C. 1980, and recorded April 14, 1980, in the St. Croix Register of Deeds Office 2403 Stout Road in Vol. 610, page 387, as Document No. 363656. Menomonie, WI 54751 ,+.i $ TRAAN~ FER 00 EE (Parcel identification Number) This is not homestead property. ? Together with all and singular the hereditaments and appurtenances thereunto belonging; and Grantor warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except: Easements, highways, utility rights and reservations of record, and will warrant and defend the Sam, . Dated this day of • , 1997. 'k (SEAL) a✓L ~tiv~ L - (SEAL) • • Norma Anderson j (SEAL) .SEAU • ' AUTHENTICATION ACKNOWLEDGEIVIENT } Signature(s) of Noma Anderson STATE OF WISCONSIN } a& 31'. CROIX COUNTY } audueinica day of , 1997. i Personally came before me this day of 19_, the above =med ~AA . r.r+ TITLE MEMBER STATE BAR OF WISCONSIN me known to be R+e p==_ arho (If not, executed the foregcAng instrument and acknowledrA the same. authorized by 1706-06, Wis. Stats.) THIS INSTRUMENT WAS DRAFTED BY: BAKKE NORMAN, S.C. o..~:. ~ PACE 459 YOl 121 NORMA ANDERSON/NOLAN & RUTH ANN ANDERSON . - NORMA ANDERSON/NOLAN & RUTH ANN ANDERSON Real Estate Description: The Southwest Quarter (SW 1/4) of the Northeast Quarter (NE 1/4), except commencing Quarter SW 1/4 2 rods West of the Northeast corner of said Southwest (SW 1/4) of the Northeast Quarter (NE 1/4), thence East 2 rods, thence South 2 rods, thence Northwesterly to the point of beginning; the East One-Half (E 1/2) of the Southwest Quarter (SW 1/4); The Northwest Quarter (NW 1/4) of the Southeast Quarter (SE 1/4); ALL in Section Two (2), Township Twenty-nine (29) North, Range Seventeen (17) West. The Northeast Quarter (NE 1/4) of the Northwest Quarter (NW 1/4) of Section Eleven (11), Township Twenty-nine (29) North, Range Seventeen (17) West. Subject to recorded easements, reservations, and rights of way.