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HomeMy WebLinkAbout020-1324-40-000 AS BUILT S STC - 104 ANITARY SYSTEM REPORT OWNER SIB l id'r~/' f ,r~' ADDRESS u r'- C a 1 ~ F, 0i SUBDIVISION / CSM# 14 AIN t < SECTION LOT # T~_N-R I , Town of ST. CROIX COUNTY, WISCONSIN NOr MTO'0-0 PLAN VIEW NoT~: -"7 SHOW EVERYTHING WITHIN 100 FEET OF SY L#4 L. S7 T ^ -lei ~IklAGC D (V6 w"Y i r r )o 'r /:/W", INDICATE NORTH ARROW P vide setback and elevat,aon information on reverse of this form. Prov' e 2 dim nsions to center of septic tank manhole cover. r BENCHMARK: ( S F rcR a_ N ALTERNATE BM: 7C> t-' rr lk r ~A I /C a h/ E 1. = • b'O ~d ( SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer:Llj /,e ,,C /4,__ Liquid Capacity: f ~_Q (o,1L, Setback from: Well 7C7 House o7 % Other ?c/ 7k) C' ,t #Ft POO:, Pump: Manufacturer Model# Size a Float seperation"Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM i Width: ~ Length -7 Z ~ Number of trenches Distance & Direction to nearest prop. line: Setback from: well: Z f~ House Other ELEVATIONS Building Sewer ST Inlet:? ~7 ST outlet:, PC inlet PC bottom Pump Off 9gr$$ FN Rio.: 1~'3d=98 Z~ FM Coo) jb,(,Vd 137,9' -N Header/Manifold Bottom of system_N ceu _4),o4, =97,s Z Existing Grade Z Final grad ~~.qF~ SZ DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/93:jt Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count , Safety amd Buildings Division INSPECTION REPORT yST. CROIX GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar~"`iii"_: Personal information you provice may be used for secondary purposes [Privacy L ivy, s.15.04 (1)(m)], tSS MPSfM¢lder'sgW: lieb fff lage Town of: State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description: Parcel MIQ-1324-40-000 TANK INFORMATION ELEVATION DATA A9700191 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark 4 Dosi n r p.,. Aeration Bldg. Sewer ing St/)Yt Inlet TANK SETBACK INFORMATION St/ Outlet TANK TO P/ L WELL BLDG. Airi to ntake ROAD Dt Inlet Ar I Septic 1174 NA Dt Bottom Dosing NA Header Aeration NA Dist. Pipe lz:76 1-2, '.411 Holding- Bot. System 1375 Z 30 PUMP/ SIPHON INFORMATION Final Grade S~ Manufacturer Demand zLb° s T Model Number GPM inrJ a c.. ` r 02, 37 1,05 TDH Li Friction System TDH Ft Fo cemain Length Dia. H Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length r No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIME SYSTEM TO P / L BLDG WELL LAKE/ STREAM Manufacture SETBACK INFORMATION Type O CHAMBER -Model Number: System: e O 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: HUDSON 12.29.19,NE,SW 1054 MOON GLOW ROAD LOT 47 Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R.3/97) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: via.'■'■n SANITARY PERMIT APPLICATION Bureau o oand ff Bui Bui safety i g Water ldiinn Water System! 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. • See reverse side for instructions for completing this application State Sanitary Permit Numb .0-:1-t 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 5 L t-.C 6L_ 1 /4 kJ 1/4, S / Z T 2. , N, R E (oW Property Owner's Mailing Address Lot Number Block Number BOX 2- 9 Z_ C , State Zip Code Phone Number Subdivision Name or CSM Number iylD CL54t~1 ta.J1 S~{Q(C© (39(o) 2-74 7-,4 NNX >P'/ufoAC II. TYPE F BUILDING: (check one) E] State Owned !t Nearest Road E] Public 1 or 2 Family Dwelling - No. of bedrooms O rowan OF tJDSo# mov G40w AD 1111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) tt~~ 1 ❑ Apartment/ Condo ozv - 3 Z T 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. ❑ 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 11E] Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 M Seepage Trench 22 ❑ In-Ground Pressure 42E] Pit Privy 13 Seepage Pit 43E] 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) 97. zS 141(6k Elevation -7 S'o 7 S"Q - $ 9 ?1 tAw Feet 101,'.00 I of o Feet VII. TANK Ca in gacit gallons Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic APP New Existin structed Tanks Tanks Septic Tank or Holding Tank X 12.~b ® El 1:1 11 1:1 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) MP/MPRSW No.: Business Phone Number: l k i MI, DO u 04 4_ ?X 5 " C7?S'4V 3 b~(e 9 >L Plumber's Address (Street, City, State, Zip Code): 14>o vWtER_ ttt?G~r F, 9>, a0so VA W IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps) X Approved ❑ Owner Given Initial wQ Surcharge fee) J t~ 7 Adverse Determination 110 X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05/94) DISTRIBUTION: Original to Counly, One copy To: Safety & Ruildings Division, Owner, Plumber 4 I 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 Permi : 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:( 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 establ ishment' of standards. SA /P fl) l1C ~ TMWEY fID(S CaT' y7 IcSy m vvewtou) kopgq TiR] LoT # 7 16A~pcf f,' ys 20 ~viga ° I Zso C~A6, Ln am, 13-5 , CIF L s t Les w 72F,Uc N / U,~, ! q c.,ts, I 1 N~~H 'T2ENGH ~ . ~ 4,1 h i ALTE,Q~yy7r I t r9 ,e i h i I f I: too. Cc z~ z160,ta' Wisconsin Department of Industry, SOIL AND SITE EVALUATION-REPORT Page 1 of 3 Labor and Human Relations Division ottSafety l;< Buildings in accord with ILHR 83.05 ~d,._.ddlt COUNTY St. Croix Attach complete site plan on paper not less than 8 1/2 x 11 inches in si I ri mupjAopti efbut not limited to vertical and horizontal reference point (BM), direction an °0W slopea f of PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMAJDIiI t" REVIEWED BY DATE PROPERTY OWNER: - $ROPERTY'L.OCATION Sam Miller 'GOVT-L~T:g 1/du 1/4,S 12 T 29 N ,R 19 E (or) W PROPERTY OWNER%S MAILING ADDRESS L BLACK # SUED: NAME OR CSM # Trout Brook Rd... ' 2nd Addn to Tanne Ridge CITY, STATE ZIP CODE PHONE NUMBER ❑CITY VILLAGE EITOWN NEAREST ROAD Hudson Wi. 54016 ( ) Hudson Tanne Lane [ J New Construction Use (J Residential / Number of bedrooms Addition to existing building j J Replacement [ J Public or commercial describe Code derived daily flow gpd Recommended design loading rate bed, gpd/ft26 , 0 trench, gpd1ft2 Absorption area required bed, ft2 trench, ft2 Maximum design loading rate C),:Z , gpd/ft2D'~__Vench, gpd/ft2 Recommended infiltration surface elevation(s) - - - - - ft (as referred to site plan benchmark) Additional design/ site considerations Soil evaluation done for plat approval. Parent material Flood plain elevation, if applicable ft rU =Suitable for system C NVENTIONAL M UND IN- ROUND PRESSURE T AT GRADE SY TEM IN FILL HOLDING DANK = Unsuitable fors stem 40 S C1 U 9 S ❑ U F S ❑ U RI S❑ U WS ❑ U ❑ S 31U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Rxx)daly Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trends 6-I jbL1P3 1 - L 1 m bk /h r w Z IB; /6 43 7syp,4 4 SL r fh c W l~ 0, 5 Ground $ 43-7/ i` R 4 4 J S, L m Sbk' A-F CW Q,2 .3 elev. ~oJ 33 ft $ LIZ& 16-Y-00,444 S /h r rh - CS.7 0 Depth to limiting fVor Remarks: Boring # ` L i M sb /t-l r CL,J 24 o 0.`S Z• •-1 s' .i!~Yre 4 4 S L > r 1 w I~ b q i(~ .S 4 $Z -'S 16L4 4 CW Ground 0 •Z ~ elev. 3S -l2 b 9 S r ri-r) d. :6 g /Op.09 ft. Depth to limiting factor ,17 Remarks: CST Name.=PleaVarve G. Johnson Phone: 386-4080 Address: P.O. Box ,-91 Signature: Date: Oct. 96 CST Number: 3484 PROPERTY OWNER SOIL DESCRIPTION REPORT Page Z of 47 t PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounday Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed nT 3 -1 16 3 L I A Slob' /h r C w 2 0 A 0,13 S IL rn s br- W ~ CL,) z ,3 Ground 94 3- A 4 s r M L 6.7 O elev. loZ•'71 ft. Depth to limiting 71 factp~33 Remarks: Boring # /0 JP.3 / L S k fh Fr Cw 2 .s A o-7 1.4 C- Lj -7 16\1 k 4 Ground EZ 3-I3 3 S r M ✓ 636S elev. ft. Depth to limiting factor > /Q~3 Remarks: Boring # ~ $ Z-9z. I < yn t~ - S z L ~ ✓h 5 /vf~r C W I ~ Q ,~.Cj,3 Ground ~z Z-IZ YQq S ~a► rye 6, 6X elev. Depth to limiting factor > Ja,4Z Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: C"on 000/)/D /null)) A ~O~iLTu Qp- Sr-4L~ V, / O g z g_ a l .off ` i t1 4S ' ' -SLAIPL A t- V- "I eb 1) ❑ S \ 2S. _ D L~ ~9 0 STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER SA /Ii /Y1 I LL 0'!Z- MAILING ADDRESS d o X 2 8 Z PROPERTY ADDRESS I 0.5-V - tV 04IN' al -4 LL-) 12 nff (location of septic system) Please obtain from the Planning Dept. CITY/STATE 1-4 0,0,50 u W I PROPERTY LOCATION 1/4,5 w 1/4, Section Z- T__F 42-N-R W TOWN OF H U DS 4) A ST. CROIX COUNTY, WI SUBDIVISION T A K NF-!e 12 1046,C LOT NUMBER 417- CERTIFIED SURVEY MAP SS 1 35' , VOLUME Sf , PAGE 7 , LOT NUMBER V_ 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 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 "!"4A t1 j M I c- co- J l2--- Location of property /1/F- 1/4 Z ICJ 1/4, Section 1 2___ ,T Z 9 N-R 19 ;f W Township 1 u D.Sa g Mailing address t-='(`,Y '8 z Address of site MOON r--4C4A--' Subdivision name _ 74 u Kt t) R l j:~4Lot no. Y-7- Other homes on property? Yes2_No Previous owner of property $-)A N G A LL 3 5""V 14 N Total size of property Z , e, o A c_ Total size of parcel Z , pd o¢ L Date parcel was created 9'- 1 -'93 Are all corners and lot lines identifiable? 3-C Yes No Is this property being developed for (spec house) ? e Yes No volume 03/ and Page Number ~OS6 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. .;C 1)9 S S , 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. `ao S/~SS" Si ature of Applicant Co-Applicant -19 -5 Date of Signature Date of Signature • DOCUMENT NO. STATE B F WISCONS( ORS[ 1--1992 THIS •.r,CS sestNV[O ,o" asCOSOINO *.T^ ARRANTY D D - so~sss iot* 103iME456 rr::C1ST.ER S OF1CE This Deed, made between ....Randall . Synan and. Patricia E. S nan, .........X . ^ec'd tbrRecyd • husband and wife , j Grantor, SEP 1' 1993 and ...Sdt°_.......Mi... r.r...a...s.ingle: person...........- 1 V • i M Grantee. 1 Q-~ss►algseds Wlt2l e$59Lh, 1-hat the said Grantor, t4r a valnable consideration...... L Randall W. Synan and Patricia E. Synan conveys t A% Grantee the following described real estats• in S t . Croix SATURN TO County, State of Wisconsin: Taz Pared No:.......».....».....»............ " The SE1/4 of NE1/4 of Section 11; the SWl/4 of NW1/4, the N1/2 < of SW1/4, and the South 53 rods (874.5 feet) of the SE1/4 of NW1/4 except the East 74 feet thereof, all in Section 12; all in Y Township 29 North, Range 19 West, Town of Hudson, St. Croix County, Wisconsin. FF~~ AND ,a A parcel of land located in part of the NE1/4 of SE1/4 of Secti i + 11, Township 29 North, Range 19 West, Town of Hudson, St. Croix County, Wisconsin further described as follows: Commencing at the E1/4 corner of said Section 11; thence S89 30100"W, along the North line of the SE1/4 of said Section, 1212.32 feet to the point 'j of ;,eginning; thence continuing S89 30100"W, along said North line, 66.00 feet; thence SOO 28103"E, 500.00 feet; thence N89 30100"E, along the North line of Certified Survey Map filed in Vol. "30, Page 722, 38.08 feet; thence N00 11'33"W, 150.00 feet; thence N03 58134"E, 351.07 feet to the point of beginning. This 1.5..1.1Qt.... homestead property. (is) (is not) Together with all and singular the hereditament* and appurtenances tuereunto belonging; And..... R4.A4A.II...K!....Y.naH.. and-•Patr_i-9.ia.. E ~-..Synan warrants that the title is good. indefeasible in fee simple and free and dear of encumbrances except easements, restrictions and rights-of-way of record, if any. a and will warrant and defend the same. Dated this ✓.1............................ day of &U9.LlBt....................................... 19-9.1. d-~Y..... i~...(SEAL) vu#'Ok ,..,4~ !tie✓ / (SEAL) Randall W. Synan Patricia Synan • ......................---••---_......................••-••--•--......(SEAL) ............................(SEAL) " • • , r AOTHNNTICATION AOXXOWLSDOMBUT ' Signature(s) STATZ OF WISCONSIN i 1 it .t ace. 'I St. Croix Coanb authenticated this ........day of 19------ ft came s before August -ass ~1 ) . day of 19........ do abort maned Randall W. S Hari, Pati'r'icfa TITLE: MEMBER STATE BAR OF WISCONSIN S nan i . (If not, ~,Oj1A0i's i . authorized by 174W0d. Wis. Ststa.)" 11 to na knows to be the parson 13 N ~l~e I r ~ 4 z 0 Yl of - ~V+f (_L C9 N 2 ti o Q ~Y N ~ CL I o 1~ 0 a I z ~I ~ N 'F ~ I ltJ i 1 I o- a 1 I I tu ~ ~ a I LL . I w 1 I IV's a I CL Jj i w n W ~ 4 ~ v I ~ I i I O i a