HomeMy WebLinkAbout020-1325-00-000
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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER 5 4 t'h W 1l L f 2__
ADDRESS /d y 3 OW K) 6 tea) ttO14 p
SUBDIVISION / CSM#-Tfq Al Alf ✓ I L1 LOT #
SECTION Z T L% N-R /y Town of H y azt K)
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WIT FEET OF SYSTEM
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INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
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BENQ K: 2 1. 1~. Q S W acv ~(/1cI X00. O Q / Or
ALTERNATE BM: , I~ cam L~ O~%T00/~
SEPTIC TANK 41PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: W E /Z t64 Liquid Capacity: /QDo ,6,4c ,
Setback from: Well House Z. Other
Pump: Manufacturer Model# Size
Float seperation Ir"- Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Z
Width: Length (AD Number of trenches
Distance & Direction to nearest prop. line: 157
Setback from: well:- House / Other
ELEVATIONS
Building Sewer ST Inlet: ST outlet: Q7
PC inlet PC bottoAtftm Pump Off Header/Manifold 00f3" sL tem S, ~Q
Existing Grade /to Q Final grade //.10
DATE OF INSTALLATION:
PLUMBER ON JOB: hffi~..t..,_.
LICENSE NUMBER: oe JJa vw
INSPECTOR:
3/93:jt
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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 289305
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
MILLER, SAM HUDSON
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
JO. 1 CLlL J 020-1325-00-000
TANK INFORMATION ELEVATION DATA A9700119
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic ld~ ~y Benchmark '
Dosing
Aeration Bldg. Sewer
Holding St /Ht Inlet y p 3'
TANK SETBACK INFORMATION St/ Ht Outlet
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom
Dosing NA Header / Man. ~ x 9 Zg
.3,~ 9s S9'
Aeration NA Dist. Pipe 9S.S~
1q, 95 cr3.95
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand I t, 3 L a7.58'
Model Number GPM
TDH Lift Friction System TDH Ft
oss
F ead
oremain Length Dia. Fi Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Len th No. Of Trenches PIT No. Of Pits Inside Liquid Depth
DIMENSIONS 1/)_1 DIMENSIONS
LEACHING Manufacturer:
SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM
INFORMATION Type O iycu•-~ CHAMBER Model Number:
System: "_A 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: HUDSON.12.29.19,NE,SW 1043 MOON GLOW RD LOT 53
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Plan revision required? ❑ Yes "/No -
Use other side for additional information.
SBD-6710 (R 05191) Date nspe o s Signature Cert. No.
i
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
SANITARY PERMIT APPLICATION Bureau of and Safety B illdinggs ater uildin 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.
• See reverse side for instructions for completing this application State Sanitary Permit Num er
The information you rovide maybe used b othevernment agency IT
y p y programs ❑ Checi revision to previous application
e
[Privacy Law, s. 15.04 (1) (m)1. 104J M ( 0t) 610w R Cl State Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Property Owner Name Property Location
SAft) 8je 1/4 s /4,S Z T 29,N,R E( W
Property Owner's Mailing Address Lot Number Block Number
47 0 P, Z 8Z-- .5
City, State Zip Code Phone Number Subdivision Name or CSM Number
19 H I 5-d/ (3 gi~) X-.74, A P I O III
II. TYPE OF -BUILDING: (check one) ❑ State Owned ❑ itY Nearest Road
Public 70 1 or 2 Family Dwelling - No. of bedrooms E3 Vo(ag of c✓.1 ~QN 404>
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) ~1 /c/•
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 12E] 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,s[7( New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
__SystemSystemTankOnlyExisting 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 30E] Specify Type 41 ❑ Holding Tank
12-01 Seepage Trench 22 ❑ In-Ground Pressure 42E] Pit Privy
1 ❑ 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
V ~e Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation
Feet 117191,6' Feet.
VII. TANK Capacity gallons Total # of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existing strutted
Tanks Tanks
Septic Tank or Holding Tank t" a k1'., -M ❑ ❑ ❑ ❑ ❑
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:
Plumber's Address (Street, City, State, Zip Code):
o 70 14 U NT-r- g-R 11:. F_ ",O~ lip v lo a ~ae
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No S
((Approved ❑ Surcharge Fee)
Owner Given Initial /
Adverse Determination 1000
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05/94) DISTRIBUTION: Original to County. 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_ 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 13 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.
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Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3
Labor and Human Relations
Division ofSafeRy rf Buildings in accord with ILHR 83.05, WIS e
COUNTY
St. Croix
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but
#
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or flARCEL 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
Sam Miller GOVT. LOT 1ASGO 114,S 12 T 29 N,R 19 E (or) W
PROPERTY OWNER':S MAILING ADDRESS C~, BLOCK # SUED. NAME OR CSM #
Trout Brook Rd. 2nd Addn to Tanne Ridge
CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE _MTOWN NEAREST ROAD
Hudson Wi. 54016 ( ) Hudson Tanne Lane
[ New Construction Use [kJ Residential / Number of bedrooms Upiy- Addition to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow gpd Recommended design loading rate O 1 bed, gpd/ft2jD 1-trench, gpd/ft2
Absorption area required bed, ft2 trench, ft2 Maximum design loading rate 6._7 bed, gpd/ft2(% % trench, 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 It
S = Suitable for system NVENTIONALUND IN-GROUND PRESSURE AT-GRADE SYSTEtd IN FILL HOLDI
U= Unsuitable fors stem S❑ U S❑ U IM SCI U ~J S❑ U 20 S❑ U 13 SNG ANK
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence BRoots GPD/ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench
/D 3/ m r m r- C f,v Z • .5
Ground i 6Y94/4' - SL A, S b /h ~r CL-Ij Q 'S
r e6p -_3tt. {~3 9-13 d`/ 3 S n~ r n11 V 6,7 O
Depth to
limiting
factor
!D-
Remarks:
Boring #
L 10A
S 12-38 o z q 5, C J rP, sbk A Ac L4 1 s~' .2 .
Ground ~2 -bZ ,24 - SL YK 5LK /'►'+`f' Cw 0, i~-S
elev.
b Z ~Z 0`lR 3 r ri► -
/00 .0 It
Depth to
limiting
factor
Remarks:
CST Name: Pleasgarve G. Johnson Phone: 386-4080
Address: P.O. Box 1
Signature: Date: Oct. 96 CST Number: 3484
PROPERTY OWNER SOIL DESCRIPTION REPORT Page of
PARCEL I.D. # 3
Depth Dominant Color Mottles Texture Structure Consistence Roots GPD e
Boring # Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bou nd~vy Bed ir
Ei3 /o-44 /OYPQ s s~ , rn w s
Ground ~i 44-IZ 4-14 s I'I1 s /h~ 0,? 0
-
elev.
ft.
Depth to
limiting
fa for
~11?
Remarks:
Boring #
Q O. / / J L l i'M c r rn w 4 •S~
-29 Y44 5<< //I, -.Lx r-h ~r w I 0 d .3
<<>v:< $ o Q 4/4 S L 1 rn s~k n~ r C W 6 2 0
Ground
nil,
ICA ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground _ S L 1 n, slot t i,0 d d,
$i 7-76 /WS
r yh 4, d
110 elev.
ft. $3 6-1 2 44
Depth to
limiting
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
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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 il> 14 z eaL
Location of propertyrl/4 541 1/4, Section Z TZ9 N-R 1,9
Township P dD.50~" Mailing address 80,k'
Address of site /C~ S~ /1 ^G CSLfCO Ge 1 ,.s"
Subdivision name ! % /~7+` Lot no.
Other homes on property? Yes ~ No
Previous owner of property 44-.- k AI A Al
Total size of property
Total size of parcel r
Date parcel was created' ~r
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)? -Ik' Yes No
Volume / 0 31 and Page Number Y) 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. , ;r ilgT r , 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 o Applicant Co-Applicant
F,
Date of Signature Date of Signature
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STC- 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
O WNERIBUYER =11 t i l /tit 1 c- t_ J i2-__
MAILING ADDRESS
PROPERTY ADDRESS I A! n C,c-.° ~
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE N v Q 5 n N i,-
f \'7' `r
PROPERTY LOCATION 1/4 t~,.~ 1/4, Section 2.. T 2 '-7 N-R a
~
TOWN OF ST. CROIX COUNTY, WI
SUBDIVISION 7NV A177 ~e P- / J ~2 LOT NUM13ER
CERTIFIEDSURVEYMAPr5 G. ,VOLUME ,PAGE LOT NUMBER s 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 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.
UWe, 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 retumed to the St. Croy
County Zoning Officer within 30 days of the three year expiration date.
SIGNED:
DATE
St. Croix County Zoning Office
Government Center
1101 Carmichael Road /93
Hudson, AV'I 54016
DOCUMENT NO. STATE BA F WISCONSI ORM 1-1"2 THIS 904ce ■esaaveo FOR e[CO"OI"O oATa
_ ARRANTY D VD
504855 VOL IMIPAGE 456 _ `T r~ C~/~
~l'• CIS T c q'.S OI~ILE r
This Deed, made between ► = -':'Y CO..ISIO
Randall W. Synan and Patricia E. Synan,
ec'd 'tx Record
husband and wife
_ Grantor, SEP T 1993
and ..Sam... E.-...Mi... Ler.r...a...s.l.n9.le...person 10:4~ O A.-'M
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Grantee I Q":~s e. ~1 Desds
Witpesseth, That the said Grantor, fqr a valuable consideration......
'r Randall W. Synan and Patricia E. Synan
conveys to Grantee the following described real estate in ..St . Cro I X aarUR" To
County, State of Wisconsin:
.f
Tas Pa" Uo
The SE1/4 of NE1/4 of Section 11; the SW1/4 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
Township 29 North, Range 19 West, Town of Hudson, St. Croix
County, Wisconsin.
AND
A
A parcel of land located in part of the NE1/4 of SE1/4 of Section
' 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 3010011W, along the
North line of the SE1/4 of said Section, 1212.32 feet to the point
q of Beginning; thence continuing S89 30100"W, along said North line,
66.00 feet; thence SOO 28103"E, 500.00 feet; thence N8q 30'00"E,
along the North line of Certified Survey Map filed in Vol. "3",
Page 722, 38.08 feet; thence N00 11133"W, 150.00 feet; thence
N03 58'34"E, 351.07 feet to the point of beginning.
g! This i.,S...AQt<..._ homestead property.
r (is) (is not)
Together with all and singular the bereditaments and appurtenances thereunto belonging;
And..... RaAda.11--- _._-.$yna.n-- and__-Pa.tr_i.c.i_a---E.,-..Synan,_.._
warrants that the title is ood .
,indefeasible in fee simple and free and clear of encumbrances except
~
easements, restrictions and rights-of-way of record, if any.
.al
and will warrant and defend the same.
Dated this ............J_..........._..... day of ....thug.us.t....................... 19...4.3..
G~Ytd' l i ....04"... (SEAL) tllaLl~.u . E.A4 ~i✓ (SEAL)
' Randall W. Synan Patricia Synan
..(SEAL) ...................(SEAL)
c. AUTHNNTICATION ACENOWLEDOMBNT
Signature(s)
STATE OF WISCONSIN
r i
ti.
St. Croix
n ....................................County. )
authenticated this ........day of 19.....
_ P rally came before me 3_.t........ day of
All Auguste
, 19........ the above named
.
Randal_ 1 W. Synan,...Patricia-----
I TITLE: MEMBER STATE, BAR OF WISCONSIN Synan
(If ot, . A. .
b by 4 706.08. Wis. Stata.).._....---........... ~ICt Ox
authorized ••..p 1
to me known to be the person ..9.......NEc e I
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