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HomeMy WebLinkAbout020-1325-70-000 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER SA M Al (Le- E ` ADDRESS S 3 7 1110 CND€'~4l6l SUBDIVISION / CSM#_ "T/t1 O K.ES! & # 0 C,E LOT SECTION 2.- T ZEN-RTown of 14 J D --c,a ST. CROIX COUNTY, WISCONSIN . PLAN VIEW SHOW EVERYTHING WI HIN 100 FEET OF SYSTEM WELL NOT ffT P f - 140 c: S E I ~S ,0TSq 3a r ~o~Cpfa 50 u7 ! t INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. i } 13ENCHMARK: T6 P a F I„ r~ I P f<7 E etk ill F 4 C C,• ALTERNATE BM: 7b~ ic F1 ~Q ~IIo U f 1 d N f f SEPTIC TAN / PUMP CHAMBER / HOLDING TANK INFORMATION Manu acturer: l.l~ f e,~ t, Liquid Capacity: l Q 0 U r A 4, Setback from: Well House 14~4 f , Other I -S G 7. /c,f Pump: Manufacturer Modelf Size Float seperation- Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: Length (gam Number of trenches Z... Distance & Direction to nearest prop. line: o Setback from: well: D House y` Other ELEVATIONS Building Sewer T- ST Inlet:` tl = ST outlet: (C - PC inlet.--, PC bottom Pump Off Header/Manifold Bottom of system ~~•g = Existing Grade 7 l L) A Final grade '7 ( Q DATE OF INSTALLATION: PLUMBER ON JOB: ( LICENSE NUMBER: ) C_'a , oeet, INSPECTOR: 3/93:jt Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count Safety arid Buildings Division o , 5 'ST. CROI X INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar~ it1N~.: Personal information you provice may be used for secondary purposes (Privacy L , s.15.04 (1)(m)]. _2armit alder'iiW: [ llage ❑ Town of: State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description: J1V Parcel ti2bQ-;13 25-70-000 93, F0 zZTANK INFORMATION ELEVATION DATA A9700222 3 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic p>>v Benchmark ~I I , Dosing- Aeration Bldg. Sewer Holdi St/ Inlet ZD TANK SETBACK INFORMATION St/ ICE Outlet /U+~z 9~~93' Vent TANKTO P/L WELL BLDG. AirIto ntake ROAD Dt Inlet - Septic NA Dt Bottom y Dosing NA Header4*1xn. Aeration NA Dist. Pipe 11,215 /i 18 ~VD, 3,2' Holding Bot. System ~a+30~~.aa 1, 'J PUMP/ SIPHON INFORMATION Final Grade 7`5+ 93,971 Manufacturer Demand ;7 EF a GPM Friction ys Ft Length Dia Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width 1 Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS p SYSTEM TO P / L BLDG WELL LAKE / STREAM L adurer: SETBACK INFORMATION Type Of rl tZj a - CHAM Moe Num er: " System: E_lrN~ OR IT DISTRIBUTION SYSTEM Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spacin Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At- a Systems On y Depth Over Depth Over xx Depth ¢f-°` xx Seeded/ Sodded xx Mulched Trench Center @>I-!Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON 12.29.19,SE,NW 839 MOON BEAM RD LOT 60 Plan revision required? ❑ Yes 9-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: ~~~LA■~ Safety and Buildings Division SANITARY PERMIT APPLICATION Bureau of Building Water Systems In accord with ILHR 83.05, Wis. Adm. Code 201 E. Washington Ave. P .P. 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. S-L • C-r-ON • See reverse side for instructions for completing this application state sanitary Pe91 rmiitt Number The information you provide may be used by other government agency programs °2 $ 111 (Privacy Law, S. 15.04 (1) (m)]. ❑ Check if revision to previous application State Plan I.D. Number. 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Owner Name Property Location 5£ tl4~yt;v 1/4, S 2., T r N, R /9' E (oriz) Property Owner's Mailing Address Lot Number Block Number City, State Zip Code Phone Number Subdivision Name or CSM Number PW N uJ i+ N t (3W. ) 'z?r ~I MNE /DGE II. TYPE F B LLDING: (check one) ❑ State Owned [3 City Nearest Road Public 211 or 2 Family Dwelling - No. of bedrooms Town ❑ village OF #6)0S0 N MOON Nil III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1❑ Apartment / Condo d z o -is?-5-7o 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. PC 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 ❑ Hblding Tank 12XSeepage Trench 22 ❑ In-Ground Pressure 42E] Pit Privy 13E] Seepage Pit 43E] Vault Privy 14E] 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 ~Q Required (sq. ft.) Proposed.(sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation :5-4 3 + Z Feet 9iK Feet VII. TANK Capacity INFORMATION in gallons Total # of Manufacturer's Name Prefab. Site Fiber- Ex per- New Existin Gallons Tanks Concrete Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holding Tank oc UJ~/5 ❑ ❑ ❑ ❑ ❑ 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) ZMP/MPRSW NO.: Business Phone Number: _111VIAr A64:!, 5-0 lumber's Address (Street, City, State, Zip Code): 0-7f U/~ ~/C /JD<o~ M0.4111-.0 U D Sa Ltt/~ Q~'~ IX. COUNTY/ DEPARTMENT USE ONLY ❑Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue IssuingA entsi XApproved ❑ Owner Given Initial p~'~ i Surcharge Fee) Adverse Determination~0 U ~t'/a 7~DZ~ X. CONDITIONS OF APPROVAL-/ REASONS FOR DISAPPROVAL: SBD-6396 (R. 05194) 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 V;suing 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 equested for numbers 1 through 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. s /°r► A)/ L L E /;d.- ?,4 k JI.F y J I DL c,Tm q* <.o 83q M00114'r oA`! 710" ~ ST F qt0, ze E LF /0 ' ~~w~ d!~'' ~ o3Sao 1 1 R r~1 i Uj ~ 3S a Y ~9 ~70~ I A,( .4 G 14o -al Y, 5 9 iro Q~1 4d lo' ~ o 0 1 ~o N OT.E ; 5 L LaT To $ E N ' i "'A DE 70 UfainTMirV (,1~ieT ,q M DE P7/14 s• ~ J J J ~ n W i i i t 1 Wisconsin Department Industry, Labor and Human Relations SOIL AND SITE EVALUATION REPORT Page 1 Of 3 Divi,ion of Stety & Buildings in accord with ILHR 83.05, W. . t „ COUNTY St. Croix Attach complete site plan on paper not less than 8 1/2 x 11 inches in sizes rust inpWe, but not limited to vertical and horizontal reference point (BM), direction and qt' a4 slope; .3cele;or` ' WCEL I.D. # dimensioned, north arrow, and location and distance to nearest road APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATI*O'N REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION Sam Miller GOVT.LOT 'jJE 1/4 r4Lji4,s 12T 29 N.R 19 E(or)W PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUED. NAME OR CSM # Trout Brook Rd. 66 1 2nd Addn to Tanne Ridge CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE OWN NEAREST ROAD Hudson Wi. 54016 ( ) Hudson Tanne Lane (j New Construction Use Residential / Number of bedrooms [ j Addition to existing building j J Replacement [ ] Public or commercial describe Code derived daily flow gpd Recommended design loading rate bed, gpd/ft2 trench, gpd/ft2 Absorption area required bed, ft2 trench, ft2 Maximum design loading rate 0:? bed, gpd/ft2o 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 ft S = Suitable for system CONVENTIONAL M~QUND IN-GROUND PRESSURE ~r GRADE ~~Y,,ssTcM IN FILL HOLDING K U =Unsuitable fors stem S ❑ U ~l S ❑ U ®S ❑ U ® S El U ®S ❑ U ❑ S Gru SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounc~ry Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed T rnch ovhk 3 - L I rh bk r C S 2 o ,j 6:5 4 >&-43 /UYp 916 - S) C 1 A 5lok t4 'r C s U.Z 3 Ground 3-7/ /Q`/ 5 Q fn jr rh I Cs Q.S ~.b e1L 9 ft. 8 1-1 1 /bvP, 11A Depth to limiting factor 7 ~0,9Z Remarks: Boring # A O-z~ /d~ >e z - L I kf~, n -Fr CW Z~ 0A O S -61 C) uj 6,1 A? Ground $Z KS3 16Y4414 sit rh 5bg M I trI o.Z 0.3 9e e7 ft g3 `3 /3~s /OYP- 44 S ©!rI ,r ✓h p,~ •o. Depth to limiting factor D, 3 Remarks: CST Name:-Plea sPrint Phone: 386-4080' arve G. Johnson Address: P. Bo 91 Signatur Date: Oct. 96 CST Number: 3484 PROPERTY OWNER SOIL DESCRIPTION REPORT Page of 3 PARCEL I.D. fJ~ Boring # Depth Dominant Color Mottles Texture Structure Consistence Boundary, Roots GPD/ft Krizo in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed rends 3'. O- /O~~Q3 L r b~ ~c.~ Z O A .S S,L sbK w 02 3 -ZZ / 6VP, 4 Ground `4 D`/R 0 A G W ~6 3 IL I 1 1094 5' S 0' Q rw r 4 'O Depth to limiting factor Remarks: Boring # --c A 0-► L jlhSb~ rn~r CUB v .4 $ p /~2 3 S, L -F cw 6,i 0.3 g 37-57 ~Oyr2 ~ S ~ L ~ 11/1 r r►ti Ccv 0.2 ~.3 Ground elev. 7124 /aye 13 p4 r 9Q ft. Depth to limiting factor Remarks: Boring # Q 10-2-2- L ~►sb rn ~ cs IoA ' ZT) Z~ /dY2 4 'S, L 1 >v1 s CS - 0-2 c~ 3 2-6 7SYR 4 Q SL S 6 Ground elev. 93 0-21 16`/12 5 m r m O.7 d$ Depth to limiting fact y iD~z Remarks: Boring # . Ground elev. ft. Depth to limiting factor Remarks: con_o"Ato nr/09) p r Irl~~ti ~E~~ ~LS~ NI I VLIRTH 1 'SG►1lC ~'~p~ i i hh !C 4 N i/ 66 V 9-3 I B- A i _ I $E~rhb,2k. IMP U) PPF" m I I~ : I Q -u I N m I 4 I o I ~ I r y, N I Z Rjo I I \ W z I ~ (Oi - o -K y 0 µ Fli Z o LAO O ~ 0 4 z A • 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 Location of property_S!f_1/4 NW 1/4, Section/ Z. Township F+ u 0,So M Mailing address B og* Z*,-L_ 14v.t--so'N 1-ki 1 5- s/oI(o Address of site 3,01 M6 Al A j"A N R© A41 Subdivision name `r'A N UF-W k 1 <0A Lot no. Cop Other homes on property? Yes_,~(_No Previous owner of property R K t 6'uL tyA m Total size of property 2 DO < Total size of parcel 7?, © O Date parcel was created ° / Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house) ? Yes No Volume (03 1 and Page Number q3%0 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. S© Y6 ;,5"_ , 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. Ki~naturj of Applicant Co-Applicant 7-/-77 Date of Signature Date of Signature STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER L C r le MAILING ADDRESS x " ;Z'- PROPERTY ADDRESS 16 3 7 • A'D61t/ 4?j5i4/l;1 (location of septic system) Please obtain from the Planning Dept. CITY/STATE y Q 50 N w f S f~J / G PROPERTY LOCATION 5F- 1/4, 1/4, Section / Z.._ T c'7 N-R / . W TOWN OF ~4 U 10S 0,V , ST. CROIX COUNTY, WI SUBDIVISION T A N,► E- y k l u , LOT NUMBER CERTIFIED SURVEY MAP f 5 r4~;VOLUME!o , PAGE 7S, LOT NUMBER 4o 0 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 DOCUMENT NO. STATE BA &+F WISCONS1 0RM I- 19U TNU 90ACt RCSIRV90 FOR RRCOROINO OArA ARRRANTY D D 504855 YOL 10 31►AGE 456 r CGSTC-1 OF~CE This Deed, made between _ y OO..I~ Randall W. Synan and Patricia E. Synan, - n d r fe Re coed ec',j br R'd h u sba • _ nd a . Grantor, $ EP T 1993 and ..Sam..E hli_1.1er a ..-.........n9.le...Fe.rs... . ct 10:4 O i; M Grantee, a-;~,~. oesm► wittiesseth, That the said Grantor, for a valuable consideration...... Randall W. Synan and Patricia E. Synan conveys to Grantee the following described real state in ...St.. Cr.'O Ix R&TURN TO County, State of Wisconsin: Tax Pascal `i<o:................................... 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, Torn of Hudson, St. Croix County, Wisconsin. AND ,d 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 lludson, 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 of -eginning; thence continuing S89 30100"W, along said North line, 66.00 feet; thence SOO 28103"E, 500.00 feet; thence N8q 30100"E, along the North line of Certified Survey Map filed in Vol. "30, Page 722, 38.08 feet; thence N00 11133"W, 150.00 feet; thence N03 58134"E, 351.07 feet to the point of beginning. 41 This ...-i.,4...AQt---- homestead property. n (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And. --Rcl.n!ikl.l.•W_..... yna-n__and Patricia E. Synan warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements, restrictions and rights-of-vay of record, if any. and will warrant and defend the same. ti 111 Dated this day of .........A11g.us.t......................................., 19...9.3.. ....lY!!^J---(SEAL) ~701r1L.<ceV.t~. .........................(SEAL) ' Randall W. Synan Patricia l Synan • .r, - (SEAL) ...............(SEAL) • . • t AUTHBNTICATION ACENOWLISDGMUNT Signature(s) STATE OF WISCONSIN i r, as. St. Croix ...................................County. authenticated this ........day of 19.....- Pe;aonallcame before me 31........ day of Augu . st _ 19. . the above named 3 Randall W....Synan,...Patrfci.. E~........ i TITLE: MEMBER STATE BAR OF WISCONSIN Synan . (If not, . A. . authorized d by 1 708.08. . Wis. Stat 3tata.) p.. ~i N:l~c e I to me known to be the person .5.......