HomeMy WebLinkAbout020-1325-80-000
ST. CROIX COUNTY ZONING DEPARTMENT
AS BUILT SANITARY REPORT
Owner _5A t1-1
Address 2ro x ,#,t / / 43 y 1 n4oe w l I" std 5 r
City/State H v b. eau w r , -Yo IL
Legal Description:
Lot Block Subdivision/CSM # if 11f NI
tom, Sec. I2., TZ? N-Rff W, Town of A/ of,l~ n -PIN # .SEPTIC TANK DOSE CHAMBER HOLDING TANK INFORMATION:
Tank manufacturer W 1 r S C ric- Size ST/PCI°10`6 / Setback from: House/ Well S®tp/I, !62..~
Pump manufacturer - Model
Alarm location +r
(HOLDING TANKS ONLY)
Setbacks: Service roadVent to fresh air intake Water Line
Meter location
Alarm location
SOIL ABSQRP I`ION WSTEM:
Type of system: 4 Width Setback from: House z.~' Well ' Number of Trenches Z•`
_ P/L _,Co Vent to fresh air intake _7 5
ELEVATIONS:
Description of benchmark Ad /
Description of alternate benchmark p o Elevation
"'o Elevation
Building Sewer ` ST/HT Inlet EI~,ZS ~
ST Outlet- ! * RI`P~C °
Inlet r---•
PC Bottom r Header/Manifold Top of ST/PC Manhole Cover
Distribution Lines O IG , 1~? '~7) ( )
Bottom of System Ea ~J ( )
Final Grade q9, Zs
Date of installation tS_/ $Permit number
State plan number ,
Plumber's si a re License number
Inspector
Complete plot plan or
f e
Y ~
NOTICE: Please provide the following:
• A plan view sketch showing everything within 100 feet of the system.
• Two horizontal reference points to center of septic tank manhole cover.
• Show alternate benchmark, if applicable.
PLAN VIEW
/y?o e
I S
1 26
13
INDICATE NORTH ARROW
afety an Department Commerce
Safety and Buildings Division PRIVATE SEWAGE SYSTEM County:
INSPECTION REPORT S4. Cra ; x
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-:
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. p99 / ~-7
Permit Holder's Nam [I City El Village El Town of: State Plan ID No.:
er
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
To C Ir r ors
01 01;110 _/3A5__
TANK INFORMATION E EVATION DATA M-700SIV
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
COO Bench o2.0 ~D6 8 O
Dosing .05- 96.75-
Aeration Bldg. Sewer t4 ti
Holding St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet a, p
TANKTO P/L WELL BLDG. Air I to ROAD Dt Inlet
Air Intake
O q5+ 15 8 NA Dt Bottom
Dosing Header/ Man. 10.0 °/D• '7
Aeration NA Dist. Pipe 11.400 87. sa 819,
Holding Bot. System 12• IZ.ZZ 88./S -a8.
PUMP/ SIPHON INFORMATION Final Grade 7 8 91,r,
Manufacturer errand +T2-NqA 6V f L.Z 9r/. 8
Model er GPM {}L
TD Lift Friction S m Ft
Force Len Did. Dist. To Well
SOIL ABSORPTION SYSTEM
DIMENSI E N Width S Length ~D No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS
SYSTEM TO P/L BLDG WELL LAKE/STREAM LE HING Manufactu
SETBACK
INFORMATION TypeCiCHA BER Model ber:
Syste (-'38 55 OR UNIT
DISTRIBUTION SYSTEM
Header / Manifgld Distribution Pipe s) , - p x Hole Size x Hole Spacing Vent To Air Intake
Lengthy Dia. Length Dia. _(l~~ Spacing !O AST"
S W a7ZGt 8 s l
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over rl Depth Over Depth Q9 OZ-AA-A mulehed
Bed /Trench Center 38 q?j Bed/Ire ges Topsoil E] Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
I) At-+• gm - 13 o Am o-r- sad;
Pi n.wl `j - /S"- '1
Plan revision required? ❑ YeXan.
Use other side for additional inftti,
S
BD-6710 (R.3/97) Date ector's Si ure
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ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNERBUYER S/} ytil 1~,a I L C. f'j2,.__
_tf
MAILING ADDRESS
PROPERTY ADDRESS &QCA / 6E~~ T
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE 1] I) C yet`. L c.1 / q D PROPERTY LOCATION 1/4, _ /t/ U-) 1/4, Section I Z T 7 N-R /1
TOWN OF P V' L) 0 / ST. CROIX COUNTY, WI
SUBDIVISION 7/4 N A/ E / I L Si LOT NUMBER
el-
CERTIFIED SURVEY MAP S Ito?,
VOLUME (,o, PAGE -7-'17 , LOT NUMBER (o
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: 0_ i
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
1
. r
' wo~iEiniiro
Safety and Buildings Division
ANITARY 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 81/2 x 11 inches in size. ' t.c4e 0
• See reverse side for instructions for completing this application State Sanitary Permit Number
299' 141-7.
The information you provide may be used by other government agency programs / ❑ Check if revision to previous application
[Privacy Law, s. 15.04 (1) (m)]. M1 MOW (q~.l/~ y~ State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Property Owner Name Property Location
S`i¢ 01
L fZ. c 1/4 1/4, S/ Z T 2 1 r N, R E
/0 41,
Property Owner's Mailing Address Lot Number Block Number
City, State Zip Code Phone Number Subdivision Name or CSM Number
ffvvsoN yoi~ (.3g~>g~gz.. TA ~iD~E hd
II. TYPE F BUILDING: (check one) ❑ State Owned E] It~/ Nearest Road
Public 1 or 2 Family Dwellin - No. of bedrooms ❑ ~irTowgn OF ~l `~12SOnl IYICb G+/1 '7"
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) a • 01
1 ❑ Apartment / Condo LD 3 Z s ~d / f ~+P
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 Systerrl
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 § f 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) vG Elevation
Feet Feet
VII. TANK Capacity
in gallons Total # of Prefab. Site Fiber- Ex er.
INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel Plastic p
New Existing structed glass App.
Tanks Tanks
r X 600 w i s EH ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ 1 1:1
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (jPrint) Plumber's Signature: (No StamUsj MP/MPRSW No.: Business Phone Number:
1,11%, -!00N4l5L4- ~ M1.4
Plumber's Address (Street, City, State, Zip Code):
70 H I../,y rC /t_ /Z 1 D ff e-) Ps c) A(
IX. COUNTY/ DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing Agent Signature (No Stamps)
Surcharge Fee)
CRApProved ❑ Owner Given Initial ~D }2,15.,q-7 p
Adverse Determination D /L~{
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05/94) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
i e
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:
I. 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 w th 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.
wsconsip°' SOIL AND SITE EVALUATIOORT Page 1 of 3
'Labor and Hi
Divisk)nofS LV l*'
in accord with ILHR 83.05,~~t Adm a ~'f WCOUNTY
Croix
Attach cor 18 1/2 x 11 inches in si2,9. Plan must uictrde; but t
not limited oint (BM), direction ands W of slope `scale,oIr I.D. #
nsior :ance to nearest road. DZO - 1325- g~
dime
61 ~~z ~fIEWED DA~
~ 5- TINT ALL INFORMATION JY -
APPLIC~ ~
PROPERTY LOCATION
PROPEh i , _
Sam Miller GOVT.LOT SE 1/4dLj1/4,S 12 T 29 N,I1 19 E(or)W
PROPERTY OWNER':S MAILING ADDRESS Lp T~ BLOCK # SUBD: NAME OR CSM #
Trout Brook Rd. o 2nd Addn to Tanne Rid e
CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE E]TOWN NEAREST ROAD
Hudson Wi. 54016 ( ) Hudson Tanne Lane
New Construction Use [~Cf Residential / Number of bedrooms 3 Addition to existing building
j ] Replacement [ J Public or commercial describe
Code derived daily flow _ gpd Recommended design loading rate -7 bed, gpd/ft2 8 trench, gpd/ft2
Absorption area required 03 3 bed, ft2 5 (y 3 trench, ft2 Maxi um design loading rate C).-Ibed, gpd/ft2 o .T. trench, gpd/ft2
Recommended infiltration surface elevation(s) - (as referred to site plan benchmark)
Additional design/ site considerations Soil evaluation done for plat approval. LtW ~,*.V1~rc
Parent material Flood plain elevation, if applicable C-~ ft
S = Suitable for System VENTIONAL MOUND IN-GROUND PRESSURE AT-GRAD SY TVA IN FILL HOLDING TANK
U= Unsuitable fors stem S❑ U ❑ S op JS ❑ U ❑ S J U OS ❑ U ❑ S [MU
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence BoLUxiary Roots GPD/ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trer&
A 0-2b 14`1+ 3 L m S Yh r CS 1 6, d
U , A v-~I' I~L-l -
17
0 3
Ground I m s b k- m g T 1 Lj 62
elev.
16Z ft 12 p 4 >n r h'► ? O g
Depth to
limiting
factor
Remarks:
Boring #
O `Sr
a A 6-13 1byo-4 3 L. S b~ 1Y► r e,C, d A
A Z 6> >.3-2-s /6--/t2 4A s rl t h K n7~ L.J - 0,2 0.3
6Z - IZ 101,2 4 D r^ m 1 a.7 0
Ground
elev.
ft
Depth to
limiting
7f%p r4
F
Remarks:
CST Name:-Plea a'rve G. Johnson Phone: 386-4080
Address: P.0. Box
Signature: Date: Oct. 96 CST Number: 3484
PROPERTY OWNER SOIL DESCRIPTION REPORT Page of 3
PARCEL I.D. # u 1
Depth Dominant Color Mottles Structure GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont Color Texture Gr. Sz. Sh. Consistence Bon y Roots Bed Trench
O.Z 3
1 i~9 dtl+~ _ S, L 1 rrn s m -Fr C LO
Ground $ L61 /O~l2q _ S ~'h r ml C5 .7 1
elev.
ft. /-/Z 16YR413 S mar-
Depth ~ 0
to
limiting
factor
y. .5g
Remarks:
Boring #
d -IO IPn / - L 1 rhsk nTC 5 p.4 o
Ground $-2 /Oy+2 4 - SL r Yh l L~ U.S O.~
3v4 ft. 6-~0 7. SY' 4 s n, r v~ Cw _ O . S o . G
8
Depth to a-i /oL/ 46 S m r N 6-~ o
limiting
fat ~
Remarks:
Boring _
1M0" /
m Sing r,,, ~
La r Cs ~ o .9 o S
S C A
Ground S 1~r^ c J
~~ev~. BZ ST/291 / D y 4 3 S ,M r m d •7 W?
`7y b ft.
I
Depth to
limiting
factor
y ~ I
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
con "Into nF aln
t 8 T C - 100
This application form is to be completed in full and signed b
owner(s) of the property being developed. An inade y the
only result in delays of the permit issuance. Shout s will
development be intended for res by owner/contractor, Should this
house), then a second form sh uldd be retained and compl ted
(spec
the property is sold and submitted to this office with
when
appropriate deed recording. the
-
Owner of property SAY
~r
Location of Property 1/4 ~/4 Section J.
Township V Q J~ T N-R W
Mailing address
Address of site y 1
Subdivision name N 1J N 4'
IZI
Other homes on Lot no.
property? Yes-y--NO
Previous owner of property 0.
S
Total
size of property
Total size of parcel
Date parcel was created 11 - c~
Are all corners and lot lines identifiable?
Is this propert k Yes No
y being developed for (spec house) ? X
Volume 19 I Yes __NO
and Page Number .~(o as recorded with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DO
NUMBER AND THE SEAL OF THE REGISTER OFT DEEDBS R' VOLUME AND PAGE
certified survey, if available, would be helpful so asdtol avoid
In ad, delays of the reviewing d
references to a Certified Survey ss. If the deed description
shall also be required. Map, the Certified Survey Map
I PROPERTY OWNER CERTIFICATION
(We) certify that all statements on this form are true to the
best of my (our) knowledge that I
property described in this (We) am (are) the owner(s) of the
warranty deed recorded in the Hoff a lof form, by virtue of a
Deeds as Document No. the County Re
own the gister of
Proposed site for and that I (wm presently
obtained an easement, to runt the above descpribed system or I (we)
construction of said system property, for the
the office of the Count ~ and the same has been duly recorded in
y fice Y Register of Deeds as Document No.
Signature of Applicant
Co-Applicant
2 /3-~
Date of Signature
y 4
1-1941 r"IS sr,ca "ssc"vso FOR "aco" I'a o~ra
DOCUMENT NO. I STATE BA F WISCONSI eD
ARRANTY 0 504
85s.. ioL 103i►ME 456 r
f CISTER,S OFF-1CE ~
This Deed, made between
E. S nan, i C0.od
Ra.nda.
.ll W. S nan and Patricia ;ec'a for ReooN
Y X..
. wi.fe. t
. and
. . .......husband
Granter. ~ SEP 1' 1993
and ...Sam Mil:1er.....a single person at 10:45 - A:•M
a-rb~e.~loseas `
71 ~i
Grantes,
Witne3Seth, That the said Grantor, fqra valuable consideration
Randall W. Synan and Patrlcla E. S nan
. .......Cro i x To
i conveys to Grantee the following described real estata in St..
County, State of Wisconsin:
Tax Pareel .40:....w...«..»
The SE1/4 of NE1/4 of Section 11; the SWl/4 of NWI/4, the N1/2
< of SW1/4, and the South 53 rods (874.5 feet) of the §E1/4 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. Fw]
^r~ AND ?~'FW
~
i
,A A parcel of land located in part of the NE1/4 of SE1/4 of Secti'1 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 30'00"W, along said North line,
66.00 feet; thence SOO 28103"E, 500.00 feet; thence N8q 30100"E,
Y 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.
i This IM..111Qt-... homestead property.
(is) (is not)
Ilk Together with all and singular the hereditament@ and appurtenances tuereunto belonging;
And..... RA.tldA.U.- K!...SY.nan.-and,-Patr.i ia.. E ~...SY.nan
warrants that the title is good. indefeasible in fee simple and free and clear of encumbrances except
easements, restrictions and rights-of-way of record, if any.
and will warrant and defend the same.
Dated this day of A11$u8...................................... . 19..41.
.
......~T...........!. ...(SEAL) .~dG`Fli04!i.C~..4~ ~'it.✓...........................(SEAL) ,
V
• Randall W. Synan Patricia . Synan
_ • ....................................................................(SEAL) (SEAL)
„ • • i
'A
A 1 i
AUTHENTICATION AC=NOWLTiDGI1tsNT
Signature(a) STATZ OF WISCONSIN j
r as. ~1
z. St- -Croix ..........cooaty. .n 1 ) :1
authenticated this ........day of . 19 FatsomAy came before m• . '31........ day of
,il I August .19..... . do 40" named
Itandall...t~l: sXrian_. Pati'r'ic~a.-~_........... '
TITLE: MEMBER STATE BAR OF WISCONSIN S nan _
(If not. Ai .12
4 d . by ; 106 6.06. Wis. Stela.Slat)
authorized
to me known to be the person fi AV a li
II i...~a........• ..A wwenl~le~