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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 i r ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: # k e Z~ / 3 ZS- 8~ - S<~'LE Iiy io /VoT t UT 7,1 eE. /y~~t~~ ~c MWtN7~rN So L)FXT i)r,PTH 1lgc;tnhtKT5 f 73 ` j i7 l 1' ~ , z~ tic n M Lort 2,GAc. c v l T3, 0 . 1 -T t~ ~T 1 w Fv~c~N ;z I -5ou-tH L,-T cin/c` Zvo, L/- x O 7 VI W i zz (1 ~V o ~ N ~ ~ ~ 40 IN OJ ~ ~ 0 40 C w I I I g t~ = f o ~ ~ ? I to I I a t a J I ® ~ I w z _o < a ~ `mot I- W ` I v I , I Z! uo I w N ~ ' I n- M IL O~ I w I ~ 4CZ W ' ? 7 R `v I I• I w a 1 Mnou WEST f D tl 0 V~ ~6e 3 , 3g g Lbw b ~ ~ ` - , ~ Y Y ~aLE I ~'qo Y~ n !r i i 1 ~FJVC_I~Md~Q1L` --rp /h' SW Ccr2r~L(~ IAJ CLLR - a~l~ 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~