HomeMy WebLinkAbout020-1326-00-000
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AS BUILT SANITARY SYSTEM REPORT
OWNER YY`~ ~C 1 (L ,
ADDRESS d10 IV661 1 3f P4 ly { 4) t~
SUBDIVISION / CSM TNN(IE q k I Oc4E LOT 3
SECTION _2 _T n_N-R 1` W own of
__LICC
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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~NDICATE 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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BENCHMARK: 1-t ,,P ,,r 1'r-11-If /I! C!J (64.
/VF 5 =
ALTERNATE BM: I c~f Ot $j0rjC i coAJON 1 tDk
SEPTIC TANK PUMP CHAMBER / HOLDING TANK INFORMATION
L
Manufacturer: U
)r / ~r / Liquid Capacity: 10ne:7 ./4 L
Setback from: Wel 1e, 0 House other 5-3 lb H6
Pump: Manufacturer Modelf Size
Float se eration
P Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
A
Width: Length 60 Number of trenches Z-
Distance & Direction to nearest prop. line: &o~ 7a Alop- 7 1W 1,,7 11"v
Setback from: well Z 7 d '4 House 1,;, Other /oS To s T
mr~N NvIE -7, (oo 1D( ~
ELEVATIONS
Building Sewer ST Inlet: `W,,- M° 400'? /ST outlet:
PC inlet - PC bottom Pump Off
FH. to -.12 : gel. -L 3 PH 10,08: 91.o-)
Header/Manifold Bottom of system 11 •o 5: q& S. 0
Existing Gradel 3,~-= IoZ~ZVinal grade 73 S': 102, Z
DATE OF INSTALLATION:
PLUMBER ON JOB: LICENSE NUMBER:"" e-> c~)
INSPECTOR:
3/93:jt
iWisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT ST. CROIX
Safgty and Buildings Division
(ATTACH TO PERMIT) sanitaryP9e9rr~it_h1
GENERAL INFORMATION G Z1
Permit Holder's Name: ~Uty _C7 N llage Town of: State Plan ID No.:
MILLER, SAM llll~0
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel TaXU
o_1326-00-000
10 / / Dv , 7i a_,°,
TANK INFORMATION ELEVATION DATA A9700439 I/ U TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Oj - la Benchmark q-(✓ L p6} 6Z) r
Dosing
Aeration Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
Vent
TANK TO P / L WELL BLDG. Air l to ntake~ ROAD Dt Inlet
Air l
Septic -7101 `j NA Dt Bottom
~oS~ 94.3 i ~
Dosing NA Header / Man. /o ,
t0.5D qq, IG'
Aeration NA Dist. Pipe /06v
(o
Holding Bot. System
n
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand `s g'
Model Number GPM
TDH Lift Fric ' System TDH Ft
Head
Forcemain ngth Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length I No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS off- DIMENSIONS
SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type O Moe Number:
System: ~(pa CHAMBER 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 -_2G Topsoil E] Yes ❑ No E] Yes E] No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON 12.29.19,SE,NW 840 MOON BEAM RD - TANNEY RIDGE LOT 63
C,,&t 43 f L .
0 &o
Plan revision required? ❑ Yes [q't'Vo 5
Use other side for additional information. I#
SBD-6710 (R 05/91) Date lnj~ etcjor'signature Cert. No.
L
ADDITIONAL COMMENTS AND SKETCH c
f
SANITARY PERMIT NUMBER:
ashington Ave sion
SANITARY PERMIT APPLICATION 201eE.Wand Buildings D
Viscli6nsin In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
Department of Commerce Madison, WI 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 1/2 x 11 inches in size. S-C, l
• See reverse side for instructions for completing this application State Sanitary Permit Number
The information you provide may be used by o~~overnm ncy rograms ~ ❑ ChecA,.2~'/Rs)application
[Privacy Law, s. 15.04 (1) (m)]- M State Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION
Property Owner Name Property Location
tt''iT r 1/4 AJW 1/4, S T off/ , N, R E (o W
Pro erty Own is.Mailing Address Lot Number Block Number
' P
eve
Cit , State Zip Code Phone Number Subdivision Name or CSM Number A
11. TYPE BUILDING: (check one) ❑ State Owned ❑ ity Z0#4 est Road
❑ Village
Public 1 or 2 Family Dwelling - No. of bedrooms W-Jown OF N v e5W A04
111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 42. 29. `A• 90?
4P z Q e I~, Z<0 (56
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 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
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 410 Holding Tank
12, CA_eepage Trench 22E] In-Ground Pressure 42E] Pit Privy
1 Seepage Pit 43 ❑ Vault Privy
14E] System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION: /ta Z. ,od'
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) Elevation
Y (fJ f ? - $ Feet Feet
VII. TANK Capacity 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 IQ~ W ❑ ❑ ❑ ❑ ❑
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 5' nature: (No St S' MP/MPRSW No.: Business Phone Number:
Plumber's A( dress (Street, City, State, Zip Code):
IX. UNTY/ DEPARTMENT USE ONLY
E] Disapproved Samar ;tary Permit Fee (Includes Groundwater ate ssue Ling A nt Signature (No 5 m
~Approvecl Surcharge Fee)
❑ Owner Given Initial ~ /a7
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R.11/96) - - DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
j
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, 608-266-3151.
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 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; replacernent 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 SURC ARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) fora 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 J of S
Labor and Human Relations
Rivision of+Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but 6R6
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL 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
'Z>AA 1 U k GOVT. LOT SI= 1/4 >4t,) 1/4,S IZ T 29 N,R 19 E (or) W
PROPERTY OWNER':S MAILING ADDRESS # BLOCK # SUED. NAME OR CSM #
L 36 AKI.-Ay ~i
L3 Z/U AoaN
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VI GE OWN NEAREST ROAD
( ) U TAB Lo&jc
[ 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/0trench, gpd/ft2
Absorption area required bed, ft2 ptrench, ft2 Maximum design loading rate n -7 bed, gpd/ft2 (3.3 trench, gpd/ft2
Recommended infiltration surface elevation(s) GJa ! 444 3 ah ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material Flood plain elevation, if applicable ft
S = Suitable for system C~~qQNVENTIONAL M UND IN- ROUND PRESSURE T• RADE Y TEM IN FILL HOLDING T91
U =Unsuitable for system Jd1 S ❑ U [ S ❑ U (S El US ❑ U S El U ❑ S U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Botr>dary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
w m Piz
AbK 3/ Z m CS O D.
Q ! Y
S ~L l r►, sb< nt~ Cw 1 ~ 6.2 O,3
Ground 2S-)!Z 16YQ4 3 A?5 SG - ,7
elev.
10LI ft.
Depth to
limiting
i f`1 t~3
Remarks:
Boring #
~~:::Z:., [-sl »y~s - S,~ 1 ~bK r►~~ w ~ ss' 03
$ 51-60 y 4 3 M:5 SG w O.7 O
Ground
elev. 0:7 o
Depth to
limiting
tof
y
71
Remarks:
CST Name: Please Print y O Phone: 4o~
Address: fox 9 1, do ~so"i
Signature Date CST Number-
ktymls
PROPERTY OWNER ~r SOIL DESCRIPTION REPORT Page of
PARCEL I.D. # Lod" p3
1
Depth Dominant Color Mottles Structure GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Bcur~ary Roots Bed wich
I 3 - 1 cY .m cs o .q o
9-3Z /b 4 - 5 rL -s r w 1~ 4.-2 3
0 8
Ground $z -4g 7. Sy 4 M S 5L rn c,J - 6:7
elev.
/Qz .o ft $3 g-g >d k 4/3 /hS SG 1h D b
Depth to
limiting
? ft
Remarks:
Boring #
Q -11 I - 1-- l c r r,~l, w `D.S
Ground I ! M < S4 a Z
elev
/134 ft.
Depth to
limiting
4ctor
T
Remarks:
Boring # L m Sb /h r- r~ ! 6-4:6,s
E -z? 1/4 - SQL 1 m~~ rn Cw .z o.
l
Ground 7 /0 Zo A -
-5"( '7•Sy' 4 MS S6 M ~ G W - 0 o.
- 6,7:68
ids eve ft.
Depth to
limiting
y f-~
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNERBUYER SA f1 tV\ I LL (f
MAII.ING ADDRESS 12 Q X s C K Le"J
PROPERTY ADDRESS 0 A/ j3 jrR in A D A f{y~ ~N
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE 14U-t) _-50%t W1 y4
PROPERTY LOCATION 5 1/4, t~ 1/4, Section 2.- T 4 N-R W
TOWN OF EI0 tD %o N , ST. CROIX COUNTY, WI
SUBDIVISION_:I u ~ ~s l~ LOT NUMBER
CERTIFIED SURVEY MAP 55 6 35 , VOLUME( , PAGE -7 LOT NUMBER 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 canaffect 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: CCU
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
8 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.
Ownerofproperty SAwl Z]j JAL-
Location of property 1/40) 4U 1/4, Section 'z- ,T~77 N-R
Township «at 7 x Mailing address .r A'"`
Address of site rvk b
subdivision name r )v df i2 t L7~ot Lot no. (
Other homes on property? Yes__,~<_No
Previous owner of property, r' ; ;^f'(~`r Al
Total size of property
Total size of parcel', r <
Date parcel was created - --Q7 3
Are all corners and lot lines identifiable? ~C Yes No
Is this property being developed for (spec house) ?,JC Yes No
Volume 103e and Page Number 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. go 4z-65-1r-
, 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 of ice o. the County Register of Deeds as Document No.
d 5
Si a e- 6f' Applicant Co-Applicant
id"1v'64, 1
Date of Signature Date of Signature
1
t ~4[
A ' DOCUMENT NO. I STATE 13A IF WISCONSI Olt 1-19E2 r"S• a++cs easa"vao FOR WORDING Dwr•
• ARRANTY D D '
504855_. Mot 103irmE 456
CIST-R'S OF1CF
This Deed, made between 1 - J:1-- CO..~~
Randall W. Synan and Patricia E. Synan,
husband and wife ~dRO~"a
t
, Granter, ! SEP T 1993
and.....Sa~..E....Mil.ter••... ...•s.3nqie...I.erson ~t 10:45 A:-M
i
assoc... L-Ts~e. ~1 wen. `
WitIlesseth, That the said Grantor, fQr a valuable consideration......
Randall W. Synan and Patricia E. Synan _
St. Croix "•TU""*O
- conveys to Grantee the following described real alts in
County, State of Wisconsin:
Tam Pared I4o:..-..»_.»..-.....
The SEI/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
Y' Township 29 North, Range 19 West, Tovn of Hudson, St. Croix
County, Wisconsin. FF~
si AND
'A A parcel of land located in part of the NE1/4 of SE1/4 of Secti
11, Tovnship 29 North, Range 19 West, Tovn of Hudson, St. Croix
County, Wisconsin further described as follovs: 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 S00 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.
This -1... kQt.... homestead property.
(is) (in not)
Together with all and singular the hereditamenta and appurtenances tuereunto belonging;
And..... Rs3 daU.•K._.,. 4ynart-.an.4 Patricia.•E,- Snan
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.
M
and will warrant and defend the same.
Dated this day of hmg.us.t............................. , 119
A-....... (SEAL) k0jW A+*k C..4~ !fir.✓ ...........................(SEAL)
• Randall W. Synan Patricia S. Synan
•
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• ................•---............••--••••......................(SEAL) ..................................................---...............(SEAL)
• •
1
t• AUTHNNTICATION ACZX0WLZD0WXXT 1
Signature(s) .STATS' OF WISCONWN
z es. i~
i
. - St Croix''
j authenticated this ........day of 19...... »..pamma•ft cane before me .dq
August N....... 19. the above named
II Randall w. 3xnari., Patricia_
.
TITLE: MEi[BE& STATE BAR OF WISCONSIN S nan _
.
(If not. »_...................Ar- r~ i
II authorized d by ; T08.06. Wis 3tat Stata) to me known to be the person J6..... AYQW& e