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HomeMy WebLinkAbout020-1037-90-000 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ✓`~F~ 1 V L- L(~ ADDRESS '771 1 dtq A" 6Z" P40 SUBDIVISION / CSM# 661tA-,":S r~ 6C LOT SECTION T21( N-R / Town of K L' O~ C)N ST. CROIX COUNTY, WISCONSIN PLAN VIEW L fa ! q"~`!? tV SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM l JAY ~ LJJ J f' F. INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. t BENCHMARK: ALTERNATE BM:> t, SEPTIC TAN PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: ~,d,).t Liquid Capacity: Setback from: Well House Other y t✓ ' Pump: Manufacturer Modell Size Float seperation Gallons/cycle: ' Alarm Location SOIL ABSORPTION SYSTEM Width: Length ' Number of trenches 19:, Distance & Direction to nearest prop. line: I/ I 74 5{_~~ l`,~1 fe Setback from: well :qc) House Other ELEVATIONS Building Sewer ST Inlet: ST outlet: ~D 7 PC inlet PC bottom - Pump Off a~ O Col l ~'y E~2 Hea er/ManifoldL $ Bottom of system /y a,T 9'yS TOExisting Grade.(, Z.. Final grade 2 - 4 407 ID,2'Z, ti, G2 Z~ DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER:/ INSPECTOR: 3/93:jt Wiscoptin Department of industry, PRIVATE SEWAGE SYSTEM Count : Labor and Human Relations ST. CROIX INSPECTION REPORT Safety and BULildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 299022 Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.: MILLER, SAM HUDSON CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: / O~ 020-1037-90-000 TANK INFORMATION ELEVATION DATA A9700387 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic 0 Benchmark , OD. O' Dosing ~ Aeration Bldg. Sewer 10 Holding St/Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet ' D ~p2, TANK TO P/ L WELL BLDG. Airi to ntake ROAD Dt Inlet Ar I Septic >a 'So • 9 • _ NA Dt Bottom Dosing NA Header / Man. "_(44" 01 AW IX Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade S. S2 2 Manufacturer Demand Model Number GPM TDH Lift Lricti System TDH Ft Forcemain Le th Dia. H Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width , I Length No. Of Trenches PIT No. Of Pits Inside Liquid Depth DIMENSIONS D .3 DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION TypeO CHAMBER Model Number: System: •S! 3~' >go / 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 o Bed /Trench Edges p " Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HVPSON 14.29.19.160A,1!~ `NNW 979 LABARGE RD LOT 9 Lgn~d IF A.) /3ot 4iL `Q-.3. Plan revision required? ❑ Yes No Use other side for additional information. SBD-6710 (R 05/91) Date In or's Signature Cert . No. ADDITIONAL COMMENTS AND SKETCH T SANITARY PERMIT NUMBER: , f a and SANITARY PERMIT APPLICATION 201eE Was6ngtongAve sion ~ iscbmin P.O. Box 7969 Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707-7969 Attach complete plans (to the county copy only) for the system, on paper not less County than 8112 x 11 inches in size. • See reverse side for instructions for completing this application State Sanit~r ,~gyryjt Nu er The information you provide may be used by other gover ent agency programs ❑ Check it revision tto~jvhJ~previous application [Privacy Law, s. 15.04 (1) (m)]. q-7q Lg* PR /y IO State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRI/N ALL INF RMATION Propert Owner Name operty Location #0V4Aj !42 1/4,5 T 2,9 , N, R / E (o~ Property Owner' Mailing Address Lot Number Block Number City, State Zip Code Phone Number Subdivision Name or CSM Number -4 v l~ I ktgw 2 '7 ~ 4 _"D 16 .4-41V (0 II. TYPE F BUILDING: (check one) ❑ State Owned it Nearest Road C] illage Public 1 or 2 Family Dwelling- No. of bedrooms ~ own of l~'+ 111. BUILDIN USE: (If building type is public, check all that apply) Tax Number(s) N. 1 ❑ Apartment/ Condo Q ZO 1037-470 ✓ 7 OCT T! 74? 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, U(New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System SystemTank OnlyExisting 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 ❑ Holding Tank 12)j![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 ©d Required (sq. ft-) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) la, 47 E)%v~ti&n (P "7 S-Q -7 C-10 lo; I Feet 1 awl , v Feet VII. TANK Ca n g aaclt llons Total # of Prefab. Site i Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- steel glass Plastic App New Existin strutted Tanks Tanks Septic Tank or Holding Tank 26~ ) (,rl) $ ❑ ❑ ❑ ❑ ❑ 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. ,(A Stamps) MP/MPRSW No.: Business Phone Number: Plumber's A( dress (Street, City, State, Zip Code): /0 ?0 %.di 9 E 4op D v o l~Itd 1 IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps) Surcharge Fee) Approved ❑ Owner Given Initial 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 - ] l INSTRUCTIONS x R 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. 11. 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 isto 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 monitor~inggro"undwater contamination investigations and establishment of standards. f v 1 sC I 41n W- z, ~4 1.s r yv Z ~ too I 'IL d ^ 6N e ti C i Lll\ O I b f O" 14 y C7 , .o m , k.A 411. m C o f~ y N ~a d FTi o ,It o SANITARY PERMIT APPLICATION Bureasafetyu aofnd Bildi uildining Water System! s ter 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 mit Number 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)]. State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Owner Name Property Location a,4ni -ld Ne 1/4 MV 1/4,S / Z/ T Z ,N,R~ E(o W Property Owner's Mailing Address Lot Number Block Number City, State Zip Code Phone Number Subdivision Name or CSM Number cO c:,~, O /v - ` sofa t' 1(384,) 2 62 ,Q A.SE ,d 2 L II. TYPE F BUILDIN : (check one) ❑ State Owned ❑ it~ Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms ~ El ff, Town OF H, ID j )ON La, QA Q_(.f III. BUILDIN USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/Condo 00- 103,9- 90 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. K 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 ❑ Holding Tank 12~Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 1 ❑ 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) ((0 1. 4 Elevation; -7 SD 56,3 Goo - $ - l o0,S.S` Feet 100~,r Feet VII. TANK Capacity gallons Total # of Prefab. Site Fiber- Plastic Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass App. New Existing strutted Tanks Tanks ~~ryry Septic Tank or Holding Tank /000 / l~-> F I $,E /L,. L~..~ ❑ ❑ ❑ ❑ ❑ 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 tamps) MP/MPRSW No.: Business Phone Number: C7 1 Plumber's Address (Street, City, State, Zip Code): 0 70 ✓Al7A/L. 2 /4. /2,1",1,`4 V IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sjpitary Permit Fee (.Includes Groundwater ate Issue Issuing A nt Signature (No am Approved ❑ Owner Given Initial Surcharge Fee) 7 Adverse Determination / v (/CJ a .0; X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: MOM- NR (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS ' a 1 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 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 8 112 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. 9 d :4 Cj d R . fj j SIN Q ° 1 1 ~V ~ a I ~V I1 1 u O N U O t^ lu l l rrD i CIA (Tl M1 O- Z r. 70 M, ~ -4 -1 m I ?Tl ~ 1 % d 1 3 ~ / 1v IQ - z ~ ~1 v a / P Z / tit -1; Q C3 ~ m . 4RI Its- >1~ I ~ ~ n FT I ° u ! a m o T m W I ~ ~ v n lu o z a rr `U I m i N I z 'U 0 I o I - W I Z I c~ I rq I go xo o N. ~ ! m LA M Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3 Labor and Human Relations Division of SafAty & 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 S 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. 00_6 --/07C9 - APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION Kernon Bast GOVT. LOT NE 1/4 NW 1/4,S 14 T 29 AR 19 fc (or) W PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # 948 LaBarge Rd. 9 na Grass Ran a Addn. CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE (2grOWN NEAREST ROAD Hudson, WI. 54016 115) 386-7775 Hudson McCutcheon Rd. [x] New Construction Use [ iq Residential / Number of bedrooms 3 [ ] Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow 450 gpd Recommended design loading rate .7 bed, gpd/ft2 .8 trench, gpd/ft2 Absorption area required 643 bed, ft2 563 trench, ft2 Maximum design loading rate • 7 bed, gpd/ft2 •8 trench, gpd/ft2 Recommended infiltration surface elevation(s) 101.92-100.55-98.75 ft (as referred to site plan benchmark) Additional design / site considerations area of B-1 & B-2 cut to code or extra rock used Parent material outwash Flood plain elevation, if applicable na ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE 7 AT-GRADE SYSTEM IN FILL HOLDING TANK U =Unsuitable fors stem :K1 S El U EXS El U CAS El U F&I S El U 0 S ❑ U ❑ S ® U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Inch 1 1 0-12 10 r3 2 none sil 2msbk mfr 2f .5 .6 2 12-33 10 r4 4 none sil 2msbk mfr if .5 .6 Ground 3 33-58 10 r5 4 none it ms 2csbk mfr crw if .5 .6 elev. 106.9 ft. 4 58-10 7.5 r4 6 none MS osa M1 Depth to limiting factor +100" Remarks: Boring # 1 0-8 10 r3/2 none sil 2msbk mfr C1W 2f .5 .6 2 8-24 10 r4/4 none sicl 2msbk mfr if .4 ':.5 Ground 3 24-45 10 r5/3 none sici lcsbk mfr C1W na .2 .3 elev. 4 45-98 7.5 r4 6 none ms oscr m 106.9 ft. Depth to limiting R CEI~~ - factor +9811 MAY 2 Remarks: ST CROfX CST Name:--Please Print Gary L. Steel Phone: 715-246-6200 f~ Z0NWGOW1CE,_/ Address: 1554 2001Y. Ave. N w on WI 54017 Signature: Date: CS 298 " 5-2-97 ' PROPERTY OWNER Kernon Bast SOIL DESCRIPTION REPORT Page 2, -of 3 PARCEL I.D._ Jc ZC~.- Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench 1 0-10 10 r3 2 none i 2f .5 .6 2msbk 1 f .5 .6 2 10-25 10 r4 4 none sil 2 Ground 3 25-45 10 r4 6 none sl 2csbk mfr C1w if .5 .6 elev. 104.55ft. 4 145-90 7.5 r4/6 none ms os ml na na .7 .8 Depth to limiting factor +90" Remarks: Boring # 1 10-10 10 r3 3 none sil 2msbk mfr if .5 .6 4 2 10-23 10 r4 4 none sl 2csbk mfr : w if . 5 .6 3 23-80 7.5 r4 6 none ms os ml na na .7 .8 Ground elev. 101.75ft. Depth to limiting factor +80" Remarks: Boring # 1 10-8 10 r3 2 none sil 2msbk mfr 2f .5 .6 5 2 18-26 10 r4/4 none sl 2msbk mvfr if .5 .6 Ground 3 126-80. 7.5 r4 6 none ms os ml na na .7 .8 elev. 101.75 ft. Depth to limiting factor +80" Remarks: Boring # Ground elev. ft Depth to limiting factor Remarks: S13D-8330(8.05/92) STEEL'S SOIL SERVICE Gary L. Steel •1554 200th Ave. CSTM2298 Kernon Bast New Richmond, WI 54017 MPRSW 3254 NE4NW'j S14-T29N-R19W (715) 246-6200 town of Hudson lot #9-Grass Range Addn. N 111=401 BM.= top of 2" pvc pie C el. 100' Alt. BM.= nail in tree C el. 96.65, I DO w ti ~r . N Gary L. Steel 5-2-97 / p AC. ExC. ESMT. 33 2.01 SO. FT. 1 ' 137,373 33' G~~ voo U`. / y. ~ \ L \ b~' I d' 3.61 ACHES i~0. / QJrd/ 'S'p 1,7r-I SU F~L` I S 2.52 AC. ExC. ESM . / 4\ a~ P 109,697 50. Ff. /o'ha,y0 ~q, 6 0 dy/516 HWL C]I M I / LOT 9 11 5 / LOT 2 6 _ 2.02 ACRES p 6 2.56 ACRES W \ D`Dt 88,055 S0. FT. 112,331 SU."FT. O 2.42 AC. ExC ESMT 105,561 Su SU. FT. - SBB°5422'"W 455.74' 96.00 12` 55'U3'~[ q °q"s> IV .o r, l P " LOT I ~ s• Op C4 2.47 ACRES °e R 1~c \ N6go 107,659 SU. FT. N ° Uq S> IV 1P Ssgo 7> d I-1 I-- I cO 3q5 'Rp Q ' 4\ R I to 3g ThF ~ ~ Sri LL-11 LOT 10 ~ ro W (V 2.63 A ° q7 ° < ' O 114. 60 SQ. FT U) N z 1, 1 'n1 13 1 3 $v v S 89 37'39"W S99°24'30"'N - - 486.12' 130.76 -w PUBLIC 6 \o DEDICATED 10 THE 523.80' S69.12 52 --=SOUTH-11r S89°3231"W 169.61 r+ TSUUTH LINE OF THENEI/4 U~ THE-NWI%4 C3I ric~U Tr c01J R0A LYI r~/a~rc. - ~JI 33 33' - Lh1 I ,~11_ . ~ ~ l~L ~ CI ~ n 0 UNPLA-_► ~a,r~~ ~rl vI _U 1NER MONUMENT FOUND BENCHMARK NAIL SET IN POWER POLE EL : 931.07 rte.. , USGS DATUM 1929 IGHINV-'3.65 LBS. PER I RSMONUMENTED WITH E G 01.13 LBS PER f.V'H. 1 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 Sa~1 /7 7 A~1 /L GEiL Location of property,~1/4 1/4, Section I TAN-R_Zfj~~ Township A J d -Zo N Mailing address ,SOX ~ ~ yL_ 6'7'? / Alk Q,4rZ4; AE/0- 0o Address of site subdivision name <Zf,*z Xt) &a4 Lot no. _ Other homes on property? Yes Sl No Previous owner of property eEI A/?. ,),A,/ ,T Total size of property ? . O '2_ e Total size of parcel 2 /1 , Date parcel was created 7 3 / -7 7 Are all corners and lot lines identifiable? Ns,,- Yes No Is this property being developed for (spec house)? Yes No Volume IZ40 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. S . $15,3 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. SAS 3~ ig ture o Applicant Co-Applicant 17 Date of Signature Date of Signature 1 STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER k F.W/Vc,~ / lS f~ T-t A5 /JA/ III iL G,--,L- MAILING ADDRESS f3~X 91/ z ~L U S C x/ Gc / PROPERTY ADDRESS 2 . LA A 0_<.C A (location of septic system) Please obtain from the Planning Dept. CITY/STATE .&p,,p ; a A/ t 4,J / _T'~122 / PROPERTY LOCATION NE 1/4, N4J 1/4, Section ! y , T z `1 N-R / ' VY~ TOWN OF ~ y 1) S n N , ST. CROIX COUNTY, WI SUBDIVISION C~k /7 - 14 Al LOT NUMBER CERTIFIED SURVEY MAPS ( 19 33 , VOLUME__~-, PAGE /00 , LOT NUMBER 9 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 /e expiration date. SIGNED- DATE: r _ 1 7 St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 VOL 1260PAC14T1 5653.E STATE BAR OF WISCONSIN FORM 2 - 082 3183 WARRANTY DEED DOCUMENT NO. VOL 125, 4 PAU59z) :77) C'--•-- Kernon T a and_.Donalda Speer-Bast ' St CR"DIX C.,., WI conveys and warrants to. Sam _E~.._.-Miller ~1~V`' `3.1' 1997 2:00 p M 4k Low, THIS SPACE RESERVED FOR RECORDING DATA NAME AND RETURN ADDR S the following described real estate in St. Croix County, 5a I-e' e _ State of Wisconsin: v. ti a iC I s"4 Lot #9 Plat of Grass Range-Town of Hudson PARCEL IDENTIFICATION NUMBER Q REGISTER'S OFFICE ST, CROIX CO.. WI Res'd for Record !ER AUG 2 8 1997 _ 11:30 AM -qk- DJ~ Re later of Deeds EXEMPT' This is not homestead property. Exception -iowarranties: Easements, restrictions and rights-of-way of record, if any. Dated this 20th day of Julv _ , A.D., 19 9 7 (SEAL) 4~ (SEAL) gJa . ee r-Ba (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) State of Wisconsin, ss. ~T ` Cfro j"A County. authenticated this davof 10 L_r___ 1 nA, _ Safety and Buildings Division SANITARY PERMIT APPLICATION 201 E. Washington Ave. N*6consin P.O. Box 7969 Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code 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. • See reverse side for instructions for completing this application State Sanitary Permit Number 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)]. State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Owner Name P operty Location n~ 4 )VjtJ1/4, S T N, R E (04W Property Owner's Mailing Address Lot Number Block Number ! j I - ......s>... City, State Zip Code Phone Number Subdivision Name or CSM Number II. TYPE F BUILDING: (check one) ❑ State Owned ❑ ityy Nearest Road,,r ❑ Village Public 1 or 2 Family Dwelling - No. of bedrooms own of III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo t•- 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. VNew 2. ❑ Replacement 3. E] Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an _ m System System Tank TankOnly Existing System _________ExlsttngSyste 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 WSeepage 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 r Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) t- F E)evpLtion i - } Feet 1, / . c Feet VII. TANK Capacity gallons Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existing structed Tanks Tanks Septic Tank or Holding Tank d : c I L a,1 I tt~ ❑ ❑ ❑ ❑ ❑ 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: fto Stamps) MP/MPRSW No.: Business Phone Number: 4T Z Plumber's Ac dress (Street, City, State, Zip Code): _ ' .s IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps) Surcharge fee) Approved ❑ Owner Given Initial 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 - s ~ INSTRUcriONS 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. ll. 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 SystEfm 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 followir+g: 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 'Zakes; pump or siphon tanks; distribution I;>oxes; 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. SANITARY PERMIT APPLICATION 201eE sBngtonnA Division isca►nsiln 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 8 112 x 11 inches in size- fill See reverse side for instructions for completing this application State Sanitary Permit Number The information you provide may be used by other government agency programs ❑ Check it revision to previous application [Privacy Law, s. 15.04 (1) (m)). State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATI N Property Owner Name operty Location --h":/?'' N is tt,11 /a, S T Z --j , N, R /7 E (oil W Pro2erty Owner'~ Mailing Address Lot Number Block Number City, State Zip Code Phone Number Subdivision Name or CSM Number C6 C II age Public 1 or 2 Family Dwelling No. of bedrooms Lown I I. PE F B ILDING: (check one) ❑ State Owned It~ Nearest Road III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 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 11E] Seepage Bed 21 ❑ Mound 30E] Specify Type 41 ❑ Holding Tank 129Seepage Trench 22E] In-Ground Pressure 42 ❑ Pit Privy 13E] 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 Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) FIevation Feet I > Feet VII. TANK Capacity ;4n gallons Total # of Prefab. Site Fiber- Plastic Exper INFORMATION x Gallons Tanks Manufacturer's Name Concrete Con- Steel ass NExistin structed Tanks Tanks Septic Tank or Holding Tank 1 = ) [ t:, ❑ ❑ ❑ ❑ ❑ 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: (Pant) Plumber's Signature: ~i Stamps MP/MPRSW No-: Business Phone Number: Plumber's Ac dress (Street, City, State, Zip Code)" /e -)4, fig.,/ 7"t le- L. ! u t , IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps) " Approved ❑ Owner Given Initial --Surcharge = Fee) Adverse Determination X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: SBD-6398:(R.11/96) - - ' DISTRIBUTION: Original to County, One copy Toe Safety & Buildings Division, Owner, Plumber INSTRUCTIONS r 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. Proper~Ly 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; 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. ~o o° O Iz- ~ ty n b n ~ a 74 ~ _ Q ~ v► o _ M `N elf CQA M N v ~0 M Y~ VP lb- LW ~ N w acs A Ilk v o = O o t v ~ ~ C7 Y ku w I H CL 1y I z I o I ----1-- a a ~ 'tt I- LLJ I I W M a ~ `d I I I o L I V U I a `g p 0 it I