HomeMy WebLinkAbout020-1338-00-000
-
STC - 104 ry 'r~~Y~O
AS BUILT SANITARY SYSTEM REPORT 0 It 19,97
ST CROIX
OWNER V ~A COUNTY
al
ZONiNGOFFICt a
ADDRESS /`~1 ~c •s`
SUBDIVISION / CSM$
LOT
SECTION___,Z_ T~ 'N-R_ ~f W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYS LM
0 I
4/14 dell
47 L~-' I
~z'x sr'
tc~tGF / 3a r
.CL = I~.y, 1Yi~~6s~~+~ walk
i
y ;~ww r.
41A INDICATE NORTH ARROW '
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tan}. mN~nl~ rnvnT
f
BENCHMARK' 2 f~ r
G ~ C - C~~GLt ! Y p ~ S rv ~OO,Q
ALTERNATE BM: - G✓O/~ ~0% 7~ i
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer:_ , Liquid Capacity: m
Setback from: Well ,,e/House Other
Pump: Manufacturer Model# Size
Float seperation Gallons c
Alarm Location
SOIL ABSORPTION SYSTEM
Width: Z 2 Length S^S- Number of trenches
Distance & Direction to nearest prop. line: So
Setback from: well: AIW House p Other ,
ELEVATIONS
Building Sewer ST Inlet:, S ST outlet
PC inlet PC bottom Pump Off
Header/Manifold P4l.1G Bottom of system_
Existing Grade- p~ Final grade X9.9
DATE OF INSTALLATION: / ,F y 7
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR:_ ~Z
3/93:jt
Wisconsip, Department of Industry, PRIVATE SEWAGE SYSTEM County:
%aborandNumanRelations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 299154
Permit Holder's Name: ❑ City ❑ Village 99 Town of: State Plan ID No.:
BAST, KERNON HUDSON
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax 0
f'F ~r. 020-1338-00-000
t6t 61) 11P 2" Pik - 1 Of, r
TANK INFORMATION LEVATION DATA A9700470
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic oop Benchm MY-5,K /oD
T.p`` 2-n Ol• 6
Dosing Ali. -14."e w.r1R {xa
Aeration Bldg. Sewer ,S
` 't* Inlet
Holding 19r qy3
TANK SETBACK INFORMATION (g)/*Outlet q2
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic na 15, NA Dt Bottom
Dosing NA Header / Man. .64 0.#/
4.6t:i. r %og 95'•93
Aeration NA Dist. Pipe itiAl f(,&
Holding Bot. System /o. j ' 9~/ Z S 9 yZ
PUMP / SIPHON INFORMATION Final Grade r q2! Gj9. /ro
Demand '7-7
Manufacturer
1 .0^
Model Number . GPM
TDH Lift -.F i ti tem TDH Ft
Loss e
ist .To
Forcemain Length Dia. D
F
SOIL ABSORPTION SYSTEM
B D RENCH Width rL r Length S/ No. Of Trenches PIT No. Of Pits Inside D Liquid Depth
_
-DTIViENSIONS DIMENSIONS
LE CHIN nufacturer:
.
SETBACK SYSTEM TO PI L BLDG WELL LAKE/STREAM
CHAMBER -Model N r.
INFORMATION Type 0 ~j ne- OR UNIT
Syste ,
DISTRIBUTION SYSTEM -EM Z'7 Z^
Header/Manifold Distribution Pip S) Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length J2- Dia. Spacing y Vv
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over De f xx Seeded/Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges soil F1 Yes C] No El Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON 14.29.19,NE,NW 974 LABARGE RD - GRASS RANGE LOT 10
Ivr~l PIS ~Of ~z ui loo vs e- e~ d s fi&4Zn k WcvrL W bVe.A.
~t ✓~z< Z ~ '
Plan revision <reI q• ui d? Yes ❑ No q-~ -7
Use other side for additional information. ll L(Q , ` ~A ~W
SBD-6710 (R 05/91) Date Inspector's Sig toe Cert
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
✓«q Safety and Buildings Division
r^~~i~'r'■ : SANITARY 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 8112 x 11 inches in size.
• See reverse side for instructions for completing this application state sanitary Permit Number
291 15
The information you provide may be used by other government agency programs ❑ Check if revision to previou application
lPrivacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Property Owner Name Property Location
o s~/4 1/4,5 T A ,N,R E(o
Property Owner's ailin Address Lot Number Block Number
city, ate Zip Code Phone Number ubdivision Nam r CSM Number
k dN S ®l4 ( 6)
II. TYPE BUILDING: (check one) ❑ State Owned E] City Nearest oad
Public 1 or 2 Family Dwelling - No- of bedrooms L rowan OF
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
' 1 ❑ Apartment/ Condo ff 2v
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 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 VI Seepage Bed 210 Mound 30 ❑ Specify, Type 41 ❑ Holding Tank
12E] Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 43*❑ Vault Privy
14E] System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation
VS-01 1 3 3 .7 f .3 Feet Feet
VII. TANK Capacity
INFORMATION in gallons Total # of Manufacturer's Name Prefab. Site - Fiber- Plastic Exper.
New Existin Gallons Tanks concrete Constructed Steel glass App.
Tanks Tanks
Septic Tank or Holding Tank tV ov ❑ El ❑ ❑ El
Lift Pump Tank /Siphon Chamber ~ 1:1 ❑ El 0
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of th site sewage system shown on the attached plans.
Plum a "s Name: (Print) Plumber's S Lignature: (No Stam fe fiml RSW No.: Business Phone Number:
s Address (Street, Ci y, Sta , Zip C
~TRUA rI X. C UNT / DE A NT USE ONLY
❑ Disapproved anitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps)
A roved Surcharge fee) / r
pp ❑ Owner Given Initial 10
4 A, fA44
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SOD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit 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 systern, 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-
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 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.
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DAVE FOGEIR-ilY PLUMBING
Licensed Pork Te •.:?er & Pluff6or
#3233 *3289
Fc-4jefty Heights Road
WOO % WISCONSIN 54023
Phone 749-3656
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Wisconsiri, Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3
Labor and Human Relations
Division 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 St. Croix
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. err Z-0 , /O Zh - 9C2
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION RE IEWE BY DATE
//-7-1-7
PROPERTY OWNER: PROPERTY LOCATION
Kernon Bast GOVT. LOT NE 1/4 NW 1/4,S 14T 29 N,R 19 kor) W
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUED. NAME OR CSM #
aBarge Rd. 10 na Grass Range Addn.
948 L
CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE MTOWN NEAREST ROAD
Hudson, WI. 54016 (71~ 386-777-9 Hudson McCutcheon Rd.
:k ] New Construction Use [x] 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) 94.30 ft (as referred to site plan benchmark)
Additional design / site considerations extra rock required to bring Tipe .n ndt-
Parent material outwash Flood plain elevation, if applicable na ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U=Unsuitable fors stem ®S ❑U ®S ❑U ®S ❑U [2S ❑U ®S ❑U ❑S 13U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Clu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
>...1... 1 0-17 10 r3 2 none sil 2msbk mfr 2f .5 .6
LLj 2 17-35 10 r5/4 none sil 2msbk mfr if .5 .6
Ground 3 35-60 10 r5 6 none sil m na na n .2
elev.
99.9 ft. 4 60-10 7.5yr4/6 none cos osg ml na na .7 .8
Depth to
limiting
factor
+106
Remarks:
Boring #
1 0-11 10 r3 2 none sil 2msbk mfr 2f .5 .6
2 2 11-38 10 r5/4 none sil 2msbk mfr gw if .5 .6
Ground 3 38-63 10 r5/6 none sil m it. cemt. na np .2
elev. 4 63-10 7.5 r4 6 none ms os ml na na-- .7 .8
99.9 ft.
Depth to
limiting
factor
/
+108
P
Remarks: `F ST CFi0 x
CST Name:--Please Print Gary L. Steel Phone: 715-246-6200 ' % ZONWGOFRCE
Address: 1554 200th. Ave., New RichinoniQ WI 54Q47
r>
Signature: Date: 5-2-97 CS elf:
PROPERTYOWNEWernon Bast SOIL DESCRIPTION REPORT Page 2: of 3
PARCELI.D.#
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourriary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
2f .5 .6
1 0-15 10 r3 2 none sil 2msbk mfr Cfw
3
2 15-3 10 r4 4 none sil 2csbk mfr if, .5 .6
Ground 3 30-6 10 r5 6 none sil m lt.cemt. CFw na n .2
elev.
99.8 ft. 4 69-11 7.5 r4 6 none cos os ml na na .7 .8
Depth to
limiting
factor
+11011
Remarks:
Boring #
1 0-16 1 r mfr .6
4 2 16-34 10 r4/4 none sil 2csbk mfr if .5 .6
Ground 3 34-64 10 r5/6 none sil m mfr C1W na n ..2
elev. 4 64-105 7.5 r4 6 none ms os ml na na .7 .8
99.7 ft.
Depth to
limiting
factor
+105"
Remarks:
Boring #
1 0-22 10 r3 2 F2f .6
2 22-40 7.5 r4/6 none sl 2csbk mvfr .5 .6
Ground 3 40-66 10 r5 6 none sil m na Clw if n .2
elev.
99 8 ft. 4 66-10 7.5 r4 6 none Ms oscr m na na .7 .8
Depth to
limiting
factor
+105"
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
STEEL'S SOIL SERVICE
Gary L. Steel Kernon Bast 1554 200th Ave.
CSTM2298 NE4NW4 S14-T29N-R19W New Richmond, WI 54017
MPRSW 3254 town of Hudson (715) 246-6200
lot #10-Grass RAnge Addn.'
N
1"=40'
BM.= top of 2" pvc pipe C el. 100'
Alt. BM.= nail in tree C el. 100.80'
50 A C-2
31-3
AA1112
Gary L. Steel
5-2-97
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
5,
MAILING ADDRESS 5-
PROPERTY ADDRESS '?7/
(location of septic sys em) Ple a obtain from the Planning Dept.
CITY/STATE
PROPERTY LOCATION W/jf 1/4,,l 1/4, Section l T__Z? N-R_W
TOWN OF 4"O'L, ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER 16
CERTIFIED SURVEY MAP , VOLUMEL U , PAGE 2-TF , LOT NUMBER
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 maintain ust a completed and returned to the St. Croix
County Zoning Officer within 30 days of the thre year exp' on date.
SIGNED: p
Z
DATE: 7
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
S T C - loo
This application form is to be completed in full and signed by the
owner(s) of the property being developed. Any inadequacies will
only result in delays of the permit issuance. Should this
development be intended for resale by owner/ contractor, (spec
house), then a second form should be retained and completed when
the property is sold and submitted to this office with the
appropriate deed recording.
Owner of property
Location of propertyejL ~ 114alk-) 1/4, Section/ TAN-R~W
Township ~ Tyc Mailing address 4&~r'oe
<a~XSrl~l~-c-~T ~'Yo/~2
Address of site ?)y ,CcaO,
Subdivision name Lot no. /D
Other homes on property? Yes__y1No
Previous owner of property
Total size of property
Total size of parcel l ;
Date parcel was created
Are all corners and lot lines identifiable? _jZYes No
Is this property being developed for (spec house)? Yes _4ZI No
Volume q and Page Number S-2?4f 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. 5 2.g 2'1S- , 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 fice of the County Register of Deeds as Document No.
YS-
1
S' nature o pplicant Co-Applicant
Ao/~~Q 7
Date of Signature Date of Signature
~ • • _ ~ T•I:f VACt fKKRVtD ►Ol~ R[G0R01NO DATA DOCUMENT NO. WARRANTY DEED ~i
WI$CON 2-1M
P TATB 1 BAR OF
1
9'745 0L 11~~~M;E~~ - r"►a
Lo.A
n LEANORE•8ROliN-alk,~a•Elinor J_-eroMm,•. I i~div,-r•,~-
RAY-. G.!.. BR41i. .4.E 5 1995
hUSQi1..r4..4.0..wift JUN
8:00 A•;".i
.
corveye and warrants to
R :3t C., !'•.ii.3
vA~uabte. consideration *Crum TO f0~
~W'F/.l.
x....» _Gwnq, 020-1019-40
the tolt owing described real estate b 5t Cro
Sat. of Wj-rcan.ls: Tax rated No: 4 4-j.Qa~0- 4_.
MW% of NO of Section 14-29-19 EXCEPT V" t to Hudworth, Inc. in ,
' Vol.,604. Page 226.
NNk of NN% of Section 14-29-19 EXCEPT part to Thomas Willy in Vol. 958..
Page 577.
Subject to town road right-of-way aloag`the southerly line of said lands
l3raates is responsible for payment of real estate taxes for the
I
y**r 1994, payable in 1995, and subsequout years.
This A.ML......... bomeete" Property.
(is) (is sot)
FAmeption to warranties: ,
Dated thbti . day of - 9114 is.. 5..
.
f (SEAL)
- . .......................................(SEAL) Rav G. Brun.,-- "
(SEAL] -
t!ACL•eL~ts~+'~. --..-.-.-.(SEAL)
Eleanore Brown
AUTHENTICATION AC=NOWLSDOWBUT
~
Siosaftie(r) .-l't-.6,.._QtGlfi!__ASTATZ OF WISCONSIN
. -_.-----Counh• 1
» _ »
1f9 Preaon&Uy cast betwo, se tbia ----------------day of
_ IfI named
• The . . . . .
rt.
TITLSs lill[BSg STATE BAR OF WISCONSIN
'Petip° who executed the
)
(a harLe »by 706.M. Wis. fiats. is ar knows to be the
fssefolnt instrument and aekn d1ae the same.
Tins 1wsrOUNKMT WAS tMAMD SY