Loading...
HomeMy WebLinkAbout020-1321-10-000 r STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER STY"! M ILI- i - ADDRESS fci ~~N N+£ ACC SUBDIVISION / CSM# r,,eA~H4 YA L LE LOT # SECTION 1 s T 2-9 N-R W, Town of U D f N ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM _ ~o~ 7~H Let ~-/~/F ~~r Z cos' Ort : b Al of S-10 nlof 10(/SF. ccc 'Ag 50 - INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. i Provide 2 dimensions to center of septic tank manhole cover. I o BENCHMARK : 1,2 P o f ALTERNATE BM: T0P of t t Calk- FO„ NC>4T 1 o Al O, SEPTIC TANK PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: WE/ 3g/L._-_ Liquid Capacity: 1e00 CO'4c, Setback from: Well /Q House Other 1S-I' TO t7oae7` !oT L/A -c Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: Length 40 Number of trenches Distance & Direction to nearest prop. line: 5-9 p °A/eeTA/ eP7' /,-,4/e Setback from: well: (o .5 , House !pO , Other ~ F 112/KGB Z 75( ELEVATIONS s 2- Building Sewer ST Inlet:_?-l Z'IZ'ST outlet: 8,03 = 92✓! PC inlet, PC bottom Pump Off Header/Manifoldl -06"'FI Bottom of system Existing Grade S7•07 - Final grade S . O'7 DATE OF INSTALLATION: PLUMBER ON JOB:/" I1 o*06 c+~..~. LICENSE NUMBER: s41IJ1Z J tt V INSPECTOR: 3/93:jt Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX 4 Safety and Buildings Division (ATTACH TO PERMIT) Sanitar PermitNo.: GENERAL INFORMATION 84240 Permit Holder's Name: ❑ City ❑ Village 'rj Town o : State Plan ID No.: MILLER, SAM E. HUDSON CST BM Elev.: Insp. BM Elev.: M Description: Parcel Tax No.: ?,20' 98.20 B ~~~,Y,Q QS pi. Pza-,, 020-1321-10-000 TANK INFORMATION ELEVATION DATA A9700007 Sa8/97 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic ~c~SQ~ ~cnC • / p1t1J ,P Benchmark 98.20' Dosing 6eA. o.76 I Id-6, (96 Aeration Bldg. Sewer Holdin St/ Inlet 'Kk TANK SETBACK INFORMATION St/ V Outlet TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom Dosing NA Headers 2 X6' p/ 9J Aeration NA Dist. Pipe 3 9/, S 3' Ho T§ Bot. System ,Wif PUMP/ SIPHON INFORMATION Final Grade 77 Manufacturer Demand del Number GPM TDH Lift LFiction Ft ead Force In Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHIN Manuf r: SETBACK CHAMPM- INFORMATION Type O R e-mv, Mo el Num e . System: + NIT DISTRIBUTION SYSTEM Header /Manifold ~i 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-Gra y my Depth Over Depth Over xx Depth Of xx Seeded/Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HU•D~SON.1/5.21.19W, NW, NW, ~LpOT 1, GRANCIE ROAD aw n 0 ~ p , yC ~ ~ ax eA1/►'►~ O~ ..ot~~. Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. S ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: vi~Fir~3 SANITARY PERMIT APPLICATION BuSafetyreau o off BuilBuildinWater ing 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 4- amx than 81/2 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Number ~ vio O 02 The information ou rovide ma be used b other overnment a enc ro rams ? Y P Y Y 9 9 Y P 9 ❑ Check it 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 ~Lo5ation <.401 Z40-or- /4 k/ 1/4, S IS' T7_9 , N, R/7 E (or~ Property Owner's Mailing Address Lot Number Block Number City, State Zip Code Phone Number. Subdivision Name or CSM Number r s©N / SYa (S j ) '2 ~C. 11. TYPE F BUILDING: (check one) ❑ State Owned it Nearest Road ❑ village Public 1 or 2 Family Dwelling - No. of bedrooms_ own OF 1111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment / Condo © Z Q ' / 3 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. ED 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 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) , - Elevation S S 0~7 9 t?.~~ Feet 9G.ao Feet Capacity VII. TANK in gallonTotal # of Prefab Site . Fiber- Exper. INFORMATION Gallons Tanks manufacturer's Name Concrete Con- Steel glass Plastic ApP New Existing structed Tanks Tanks Septic Tank or Holding Tank 1 ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (No mps) MP/MPRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issuing Agent Signature (No Stamps) [Approved E] Owner Given Initial Surcharge fee) Adverse Determination cZ u p X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 0"41) 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 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 8, 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 exis:ing 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 applicatio,) 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; vvater 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. _ 7 Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of a- Labor aV. 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 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 0 NER: PROPERTY LOCATION M M f L_ Ck GOVT. LOT r ,L j 1/4 NW 1/4,S T-49 ,N,R 19 E (or) W PROPERTY OWNER':S MAILING ADDRESS L # K # SUBD.AIAME OR CSM_# U ► IL CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VfILLAGE EITOWN NEAREST ROD ( ) I^l uLso 1.4 C i N [Od New Construction Use Residential / Number of bedrooms 14NK [ ] Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow gpd Recommended design loading rate ? bed, gpd/ft2_trench, gpd/ft2 Absorption area required bed, ft2 trench, ft2 Maximum design loading rate !~i bed, gpd/ft2 6,.? trench, gpd/ft2 Recommended infiltration surface elevation(s) ftAsreferre to site plan benchmark) Additional design / site considerations 7S61 L L VAi i4 . 10Q 60►y L VO'P, Kod ' pip L Parent material Flood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL MOUND F IN-GROUND PRESSURE &T~•GRADE SYSTEM IN FILL HOLDING T K U= Unsuitable fors stem Jf S❑ U MS ❑ U P1 S❑ U K S E3 U S❑ U ❑ S U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Bourclary Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench /0y ie SL Afil-'-Joe, 6--Z 4.. b Ground "l -/lQ QY~2 4 f>^, r 11.11 elev qKA- ft. Depth to limiting ~ ctor Remarks: Boring # yf t sbK f►~~~ t.J jF A 'a K -8 ~Y 3 Z `h b k-S ~Y 4 14 ~jC_ r' rbr r w 0.1 lg.~ $ - 9 7. S Y44 4 1~, 13 c• t1l - 67 6.Z. Ground Al_ev_. Depth to limiting Remarks: CST Name: Please Print 11A Phone: ~ p f~ Ns~,v - 08 Address: Signatur : Date: Zl 9 CST Number: >rf't' PROPERTY OWNER Z Page AA MILLLk SOIL DESCRIPTION REPORT PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench -7-2-4 /on,/44/3 st- r f%, yr c_.► ! ,4 O Ground "46 /6Y 3 n~ r n, W 4 ? d~ ,elggv `1 b . I ft. n7 .7 16% Depth to limiting factor >i) Remarks: Boring # p A /oyez Sl t s /-F a .4 16 76 7 4 S n r ~1 - 4.7 O g Ground ft. Depth to limiting f ct~ or Remarks: Boring # a 'A lo, -46 yK 9 4 g Ground -l2: O _ S r., , 1t? I iol elev. ft. Depth to limiting factor 7 Remarks: Boring # ra.•ri•v~ gib: vk}5,' \'i Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) W Z 4L I ~ 1 N_ I f ~ I I 1 YQ I I z I ~ 4t d ~N 4_ PVO ~ Qtr ~ Nom; ~ M ~ M oa - cb W 04 `v+ N a ~ M 9 0 Z YA 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 s,4m n'f /LL E/2 Location of property /!V 1/4 Nu-) 1/4, Section T 29 N-R/? W Township H vDS o N Mailing address Z(nx' Z Fr -t-- C5 - YOI r. Address of site (41 <S 2 Al 4 F R-06 D Subdivision name Cpp-q~,4E'. VA LL- F -r-' Lot no. Other homes on property? Yes .X No Previous owner of property Do ,)ct (n. 4 k g'r b i Total size of property 2, q r¢ c. Total size of parcel 1, ')I Q c . Date parcel was created f- 2-7 - 9 S Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house) ? -r Yes No Volume /Iq z and Page Number to7 4 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 igloo A , 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. a 31-/ L/ a o c4 Signature o Applicant Co-Applicant 1 2~1` el- Date of Signature Date of Siqnature STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER p ~'1'L /~l l L MAILING ADDRESS o k Z Z-- PROPERTY ADDRESS I Al (location of septic system) Please obtain from the Planning Dept. CITY/STATE V b SO ~ U) k /1:~' PROPERTY LOCATION 14 1IJ 1/4, 1/4, Section T N-R W TOWN OF /LL) D so 1\/ j ST. CROIX COUNTY, WI SUBDIVISION K' j4 A C L/ L LOT NUMBER CERTIFIED SURVEY MAP 2- -'If, VOLUME PAGE, 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 maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. SIGNED: - DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 g, ~0,,~\, ' i C I p I T ~ f f rn ro ~ J o Nr\ 1., -4 \ ,No TY) i I f ~ti )h t 6 r N 0 N jj7 r~ I O ~ I ' r I m i R+ -o I m I N I =I 4': w ~i r i o. I Z •t) 46. I N I O - ~ w ~ Z I c4 •v I ~ 1 I - ~ Z O o ~o G ,r,LA Goz 1 y, St.rtr It- of 11 iw (m;a 2 19.42 WAR, 1'iTY U1'f;i) I tt~~ I-X DOCUMENT NO Fff a SI J9 F j~~ v tlt'I iVE Douglas C. Katner, Bernard J. W un, SEN 1 9 I99b __and Chris P. Neuman - J 1 84 12:30 P.L1 conveys and warrants to Sam E. Miller Regl,,~ tor of De, is II - •M~ $PAr,f RE',EHV,rI FOH HEr'()n G;N- rWA HAVE <ND RE runN ADOHESS I the following described real estate in St. CIO i X County, State of Wucoasin: 1 fF'A 40 (Pa,ecl Wtnt,ficatior+ Numlh<i) r I ~ Ij NW1/4NiW1/4, Sec. 15-T29N-R19Ft, except Certified Survey Map recorded i in Vol. 5, P-ge 1418 as Doc. No. 393288, and except Certified Survey Map recorded in Vol. 6, Page 1761 as Doc. No. 420627. i ~I II II :n Ii It is not II This bomestead property. (is) (is not) i e I~ Exception towarrartti~s: easements, restrictions and rights-of-way of I' record, if any. II Dated this -T----- - - -September 95 d y i1 - . 19__. I ;I - - - (SEAL) 11ea 41 - (SEAL.) ? Douglas C. Katner Bernard J. Neuman .4 - - (SEAL) w~h-.- - (SEAL) Chris P. 9euman AUTHENTICATION ACKNOWLEDGNfENT c i Signature(s) Berlard STATE O V WW, ;W Chris P. Neuman sa. County. F authenticated this _ y of _ gptQmbeL-- , 19.95_ r4lullgre me this day of k an-sG"C Katile 19.9 venamed i C 1Q - - - Krishna gland - - 1¢ ~G:- - TITLE: MEMBER STATE BAR OF WISCONSIN I (!f not, - - - - - _ 'r+r~ a authorized by §706.06, Wis. Stats.) to me known to be the person a e:ea rrurttV foregoing in;irur;rkat and acknowled~(i+e~ ~ •.1 G y THIS INS TRUIJENT WAS DRAFTED BY Krishna Ogland ~ f