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HomeMy WebLinkAbout020-1308-80-000 v STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ADDRESS &",6 v Z F SUBDIVISION / CSM#~~5a~ct` LOT # Q SECTION _T 1 N-R l W, Town of ly"k'd erev ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM p r oa ~ nJ ~tinr v ~ rt~cw~ N INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. ~~c yn 2 ~l //s BENCHMARK: ALTERNATE BM• SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: laDd 'xid Setback from: Well '7- House Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: j Length ? S Number of trenches Distance & Direction to nearest pro. line: cf Setback from: well: House Other ELEVATIONS Building Sewer ST Inlet: ST outlet: PC inlet PC bottom Pump Off Header/Manifold Bottom of system Existing Grade Final grade DATE OF INSTALLATION: g PLUMBER ON JOB: ee) LICENSE NUMBER: JY1~© 3'G INSPECTOR: 3/93:jt Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Libor and'HuianRelations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No-: GENERAL INFORMATION 284284 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: CHARTS HOMES HUDSON -7 1 Insp. BM Elev.: BM Description: Parcel Tax No.: CST BM Elev.: 020-1308-80-000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft Forcemain Length Dia. Fi Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS LEACHING Manufacturer: SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM INFORMATION TypeO CHAMBER Model Number: System: 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 Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON.16.29.19,W,SE WAXON LANE LOT 8 Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: • I Safety and Buildings Division 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 (y L than 81/2 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Nu ber 78 -1 2 $ 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 e Y 1/4S',4_7 1/4, S lG T N, R ~Q E (or) Property Owner's Mailing Address Lot Number Block Number 73Q c oe IF I City, State Zip Code Phone Number Subdivision Name or CSM Number ►~a Qtr~f YyS (&Z ) Q - C f I,/ I.Cej II. TYPE F BUILDING: (check one) ❑ State Owned ❑ ity Nearest Road ED ag Public 1 or 2 Family Dwellin - No. of bedrooms Town of o cJ ea ~d III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo I S cr_ Fd 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. rOLNew 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 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 [RSeepage 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 a00 -?5-0 . r G~ y~ SO Feet /d/. © Feet VII. TANK Ca in gaaltuots 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 /2o0 m i dk/ e_ see.t R ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATE-MENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: o Stamps) IfAqAPRSW No.: Business Phone Number: L~J~~LI'.~ ~~er '.2 ?es-3FG -3 /;Z C Plumber's Address (Street, City, State, Zip Code): IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing Agent Signature (No Stamps) Ol Approved ❑ 10 Surcharge Fee) Owner Given Initial Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SOD-6398 (R. 05194) DISTRIBUTION: Original to Counly. One copy To: Safety & Buildings Division, Owner, Plumber INSTRUC7IONS 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 nevv criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit ssuing authority. 4. Changes in ownership or plumber requires a Sanitary Permi t 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 roust include: .I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement- Installing plumber 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 112x 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. Q ('Y p use. J 6 I t Il a ! 4 1 kA ! 1 s e~ GJ ` ' vrri wonsin Department of Industry, SOIL AND SITE EVALUATION REPORT Pa 3 Labor and Human Relations ge_Of oNision of Safety a 13uildinps in accord with ILHR 83.05, Wis. Adm. Code COUNTY ST. G (to l' >L Attach complete site plan on paper not less than 81/2 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 l~1TE PROPERTY OWNER: PROPERTY LOCATION (/OA100 5• lily' X oN GOVT. LOT wE(' -SX6• 1/4,S 4 T 2 9 N.R. I q E (a~ PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUED. NAME OR CSM # s 9 c-r . 'Rfl . A 8 PIC*SAhbT utl_w CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE OWN NEAREST =RO$ voso.~ 4~ts. SYo/e. (7/5) 96.31(38 HUDSo,J Cry. 1-fNew Construction Use[ Residential /Number of bedrooms -3 40 [ J Addition to existing building [ [ Replacement M- [ J Public or commercial describe Code derived daily flow &cv gpd Recommended design loading rate 7 bed, gpolft2 • ,P trench, gpolft2 Absorption area required bed, 11:2 trench, ft2 Maximum design loading rate • ? bed, gpd/ft2 • a' trench, gpdnt2 Recommended infiltration surface elevation(s) 5-en- p S . 3 47• SD ' It (as referred to site plan benchmark) Additional design / site considerations Parent material 5C5 -T (3 K G ~~-F- Flood plain elevation, if applicable N• . n S = Suitable for system DON IONAL MOUND / IN-G OD U PRESSURE A❑T S DEE U SYST ❑ FLL HO ING TANK U Unsuitable fors stem ❑ U ❑ S [3'lj SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed hartdh t o- !a ,Q V2- S. L s6.C 0r ti es 3 f N P N s • G Z S7-2-2- iDyie y' S./ Z sd f' Asti s I :f Ground 12-1-32. 7.5- YR y/(o I s I, A," , le dX c S • d' a fL ,t-~3 7.5YR '116 c.S. p, s , Depth to limiting factor L~ Remarks: tlbt' i zo,.> i S 4J,~P~4~T~l~ - a"'L P--~,~- (S S46. Boring # 0-0 /o YR )i'2- SO. Z mox 56,E . ds'4 cS 3 f- .s • ~ z loy,e 3116 - - s z f s6~ Asti cs Z . s ; Ground ' 36 7-S y'9 'V/~ of • 7 • ~ elev. 7.5 Yk y/~ C • S s ~,2 ? • d /O/_Y ft. Depth to limiting factor~ . Remarks: CST Name:-Please Print BE R r L d f2 ; C T. Phone: 715- 3 AM ' Q 19S less: & 55 p' NEi L 'RD. t+UOSoA9 W t S . SN0I4, y' CS vi 2 48L Signature: Date: CST Number: w Xo~ , PROPERTY OWNER VORO ~ SOIL DESCRIPTION REPORT Page? Ofl PARCEL I.D. i LO f Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bouxd3ry Roots GPD/ft in. Munsell Cu. Sz. Cont. Color Gr. Sz. Sh. Bed mrch 3 . S • b 0,& /O ~IQ Z/2 S~% Z- /NA SbK eQ S K CS 3 2 . so ,b ye y/G si/ I. f Sbe dh CS I . s • G Ground 3 d •3 ~~//2 f//(~ S~ l,µ►,l~/t' G~s~ CS s elev. • `j !O!•G ft. /07.5 y12 Depth to [-5 d • 7S yip ~.5, o S d • 7 = limiting factor Remarks: Boring # p /6 /o -I/~ IoM ,~`r~o 5511 2-,A,-) d u k CS z-F NP €>J 13- P- 7 is y e y/G 5"/ I f sdie nM~ • C s z f • . S 3 V7,.2,7 log y , s: / of s!>,e I-km -f / es Y , • S Ground l1-'' rYP~/~v 1"-Ie le 3 ' Q we1~ • ft, 27.3 S, yo AAA, Depth to !Y/6 I S - f /a R sly S o, s a°:Q • "7 . ~ factor Remarks: Boring # 40 Sid , C S• 2 f 1 I 0-9 i6!~.Zlt spa cr~1~ Z M -Q. d1 u nJ. . LJ Ground o f elev. z - 36 S M y. 5 • J6 16YR Sly .S. D. s •1 Depth to i Gmitlng factor M Remarks: ! 1 n R p.22 I e,~p -f -o j-o R Boring # i I Ground r elev.. it. Depth to limiting factor Remarks: N • O ~c N 70 c rn c ~ ~O o o ~ 0 7D • Ow - ~ ~o 0 i r ti c o a 0o i 0 r Z 0 0 O N W ~ H w -0 r 0 J o ose: P~ e eF 6r61(TyP.) d~ C M ACRES W 39 SO.FT.) I c 2 0 6.92 ACRES I e ( 301, 632 SQ.FT.) 0 6.11 AC. EXC. ROAD EASEMENT (266,188 SQ.FT.) Z 260. oo.- 26 QT' E-_ \ 3/p• 00' 190.00. PONDING \ \ EASEMENT \ ~2l0.001` 879.0 O `fie 1 ` l OT 00 \O0 , , o r Ab 7 0 2.62 ACRES \ 2. "CRES ( 114,052 SO. FT) 87, 171 SO. FT.) 1 1 2. 00 ACRES ~ w 1, (87,332 S0. FT.) / C - r 40 0 2.00 ACRES 41 \(87, 170 SO. FT.) LOTS 7 AND 8 S HALL HAVE A COMMON DRIVEWAY T 14 E' U zs~ 0 * 15 TEMPORARY / Z ~G y~~ \ \ 3 CUL-DE-SAC 9• Z9 3S ID 203•~~ 801 RADIUS) S. ~Z6%/ .14 o o x.20 ACRES a / 96, 018 SO. FT.) /N 2. 12 ACRES 2 0 ( 92, 2 10 SQ.FT.) / _ _ e ; W ti , 2.0.1, ACRES r STC-105 SEPTIC 'WANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER '1 r S G MAumG ADDRESS PROPERTY ADDRESS (location of septic system) Please obtain from the Planning Dept. CITY/STATE P1 A 5 S PROPERTY LOCATION \P) .1/4, C] E 1/4, Section P ( , T_2~-N-R~-<iD TOWN OF 1 L ` ST. CROI,X COUNTY, WI SUBD)<VISION r1 ('1. V I P ~M LOT NIJIVIBER CERTIFIED SURVEY MAP , 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 rho 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. 'T'he 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. C ATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11193 ZO 39Vd vd9r L9 10:9Z L66Z/9Z/E0 t aTC-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 Location of property 1/4 1/4, Section _kp-, T 2'- N-R_ i LwJ Township Mailing address _ 7 3 f1 ' z1a, 4 e. ~41 Y` ,5; ~f .e ms Address of site . ~G16 Subdivision name Lot no. other homes on property? Yes___✓_No Previous owner of property ~j~• r nr~ n ' TX ne- d )inn - Total size of property Total size of parcel 2-- Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? ✓ Yes ____yo Volume 2r and Page Number Y,,,'7 as recorded with the Register ---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. f the deed fled Survey description Map references to a Certified Survey Map, the 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. _C/'V Y V:- and that I (we) presently system or T (we) own the proposed site for the sewage disposal 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. 6 nature Applicant co- pp1 ica.nt -97 Date of signature Date of Signature 60 39Vd Vdo L9 Zb:9Z L661/9Z/60 WARRAN-ry DEED 9?gfv° LP~G Document Number ttetum Address A't l FR7-a Parcel I.D. Number: 020-1308-80 husb'And wife, alk/a and Irene S. Waxon, and Ir::ne Waxon, ration, the following described real estate a Vernon E. Waxon, Vernon Waxon, Inc., a Minnesota Corp, and warrants to Charis Home3, conveys an State of Wisconsin: in St. Croix County St. Croix County. Wisconsin. Lot 8, Pleasant View in the T° of Hudson, stead proper' if any. This is not hom- ts-Qf-way of record, ' n to Warranties* Easements, restrictions and nP,h Exceptto Tf4pNo t=ER March, 1997 ~ c(/day of SEAL) Dated this (SEAL) Irene WaxOn' a/k/a Irene S. Waxon 1 / L-XA~l a Wa Ve n E. Waxon ern n Waxon, AUTHENTICATION a/kla Vernon E• Waxon, Signature(s) Vernon Waxon' Waxon, husband and day of March, 1997. W axon, 94 Irene S. and Irene wife, authenticated this ICristinaO lanndd3ER STATE BAR OF WISCONSIN TITLE: MEMBER DRA• ED BY: WAS THIS INSTRUMENT inn Ogland Attorney WI 54016 Hudson, 7 so sz