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HomeMy WebLinkAbout020-1269-70-000 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ?e4 / R /E ,C N,F_ ADDRESS N~ Qsa N 1,Aj SUBDIVISION / CSM# _TAC68_5 LX VD 1A/6 LOT # SECTION 0/ T o2~ N-R / ~ W, Town of j4~UAoZe, & ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM _ p nor c.~N E rob 71' At. S R c c T VA - ! :FgDN ip E 6jkA16X 4 RFA AT ~t~ f1 rlrao~a A I ~LTF~ rt4 ,4 _ ' s'I - - - - - _ hd Pet 7z~ - - - s 75 t ' ~ wo b (rid LL~ - - - - - - - - - - - l 'v✓ E 5r i E A31r Ir GgrQRpf ~-I G'1tAtoE h ' 13.10 DRIvF uVAY INDICATE NORTH ARROW - - ~alE SANE rovide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover.: A a BENCHMARK: 77 ALTERNATE BM: rmp Or >3 toe ~ ~pdwd ATl o N - Z, 'L. SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufactu er r: 4JE/.SEo0 Liquid Capacity: 16VO r6r1C, Setback from: Well S House $ Other %o Lr>E51~Tid/V/~ Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: S~ Length (o O Number of trenches o~ Distance & Direction to nearest prop. line: TT fiO A169-T8 r0'T L /N f.,,._ Setback from: well: 1001 House Co Other ELEVATIONS Building Sewer ST Inlet:?-(,,D - 17, 1 7"ST outlet: 7.91 = 14,147- PC inlet PC bottom Pump Off +a,-rN .F H 9 s R W a. 7 10.'7 0 A/6,C7- M_ Yl P 04 cl. 3 y Header/Manifolds./N9./R,49.33 Bottom of system /0.7S- so01N X3.97 Existing Grade :",XF21-n-a1 grade 4.z- DATE OF INSTALLATION: PLUMBER ON JOB:'_-~R LICENSE NUMBER: Al"s ° 01?1S10 O INSPECTOR: 3/93:jt Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX -,Safjty and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 284262 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: MILLER SAM E HUDSON CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 020-1269-70-000 zlz_ i TANK INFORMATION LEVATION DATA A9700031 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark i Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet 7 S ' q 7- TANK SETBACK INFORMATION St/ Ht Outlet 0V 26, 7 2 TANKTO P/L WELL BLDG. Vent to ROAD Dt Inlet Air Intake Septic NA Dt Bottom Dosing NA Header/Man. 91 Aeration NA Dist. Pipe , y 9 S , !o. o' g3.4S, Holding Bot. System /o. O . S' PUMP/ SIPHON INFORMATION Final Grade j ' Manufacturer Demand Model Number GPM TDH Lift Lricti System TDH Ft Head Forcemain Le th Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width I Length s No. Of renches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSION -6_ Z d DIMENSIONS LEACHING Manu acturer: SETBACK SYSTEM TO P / L BLDG WELL LAKE /STREAM CHAMBER Moe Number: INFORMATION Type O /1'LtAJ r OR UNIT System: {~i., 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 21.29.19.1331, NW, NW, PRAIRIE LANE LOT 38 EAST I'A _tb Plan revision required? ❑ Yes E No Use other side for additional information. SBD-6710 (R 05/91) Date sp d s Signature Cert No ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: 'f f Safety and Buildings Division r^~~ii;n 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 Sanitar Permit Number ~q 910 12 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)]. A1 / ID 1,6 Lam State Plan I.D. Number 1. APPLICATION INFORMATION- PLEASE PRINT ALL INFORMATION Property Owner Name Property Location /LL 4 /4,S Z~ T LGJ,N,R/g E( W Property Owner's Mailing Address Lot Number ST, Block Number At:ee If EF City, State Zip Code Phone Number Subdivision Name or CSM Number Iv5o N c.tl / o/ (32fo i'7 roof J # c_ e,;, (?S ILIA A/Ai II. TYPE F B ILDING: (check one) ❑ State Owned ❑ itv Nearest Road A I R ~E Public 1 or 2 Family Dwelling - No. of bedroom X Town of (J~So N p LAA/z 111. BUILDI USE: (If building type is public, check all that apply) Parcel Tax Number(s) 127 • !9,133/ 1 ❑ Apartment/ Condo 0 Z 0 - 2 Gl - 70 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. ew 2. ❑ Replacement 3. ❑ Replacement of _ 4. ❑ Reconnection of 5. ❑ Repair of an ystem________System_____________TankOnly______________ 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 j)tloeepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13,0 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) G~ Elevation T Is 3' S Feet C , W Feet VII. TANK Ca in galloacitns Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- steel glass Plastic App New Exist in structed Tanks Tanks Septic Tank or Holding Tank X Loop 1 _S44'r- C_~, ❑ ❑ ❑ ❑ ❑ 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: QLp Stam MP/MPRSW No.: Business Phone Number: l k N1 c DO ~C_ ~jQ -0-0 $r~ 0o`1' Z-,, Plumber's Address (Street, City, State, Zip Code): ©o 0 2 j?_1DraE AD 400,SON S o! IX. COUNTY/ DEPARTMENT USE ONLY E] Disapproved Sanitary Pe[A(1it Fee (Includes Groundwater at/ e Issu/r Issuing Agent S ture (No Stamps) ~ Approved E] Owner Given Initial C v Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05194) 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 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.c3. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. Complete plans and speci fications 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. L E I f !c:) looe v X15 T . y ~ . s" oo ~ ~Yoerv nor 1 ~ ~iNE S~zyi) AT Nw [OT- e. D~NE~ 00 ?S' ~fp LdT*3 $ 36 Z \ AtIA r so qo" So ; SCR (00' -05 B 9 f t~ v Zo S Zo w E s~` / j E AsT E 90' Du,AEx DvaCEX ajq M Z ~ ~t o Z ~ M OQ \ ~ Q Q ~ Q W g0J5aa .a 2 4 al P = 3 ~a^ s6 V ` r r4 ` y o No 14- QI i ll~j j ` N 4w d d i ~ Q s M- ~ a r s a ~ f 4 a 1 Z Q X N d rI l h. x, ~ j a ~.1 _ ba pr, 'i a 4Q I rn p~ C) i ° . I rri N I I M ~ U! (f~ I i N -~41_; m~ rzo m L LI ~I I C I ~ ~ L1/ ~ °C I O I Z i 0 b N o z 41. 0 Wisconsin Departrnent of Industry, SOIL AND SITE EVALUATION REPORT Page _ of t Division of SHuman Relations afety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but -S-) 4 1 Y- 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. LriT REVIEWED BY DATE APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION PRO ERTY OWNER: PROPERTY LOCATION n ILLS GOVT. LOT nl W 1/4t f W 114,S-Z.f T -9 N,R 19 E (or) W PROPERTY OWKR':S MAILIN ADDRESS T BLOCK # SUBD NAME 0 CSM!/ CI , STATE ZIP CODE PHONE NUMBER OCITY V LAGE OWN NEAREST ROAD New Construction Use M Residential / Number of bedrooms 14nIK (J Addition to existing building j J Replacement [ J Public or commercial describe A Code derived daily flow gpd Recommended design loading rate bed, gpd/ft2 trench, gpd/ft2 Absorption area required bed, ft2 trench; ft2 Maxim! design loading rate n bed, gpd/ft2 Q'$ trench, gpolft2 Recommended infiltration surface elevation(s) In( P[.OYr PLAN TAC; ft (as referred to site plan benchmark) Additional design / site considerations Parent material Flood plain elevation, if applicable It S =Suitable for system cIiVENTIONAL r~guND 1 ROUND PRESSURE ABRADE TEM IN FlLL HOLDING K U = Unsuitable for system L~ S 1:1 U (1~ S ❑ US ❑ U IRS ❑ U YS ❑ U ❑ S U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Bound3y Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench 4 Q oy 3! L nn 5 b K nt r C Z e, --A 3 S ; t'_ rh SDK M ~r ~S i Ground -111 IbYk4ll n S M g r M O o el~vy IDQ,S' ft. Depth to limiting Remarks: Boring # I _ L ! n. s b ~ rn~f' 2 9x _ .z jay, 4-14 s J r- I Ground ► elev. /L`3.3Zft Depth to limiting factor > 70,Ob Remarks: CST Name:-Please Print e'v et Q l~ N j 0 N Phone: T~ Address: , o, -96 X, 9 ! U &S0 n► Signature: Date: I I S CST Number: 31 ~ '1 PROPERTYOWNER S4A SOIL DESCRIPTION REPORT Page _of PARCEL I.D. L6,- Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bound3y Roots GPD/ft in. Munsell . Qu. Sz. Cont Color Gr. Sz. Sh. Bed nch 13 A O-IZ ~+~3 l L wla JC r Cw ~ 19, 1 v k 4 -3 `a , L I n s b~ m Ground g-n ,e 4 S n~ th 02 , elev. ft Depth to limiting factor Remarks: Boring # Q I C~-I ~ id Q3 z - abb. nd,Vr I ~r I I- z JQYk414 - S n. r m Ground qi ft Depth to limiting fac Remarks: Boring # o .2b X23 M q b~ i`h Y' (~,W I T &WIZ4 Q 4 S n^, i r rn Ground elev Depth to limiting Remarks: Boring # / L I Q b ~r, r w I Z- mye g i -5 9 L L /I, S bi~ n, r Cw 1 tir n -12 1 Y /4 no Ground 411-0 ft Depth to limiting factor > Remarks: SBD-8330(R.05/92) STC- 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County O WNER/BUYER MAILING ADDRESS ~3O T* L-S~ Z PROPERTY ADDRESS (location of septic system) Please obtain from the Planning Dept. CITY/STATE U DS O~~ ~y0 PROPERTY LOCATIONNU-) 1/4, &U.1 1/4, Section T N-Rl,5~ ~VV TOWN OF WO QSa 1.~ ST. CROIX COUNTY, WI SUBDIVISIONS-r--6t SJyPLOT IYUNII3ER 3V "le CERTIFIEDSURVEYMAP4,~-30-2,3,VOLUME727PAGE02, LOTNUMMER --tF? 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. LfWc, 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 a SIGNED- ` DAT[J St. Croix County Zoning Office Government Center 1101 Carmichael Road liudson. AVI 54016 11/93 S T C - 100 This application form is to be completed in fu71 and signed by the owner(s) of the property being developed. 7~n7 inadequacies will. only result in delays of the permit isfuaice. 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 5 A e7? N&646 t_ Location of property/ 1/41/4, Section 2- N-R_Z_7 ~D Township //OOSdA- Mailing address_&OX z fL-- Address of site Subdivision name .316 ep LO ' ~ AY n Lot no. Other homes on property? Yeses(' No Previous owner of property ec HA /Y 1 ° W Total size of property C- Total size of parcel 3 J T 14e Date parcel was created Are all corners and lot lines identifiable? Yes _ No Is this property being developed for (spec house) ? _Yes No Volume 770 and Page Number (pt'z- as recorded with .he Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWIN,?s A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLJME 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 (arcs) the owner (s) of the property described in this information farm, by virtue of a warranty deed recorded in the office of the County Register of Deeds as Document No. q 2_j c>_33 , 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 reeds as Document No. ature o Applicant Co-Applicant D D1~ _C~ Date of Signature Date of Siqnature r s DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1-1982 THIS SPACE RESERVED FOR RECORDING D/.l 444 WARRANTY DEED cc~~ cc~~ REGISTERS OFFICE 4113033 BOOK 770 PA"E6J2 ST. CROIX CO., WIS. Recd. for Record thh . 5th This Deed, made between .-..Virginia.......Hanson~ .a............ day of March A. D. 198 -----------------••••-•--single woman at 11:45 -At Grantor, James O'Connell ~ and_________ _________S _ Miller,--.d/b/a/--Sam--Mille...Construction ~f DOW deputy , Grantee, Witnesseth, That the said Grantor, for a valuable consideration.--... e ollar__and..other-_valuable__cons deration•- ..._.1~ • RETURN TO conveys to Grantee the following described real estate in .--...~.t....CxO. zc......... County, State of Wisconsin: e Tax Parcel No: Part of the SW;- of the S14- of Section 21-29-19, described as follows: Lots 5, 6, 7, and 8, Certified Survey Map filed November 19, 1986, in Volume 11611, Certified Survey Maps, page 17+7, as Document #419479. Subject to recorded easements, reservations, and rights of way. TMIA r This i$.=t------- homestead property. (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And.--------- Virginia M .•:Hanson warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except no exceptions and will warrant and defend the same. Dated this 4th----------------------------- day of March 19-.87... (SEAL) ....C.C' !tel.-~'Y SEAL) 4 rginia M. Hanson •--------.(SEAL) (SEAL) s AUTHENTICATION ACKNOWLEDGMENT STATE OF WISCONSIN Signature(s) ......Y!rg'!B14--M-,--H=54A ss. St. Croix ......................County. authenticated this 9th-day of._._. March....•-_ 19.87. Personally came before me this A .......day of