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HomeMy WebLinkAbout020-1331-60-000 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER -1JQ ADDRESS G'}~? Zt~~ ~,rJ e r SUBDIVISION / CSM#_ i~;Ueyev -e .rJ LOT # ~L SECTION .23 T _4, y N-RAW, Town of d r ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 4v `Zd b 0645 C- 2 ~D 07 -S'X?.~ Trg~~°5 o ,per INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: u ..e a y ~l ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: Setback from: WellyO~a'r House SGf~ Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: Length 45- Number of trenches Z Distance & Direction to nearest prop. line: S"0e,-t 715- ° 11 Setback from: well:,dvT~%e,/4r-4fouse So-~ 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: e2S~~j PLUMBER ON JOB: LICENSE NUMBER:,( 6 ~~2 INSPECTOR: 3/93:jt Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM = Safety and Buildings Division County INSPECTION REPORT ST. CROIX No.: GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar Pe94rmit89 Personal information you provice may be used for secondary purposes [Privacy L s.15.04 (1)(m)]. X18 ftTti dej ldWe: EkftkgIlage Town of: State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description: Parcel T d~W=1331-60-000 TANK INFORMATION ELEVATION DATA A9700305 aS TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosi ~ a I~ NT"/vt 0 Aeration Bldg. Sewer Holdin St/6W inlet TANK SETBACK INFORMATION St/ Outlet Vent TANK TO P/ L WELL BLDG. Air Ito ntake ROAD Dt Inlet Septic 3 ' P NA Dt Bottom 1 (2) Do NA Headers 4 Aeration NA Dist. Pipe 6, 3~ 7. M' H g Bot. System .s PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Mo Number GPM TDH Lift Lriction Ft g:jf For ain Length Did. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Insi Liquid Depth DIMENSIONS S -DIM-EN SYSTEM TO P / L BLDG WELL LAKE/STREAM LE G Manufacturer: SETBACK INFORMATION Type o AMBER System: OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) "ole Size x Hole S Vent r Intake Length Dia. Length Dia. Spacing ystem SOIL COVER x Pressure Systems Only xx Mound Or At-Gr9jk: 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 23.29.19,SW,NW 707 WALDROFF FARM RD LOT 16 Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R.3/97) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: Safety and Buildings Division SANITARY PERMIT APPLICATION 201 E. Washington Ave. ^isconsin 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 1/2 x 11 inches in size. y • See reverse side for instructions for completing this application State SanitaT Permit Number a89z1 89 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 INF RMATION Property Owner Name , ro/4Vkj 1/4 5 a3 T N, R E (or) tJ 7't <41 ~v Property Owner's Mailing Address Lot Number Block Number 8,7 e. I/ City, State Zip Code Phone Number Subdivision Name or CSM Number r II. TYPE BUILDING: (check one) ❑ State Owned ❑ City Nearest Road ❑ Illage Public 1 or 2 Family Dwelling - No. of bedrooms Town OF pz~ III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) O;2 o (33~- d 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. 14 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 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 [;q 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) /63. P'a Elevation 7 S'd ?~'d Feet 1a?'3[I Feet VII. TANK Capacity l~f2 Iqd in gallons Total # of Prefab. Site Fiber- Plastic Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass App. New Exist in strutted Tanks Tanks Septic Tank or Holding Tank X ~Q(f !Je Je T ® ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite s ge system shown on the attached plans. Plumber's Name: (Print) Plumber's Signatur • (No Stamps) MP PRSW No.: Business Phone Number: Plumber's Ac dress (Street, City, State, Zip Code): IX. COUNTY / DEPARTMENT USE ONLY ❑Disapproved Sanitar~PermitFee (Includes Groundwater EDatelssued Issuing_Agentignature(NoStamps) NJ Approved ❑ Owner Given Initial Surcharge Fee) J`' Adverse Determination h7 X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: SBD-6398 (R.11/96) 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, 608-266-3151. 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. 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 or 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. Chea:k 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, Iocation 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. /v c ~vry s ;~--3X7STYc.✓G~.3 o ~ / CL G ~ i a T2 C3s AA 7- aY-e- a- 9e 'A Wisconsin Department of Industry, SOIL AND SITE EVALUATION 2 Labor and Human Relations Page / of 3 Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Attach complete site plan on paper not less than 8 1/2 x 11 Inches in size. Plan must County Include, but not limited to: vertical and horizontal reference point (BM), direction and S G~~/ X percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # PFN~/N Gr-. APPLICANT INFORMATION - Please print all Information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.14 (1) (m)). Property Owner Property Location q 11(]413400 /-A-A/v 4,, Govt. Lot SW 1141''IIW 1/4,S 23 T 2 N,R / E (or)(0 Property Owner's Mailing Address F ,4S T' Lot # Block# Subd. Name or CSM# 33z MiNAje$OT-A S.r h~K L06- . /CO FvER~r~PEE~! 6_57,1L 7-,67-5 City State Zip Code Phone Number Nearest Road //IV/ 12 ST PAU L- NWT 5910)_ j(&I Z) 22.7_- 5Sss ❑ Ciu ❑~Village [EI Tole cfM~ New Construction Use: ET-Residential / Number of bedrooms 3 - Addition to existing building ❑ Replacement ySc7 [j Public or commercial - Describe: - Code derived daily flow & p_D gpd Recommended design loading rate bed, gpd1W • e trench, gpd/ft2 Absorption area required / bed, tt2 75 D ttranch, ft 2 Maximum design loading rate '7 bed, gpd1ft2 • Y trench, gpd/ft2 Recommended Infiltration surface elevation(s) _ P Y • 3 ft (as referred to site plan benchmark) Additional design/site con ations _ WS&- Gavle 7(°Ev4V,..,5 PAp (381_ 1)i STj01'!3 Parent material _SG-S 58 ' P/.//o T ' S~rT-A'E Am'-fs Flood plain elevation, if applicable S = Suitable for system Conventional Mound In-Ground Pressure AT-Gr System i ill Holding Tank U = Unsuitable for system Q S ❑ U B'S ❑ U gt ❑ U L'~ S❑ U 0 U ❑ S SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft2 In. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed ,Trench l / 0-2"f to WR L~ z- S/L /fSd,~ n~ fR CS / f .2- ;1J 3 y 16 Y/? 3 f3 SL I~C,5-b e e CS - Y ' . s Ground 3 34.04 /a y S D S GQ.2 'Z c9 elev. to I - eft. Depth to limiting factor Cf In. Remarks: Boring # 0- to io vie 3/31 L - l y /o Y/? 31y 5IL 17es4& W 3 W_ 7. s Ye `,/6 S 0, s d cS . ~ : , Ground 36-%j to v 516 S S GQ - 7 107. elev. -ft. . Depth to limiting fac r ? J~Xjn. Remarks: CST Name (Please Print) Signature Telephone No. ROQERT- 2,«[3121 c~tT- 713-• 396- Address PROPERTY OWNER C SOIL DESCRIPTION REPORT Page -2-of 3 PARCEL 11.131 G 6 f ` c dw ~ ri 7- Boring # Horizon Depth Dominant Color Mottles Structure 2 In. Munseli Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench 3 t o io V/j ~~3 Sim l~sb,~ GS Z 3 L U-lo /o y/~ 3/ S L 7'sh,4~ ^0 -rx C15 - • w '.5 Ground 3 S y S Q S (it C S O ele d(0eft. -~7 0► S/ S p • Z Depth to limiting factor In. Remarks: Boring If . I ioY~ L S/6 /fsf~ cs Z 3 Ground elev. Depth to limiting factor ln. 5 Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots D In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # 1 0-7 40 V 3/ 3 S L I CS,~it M-+ 1W 170 S 5 7-is goy ( Ifs nM~' s . z• 3 IS- -7.5 YR 5/le s s d ~f cs - ; , Ground vie S/ S o~ S ek elev. 0 3, d ff. Depth to limiting factor 7 yin. Remarks: ~ Boring # Ground elev. K. ' Depth to limiting factor in. Remarks: SBDW-8330 (R. 08/95) O ~ u,EST GoT - - o 1 w to 00 0 o 0 r 0 . s w 0 0 N -o ~ 0 ti a G I m~ o D ~w O v S00°04'51" S .41 N O C~ r C, s b °Go 'gyp ZIE . 0 l tp , ocs , /so t \ ` '7, ~O f r \ w 0 C~ • aZe~ )3 N S 0 0 ;2 ~o •3 ~9o 14 o L" I ~o yr' o 4 p1 W "IQ R1 c I NOO013'54 E C (A 190.00, A CD iv O I t0 = ,acv O, F- ° I A n Y o I D m wv ~o - I Q ( FD IV v I --I O I m Q1 ~r` j m m a I m N ch G O -4 -1 t o tDN r"OmA i I F) O Mmv m NOO°13'S4'~E 230.00' N o D mi D M A 0 Z p cn ;D m N/3°p8l N o m a o 4p 36 cn . : mom 0.85, C N O O C M c' o m v Z~ N D O xn CID N l~N I -n _ ~ N O m VI W O W N o° Z D rn o .4 p o m I O W m cp N r ll 0) D CD 0 Zm m p N A O poi NA M < N l N R N D m I(- 7' I D IV 08 I z ~ m 0 ~\83 ~ 3j 7.2 36", g Qo ` (b 0 0 ` 0u (A N I to L S9 S% F. e, O N N to 8 0 N33 \ m n F W 92 . h o q 0 ° K oz Z a \ ' ae FF ~s S9 y` . N 01 ~ <<, S 01 O ~ N M hO\ 0 OD ~ O O ~I 9z Z •<<£ 'F9~ O cD Z I lgOo£/N ^ b~ ® O Q U- 1~ p tf . w 0 4 U N Z N (A W ` Q N i Z VI } f tY N O O N O (D 2 p p Ul) O I W Q~ l0 N01 O t. NF- M O - o M QZ 0 0 N H - (1 K) W H O iff I <L D NQ1 N c QW 0 N tD N I zO W z ~W O N D 9 •00~ u > - N 10 y 100 z 9£,80o£lN W Iwo u N N Q~ ~ 0 U) Q ,00.0£Z O 00 2 - CL 3„b6,£Io00N c0 IOD _ 0 O N 01 FO a to N t0 OD 1C) W D I W~ y~ LL ~ °D U a - O W ix It < u -J X0041' Q~ ! C CD ZI N , 00 ' 061 (A 3„bS,£IoOON • I _ W In O F~ Sso , SF • o 2a W I O Ckj 0 00, 'S2 Q N cn N Sso 6~S O \ \ O N cc N O) 76 410 32" E Oc)0 45' 5p\` S C (eD` 0 is Al 101 d a Ira tlo 000S 3: p p M8 < 0 STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County • MAILING ADDRESS _ a •7 Z P11 ~ Ant. /✓Lt JSOPt &1 PROPERTY ADDRESS _x'07 l+1o~le~YoeCF /ic►r`it /P (location of septic system) Please obtain from the Planning Dept. CITY/STATE PROPERTY LOCATION 1/4, Section, T Z~N-R___jq W 'SOWN OF ST. CROIX COUNTY, WI SUBDIVISION PN-4, LOT NUMBER _ CERTIFIED SURVEY MAP , VOLUME J , PAGE 4d4 , 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 maximurn 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) aller inspection and pumping (if necessary), the septic tank is less than I/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 yea )iration date. SIGNED: DATE: 8 -S 9 -3 St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 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 Location of property 1/4 A/14) 1/4, Section _,`i' _N-R_,.~W Township h u-Q.40 41 Mailing address 6g7 -2*_-rjejr_ j~ - O UAII•-A, , UJ Address of site 96-7 fJti~elroFir Rid Subdivision name j:7 er- UA, Lot no. J Other homes on property? -Yes No Previous owner of property ~ 4J X . cgj_ _V .$C Total size of property Z , D AC_~ Total size of parcel PO Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes _A,--" No volume 3a~F and Page Number as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION TILE 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. 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 officer of the County Register of Deeds as Document No. Signature of Applicant Co-Applicant 0,1to of ';innat-ii- a J 563577 STATE BAR OF WISCONSIN FORM 2 - 1982 1 k DE1D86 R^17 - ^C DOCUMENT NO. Richard W. LaCasse and Grace J. La.Casse, dim PAG i -tiusba-nd an wi a AUG 7, 1997, 10:30 A. ~y( conveys and warrants to Ronald J Bates and Paula T. `Y414l.- .•Ik 0 1, Bates, husband and wife, with survivorship fwy1ssw otoW.d* marital property. THIS SPACE RESERVED FOR RECORDING DATA NAME AND RETURN ADDRESS the following described real estate in St. Croix County, State of Wisconsin: miDAMERICA BANK HUDSON 600 2nd Street Hudson WI 54016 PARCEL IDENTIFICATION NUMBER Lot 16, Evergreen Estates in the Town of Hudson, St. Croix County, Wisconsin. $ T S i~§RER is not This homestead property. X30a (is not) Exception to warranties: Easements, restrictions and rights-of-way of record, if any. i Dated this day of August A.D., 19 97 r (SEAL) (SEAL) Richard W. La sse (SEAL) (SEAL) ace J. Casse AUTHENTICATION ACKNOWLEDGMENT Signature(s) State of Wisconsin, ss. St. Croix County authenticated this day of „~~il!!lJh,_ Personally came before me this day of 00 .a ' NORFLEX o DRIVE loo' o z z cl C) 0-0 C > W wn a°m" Z ~ CD O1 co CD o ws b t O 'n 0 rn w N " : •-r «ti m N J v " ~ D r o 02 In m rn - 11 --I z m I- IM o cm~ft o U m O N o 1Z IT W-4 n m tv I of m 99 M R Y7 p i~ 2+ m ~r o Or eC2 N _ ~rn I o.~e ~o U) I~ I r0 4 o ; in z 10 o IC es w O CD 4n Q1 m IC-) Irn p a ap ~a IN I ~ z CD pr m w . t0 ~O w l R c1q, 9r rn i-~ cr C ~ z O G p 0 • 7 o y M r Z Z W r-t ,~w` u Z 0 ts N,~ c D m co Fr _V4 = z m N w^ - oz a 93 10 ow CD va 0." 4n P4. z m c - ° ;;m°o W C, co 2 r-1 N o Cr o n - CD W kl A H~ p to 1 1 n Cr W • ~p • ry -o n O.O p P,s Co 1 ' m tv 40 C, cr~ COS ".-C% !C9 t0 A O . R Q o p ~ CA tip Mr • 'atar~e~. Z w r Ic Ic 1--i 10 I'Tl Z ~ N I (n - - Ir rn 10 a~ cNn jG~ I-p ~C I= IG) I< O I IDC IN I U) m IN ID rn