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.
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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)
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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
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