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HomeMy WebLinkAbout020-1294-60-000 A` ~`!1 Ate'` NOTICE: Please provide the following: • A Plan view sketch showing eve rything within 100 feet of the sy tel. ~y(y • Two horizontal reference points to center of septic tank manholei~Cr . vc~ r ' Show alternate benchmark, if applicable. PLAN VIEW ~D p /K C, INDICATE NORTH ARROW ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT G- Owner MA4 Address 7 City/State Legal Description: ' Lot I_ Block Subdivision/CSM # -~-F1/. "Sec. IX, T jaN-R jfW, Town of PIN # . SEPTIC TANK - DOSE CHAMBER HOLDING TANK INFORMATION: / Well - P/L Tank manufacturer Size ST/PC I s0/ Setback from: House -j Pump manufacturer Model Alarm location (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM: Type of system: Width _ Length 69 , Number of Trenches 3 Setback from: House'IS , Well - P/L Vent to fresh air intake ELEVATIONS: Description of benchmark 7'0P ct~ S W `i~ Elevation Description of alternate benchmark Elevation Building Sewer ST/HT Inlet ST Outlet. ya _ PC Inlet 3, o.s-a PC Bottom Header/Manifold Top of ST/PC Manhole Cover 0 Distribution Lines 13 , i S / a3 l yt / Bottom of System ) ! JS r Final Grade ( } ( ) ( } Date of installation / a ?Permit number j t State plan number Plumber's signature /14-1h License number )0 7S/5 - ig' Date Inspector Complete plot plan aw 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 than 8 112 x 11 inches in size. -5 7~t • See reverse side for instructions for completing this application State sanitaarr Pe ,t The Info Mation rmation you provide may be used by other government a9encY Pro9rams ❑ Cf revfs[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Property Owner ame Property Location tLu~G`!l` 51--114 A) /4, S a T , N, R C E (0099 Property Owner's Mailing Address Lot Number Block Number 3 Jl- 3 Ci tate Zip Code Phone Number Subdivision Name or CS umber II. TYPE BUILDING: (check one) ❑ State Owned L El city Nearest Road n 114 ❑ Vll age C 1/ A E] Public 1 or 2 Family Dwelling - No. of bedrooms Town OF III. BUILDING SE: (If building type is public, check all that apply) Parcel Tax Number(s) _ aC/ ~ICj - 11 fs~ 1 ❑ Apartment/ Condo C/ ,r C/ `l [C ~ O 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. E] Replacement 3. E] Replacement of 4. E] Reconnection of 5. E] Repair of an _____System ___System_----- __TankOnly- Existing system -----Existing ❑ 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 410 Holding Tank 12&0 Seepage Trench __7`,SX 7 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) 103,5 Elevation C+ e G~ S Feet Feet TANK Capacity VII. in gallons Total # of Prefab. Site Fiber- Exper. Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic INFORMATION App New Existin strutted Tanks Tanks Septic Tank or Holding Tank d 0(b o PH I L 1:1 ❑ 1:1 Lift Pump Tank /Siphon Chamber Ej Q El ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite s age system shown on the attached plans. Plumber's ame: (Print) Plumber' Ignature: (N Stamp P/ PRSW N Business Phone Number: OL Plumb d ress (Stree City, State, Zip Code): e, 3 '1 CL , Cc, IX. COUNTY / DEPARTMENT USE ONLY ure No St ) ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issue IssuiSign Approved F1 Owner Given Initial Surcharge fee) (y/) Adverse Determination QV X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SHD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Divi ion, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit maybe 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 year>c- 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'sani tary 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.- . . IL 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 onlyone online 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.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 8 112 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. I" 5C ww 5 ,94 a4 Ia 3_s~X rv v ~~~k B-3 Soo r Wisccisin Department of Industry, SOIL AND SITE EVALUATION Labor and Human Relations age of :3 Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. _ A 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 5 / d/IW percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel 1. D. #I I P i N&I APPLICANT INFORMATION - Please print all information. Reviewed by crjc/x. Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). ZoUN1 y Property Owner Property Location ',1 ,q j~?jK J 1i M f2U'TC Govt. Lot $E` 1/4 AV 1/4,S T E (or W Property Owner's Mailing Address Lot If Block# Subd. Name or CSM# 31Pv sr. 33 1,-- city state Zip Code Phone Number Nearest Road El village 0-1-Town vpso Fj G(J/ 57VvI6 ( 715^) 3810 -_V_ 7X ❑ city 44 t-) n 0 NN B -New Construction Use: [~'~esidential / Number of bedrooms 3 Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: ~~R = Not- PEcO I-I H E DED Code derived daily flow I R; and 2 / Recommended design loading rate bed, gpd/fi2 trench, gpd/fit Absorption area required N~~bed, fttrench, ft2 Maximum design loading rate N/k bed, gpd/fl~ • & trench, gpd/ft2 Recommended infiltration surface elevation(s) s I- 3 ft (as referred to site plan benchmark) Additional design/site cons rations L Parent material 5C.57 7"11 S/+TTe,,r-- , 5" L7- 10&55 sq,1,P Flood plain elevation, if applicable /V~1r" ft S = Suitable for system ~Conventional Mouunnd In-Ground Pressure AT Grade System in Fill Holding Tank U = Unsuitable for system IBS ❑ U 216 El U t~5 ❑ U 21, ❑ U [t~~ ❑ U ❑ S 19< SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft2 Texture Consistence Boundary Roots Bed , Trench in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. /o y/P 31Z - s/ ySk,e S 2f s. G Z 25 2/w s,dlk ,e cw 1-yc . ~o Ground 3 S 7 s'YX' / l s 2 4 ..5: elev. A T- -7" ,57:e, T-o,-1 E ,001 41- La Depth to limiting factor 7.,?, in. /nnJ'k Remarks: Boring # /o Z -6f CS f 4~, 3 .21-3S' 7,S-Yf /on 5W Ground 75y s/ ~7~sOi` ~+i'~eejC 7 ✓ elev. ft. 7,S C dr 3 7, -F siv, fA Depth to limiting fact pr 7 7in. Remarks: CST Name (Please Print) Signature Telephone No. ©FSERT -ZILQR i GkT 15 - 3~CQ~ g l8 S Address Date CST Number till y - 2 3 - 9G C'STti S/ ~Z Private Sewage Consultants wee nsm-11 CA SOIL DESCRIPTION REPORT , Z' .3,' PROPERTY OWNER Page of PARCEL I.D1 LO r 3 3 SUti ,P~DG~ Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots G~pjft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed . Trench 3 i -7 l oYA 31-)-- 14 L-f ,A.- fie cs '5 G Z 17-/G /0 ye Y- 3 v 2-f 5, e (y, 04k 0 w If . s(~, Ground 3 - to 7je w G, `f¢ . s. 0' S d t rC 5 i 7 ' 0 elev. IOg ft rl 7 5 yip ''tis OF S' Aort 7c,p S S . G Depth to limiting factor 7 17 Remarks: Boring # f 0-~ ~ o yR 3 S/ l f s b k n•^f ~e 5 2 f ~ , S y 2- i0 Yoe /V" R_ cs /z) f 3 7, St/2 lalel' QS4 114d Ground elev. to S. (~G n. Depth to limiting factor 7 i:o;?_.0_in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # o-11 y d yp 3 Z Sil .2f 564- "M-OO,e S/ f "7: . 6, 2 3 0 3 511 2 Fsb,A~ IM-J(,e ew Ground - 7's 2 / ~vr/J iyn!/iP .S ' • ~o elev. 52-ft. 5 0 7, 5 y S O S 7' Depth to , limiting factor 'n' Remarks: Boring # Ground elev. ft. Depth to limiting factor 'n. Remarks: SBDW-8330 (R. 08/95) W s N V y G Ile- (A O sr 527 O - 401 . wES~ 0 Q - o W O o ~ 1 v ~ UKS^ 3 rn c c 3 ~ G ~ c o °o cn Gs i ro R' 1' / D Qj n z ~ w 4, ow 5 p9 C \ 1 4Q.1 \ a \ o W co p 0 0. -17 j.3 o (D 5. 4 cn m \ \ \ ~~~0 N 1 cn o >o OD o A - I-OiD o \ o° \ \ w(A ° o 0 - - - - - U) Ap \ ( W n N m s \ \ \ w ul \ o O~ 4 m Z 3 W N \ 27 51"W o 0 y ti co \ .0 12 A3 i 00 • o \ o N I ° 01 i N_ \ \ N-pc C ~ r (OD W A) pO oZN n p .s - \ 9 9 iv stn A w p, n .0 0$ \O W O ~O %P 0, Ix U) (A op. ~SF~2 X0 00Z~` \ 00 0. 0 (S\ I so.~o~y0 2 ~9~F sg 2 N \ N0 0 \-n O i 0 10 .~O M,,00. /N \ - - \ oooc,\ N ~o w o \ O \ I 195 . 00000 D v' / O \ 22 a M., -4 :,4 C ~D -4 m / Cn . ` I' OO \ \ c0 . z 6 OD 1. r-vv N) • ~ 00 •ti -6 14 \ \ N F Ul W to I \ '0 0 tU ~ n p D A 0. O- tU~ O H N A T \n / I U1 z -4 (f) 0 I t9 n 4 \ p ~ O . -n q o0 rpGi 6~v .0 0, 0 ~OS moo/ 0,0 v ~~yti s~ \5d tit NA \ r ° ti 0 w S'I'C-105 SEPTIC TANK MAIN'I'ENANCI?, AGREh;1\71?N"I' St. Croix County OWNEIZ/BUYI?IZ MAJLING ADDRESS e PROPERTY ADDRESS (location of septic system) Please obtain from the Planning Dept. CITY/STATE _ 4 C/S&-) / W / PROPERTY LOCATIONS 67-114, N 1/4, Section , T N-IZ TOWN OF S ST. CROIX COUNTY, NVI SUBDIVISION LOT NUMBER 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 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 necessar-y), 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. / S I G N IUD: DA'fL:: -a----_R---- - St. Croix County Zoning Office Government Center 1101 Carmichael load (Judson, \VI 54016 1 03 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 Q Location of property5~ 1/4 /4, Section o?,TN-R W Townshi Mailing address Address of site 7q 1 C ~ut ~subdivision name I~l Yh Lot no. 93 Other homes on property? Yes No GIC~ Previous owner of property Mau `f Total size of property I ac' Total size of parcel Idag lJ2- Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes V No Volume and Page Number 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. / 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. Signa ure of Applicant Co-Applicant 01- g5- 17: Date of Signature Date of Signature vK E ' wANSLaSY DEED gEGI5rER5 a-~ E 561827 RCROa M.va Document Number: ir,wrrtotti- ~1UC 2 1991 Return Addrees: EQ T S * . aoi ~z= r Parcel I.D. Number: THIS DEED, atade betwxn Gsewwood EWffprbea, Inc, a wiaolrn corporation, Grantor end Mart F. Gibrud and Deem It. Giieetd, bud wW and vi*e as twnivorslrip w aritol IF V , tj Grantee. WTINE3SE I H, dot &a said Grantor, for a valuable consiAwainn of ace dollar and other good and valuable consideration conveys to GretMee the following desen3 real estate in St. Crain CAGY. State of Wisconsin: Lot 33, of the Pie of SunRidge H, filed in the Office of Am McCiAw of D&A- s for St. Croix County, Wisconsin, on Aug" 1, 1994 in Volume 6 of Plats, at Page 17, as Document Number SIl M This is not homadeed prnpeaty. Together with all and siagular the bereditaments and apps thereunto belonging: and Greenwood Enterprises, Inc. warrants that do lifk is good, indefeasible in fee simple and free and clear of encumbrances exceig easements, restrictions and reservations, if any, of record and will warrant and defend the same. n N R ~FE Dated this Z4+~dy of Jae, 1997. _ ~ C. G OOD ENTERPRISES, INC. GREFACX"NOWLEDGEMEW B. Ruses, its president r LA AUnUMICATION Signature James E. Rusch, its pmidew STATE OF WISCONSIN ) L4~.y of J 97. ) ss. ST CROIX COUNTY ~y came before me this Lois y MEMBER TE BAR WISCONSIN AV OFF J 997 the above na)Aed Mary R. Rusch, its secretary to me the person wl)dexecided the foregoing instrument and ~ tthe l~ufO✓ THIS INSTRUMENT WAS DRAFTED BY: u ``v Lois A. Murray c Zdz, Estreen & Ogland Public, State of Wi 304 Locust Street My commission expires / / S el OOD P.O. Box 359 Hudson, WI 54016 s Brenda Poulin Notary Public:. State of Wisconsin _ f