HomeMy WebLinkAbout020-1329-40-000
/UA
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER G~ G
ADDRESS !59/37 ~yy£ 5.
!~4 &Z A) 5-3E'// 9
SUBDIVISION / CSM# /-Z/uCDwmd/' LOT # T
SECTION TZ:ZN-R__Zf W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIE
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
V
a
76r
c ~qr
0
rd 3G r
4 rco VV Z y~
,IYG/ u, INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK: 0 o 1 OlOG
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Liquid Capacity: 4,24:91
Setback from: Well House Other
Pump: Manufacturer Model# Size
Float seperation Gallon e:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: - Length 7~o Number of trenches
Distance & Direction to nearest prop, line: AZM: > 2~'
Setback from: well:--1 House O / Other
ELEVATIONS,/ l0 • 0
Building Sewers ST Inlet: ev!&le ST outlet:
PC inlet PC bottom Pump Off
# r ?y''8 # ( 9~7. Y2-
Header/Manifold-tr2-ry,V1 Bottom of system ffi_ 9f!P7
Existing Grade Final grade
DATE OF INSTALLATION:
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR: 1
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT ST. CROIX
Safety and buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 289334
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
WANKERL, JASON HUDSON
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
O, 020-1329-40-000
TANK INFORMATION ELE ATION DATA A9700150
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic, Benchmark
O_
Dosing
Aeration Bldg. Sewer
'
Holding St/ Ht Inlet /04, 6:Z
TANK SETBACK INFORMATION St/ Ht Outlet , j4,
Vent
ir ito ntake ROAD Dt Inlet
TANK TO P/ L WELL BLDG. A
Septic _ NA Dt Bottom 21 Nq 8
Dosing NA Header/Man.
Aeration NA Dist. Pipe ~`gG g5.f.V
-7-' rep
Holding Bot. System f, 76 ' 97• "
46,04
PUMP/ SIPHON INFORMATION Final Grade ol S'-a' Manufacturer Demand , O6~ '
Model Number GPM
TDH Lift Friction Syetem TDH Ft
oss ad
Forcemain L Dia. FFii Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width 1 Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSIONS
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING manufacturer:
SETBACK
INFORMATION Type O AU, CHAMBER Mode Number:
System: I Q' X 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 11b_11 hl Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON 24.29.19,NW,SE 862 WYLDWOOD LANE LOT 4
/0 ~lf'1/1 1 " Pvif 4).4 .LL.~ a , w sf /cov r
Plan revision required E] Yes ❑ No
Use other side for addi tional information. W 121
SBD=6710 (R 05/91) Date s dons Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
vi~■'7'R SANITARY PERMIT APPLICATION Bureau o off Buiui Safety ildinWater System!
ng Water 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 1/2 x 11 inches in size.
• See reverse side for instructions for completing this application State Sanitary Permit Nu ber
The information ou rovide ma be used b other government a enc ro rams R
Y P Y Y 9 Y P 9 E] Check rt revisio to previous application
[Privacy Law, s. 15.04 (1) (m)]. 9&A VI/L 1 Iw1OO d L = State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE P INT ALL INFORMATION
Property Owner Name Property Location
L 1/4 1/4, S .Z T ; , N, R E (or
P rty Owner's Mailing Address Lot Number Block Number
>E. S
City, State Zip Code Phone Number Subdivision Name or-Q&#A-NvnTbtrr-
(6 z > ~s-
II. TYPE F B ILDING: (check one) ❑ State Owned ltd Nearest Road
❑ VII age
Public 1 or 2 Family Dwelling - No. of bedrooms _ Town OF
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment /Condo dl' q. S q. /9-17/7 1.2r
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. pr New 2. ❑ Replacement 3. ❑ Replacement of 4. [Reconnection of 5. ❑ Repair of an
System ________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 JZ 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)/ YS•D iW
400 1 O ? a 2 97. J' Feet Z, d Feet
VII. TANK Ca
in gallons Total # of Prefab. Site Fiber- Plastic Exper.
INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete st noted Steel glass App.
Tanks Tanks
Septic Tank or Holding Tank 4e 44 Z ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the site sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: (No mp 'N410MPRSW No.: Business Phone Number:
Xz)
VTi v 7
er's Address (Street, City, State, Zip
D L,tr Q
IX. OUNTY DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing Ag nt Signa ur (No Stam
~,,r Surcharge Fee)
Approved ❑ Owner Given Initial sj~f ,5/~3~7 S_
Adverse Determination '
X. CO ITIONS OF APPROVAL / REASONS FORD APPROVAL:
~ e4
56D-6398 (R. 05/94) DISTRIBUTION: Original to Counly. One copy To: Safety & Buildings Division, 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 i-;suing 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 mfiintained. 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-
11. 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 13 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 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.
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Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of
Labor and Haman Relations
Division of Safety & Buildings in accord with ILHR 83.05, WIS. A
t. Croix
3 V Or.
Attach complete site plan on paper not less than 8 1 /2 x 11 inches in size Plan ~ot include but
not limited to vertical and horizontal reference point (BM), direction and % of `f scab,.,- I.D. dimensioned, north arrow, and location and distance to nearest road.
pending
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION DATE
PROPERTY OWNER: PROPEW LOCATION',-
Greenwood Enterprises, Inc. 66V.T.LOT 24 T 29 N,R 19 Xk(or) W
PROPERTY OWNER':S MAILING ADDRESS tQT4.:. -BLOCK 4 SUBOt NA OR CSM #
1416 3rd. sT. ` a cYrao d
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY tLLAGE,&OWN NEAREST ROAD
Hudson, WI. 54016 (715 386-3674 Hudson Badlands Rd.
[x] New Construction Use [x ] Residential / Number of bedrooms 3 [ ] Addition to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow 450 gpd Recommended design loading rate .7 bed, gpd/ft2 .8 trench, gpd/ft2
Absorption area required 643 bed, ft2 563 trench, ft2 Maximum design loading rate .7 bed, gpd/ft2 .8 trench, gpd/ft2
Recommended infiltration surface elevation(s) trenches 97.8 & 95.00 ft (as referred to site plan benchmark) used
Additional design / site considerations alt. area 94.5' system el. system to be backfilled to code or extra ock
Parent material outwash Flood plain elevation, if applicable na ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U=Unsuitable fors stem ®S ❑U 9]S ❑U 0S ❑U ®S ❑U RIS ❑U ❑S ®U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
1 0-10 10 r 42 none sil 2msbk mfr aw 1m .9
2 10-4 10 r 54 none sil 2msbk mf' cm if .5 .6
Ground 3 40-98 7.5 r4 6 none cos osa M1 na na .7 -8
1455
ft.
Depth to
limiting
factor
+98"
Remarks:
Boring #
Mfr
0-12 10yr4/2 none
2 . 12-51 10 r4 4 none ~qii Ir-,bk Mfi if -9i -1
r32
na -7
Ground
Depth to
limiting
factor
+98"
Remarks:
CST Name:--Please Print Gary L. Steel Phone: 715-246-6200
Address: 1554 200th . e. New chrnnd WI 54017
Signature: Date: 10-15-96 CST Number: m02298
PROPERTY OWNER Greenwood Ent. SOIL DESCRIPTION REPORT Paget' ofd
PARCEL I.D. #_'endina
s
Depth Dominant Color Mottles Structure GPD/ft2
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Bo~xxiary Roots Bed Tn?nch
3:. 1 0-6 10yr3/3 none sil 2mSbk Mfr 9M -C; -F;
2 6-48 10yr5/4 none sil lfsbk mfi crw if .2 .3
Ground 3 48-63 10 r5 4 none
elev.
100.25t. 4 63-11 7.5 r4 6 none oscl
Depth to
limiting
factor
+110"
Remarks:
Boring #
1 0-12 10 r4 3 none
4 2 12-29 10 r4 4 none sl 2mcfr mvfr cm if .5 i.6
Ground 3 29-98 7.5 r4 6 none ms os ml na if .8
elev.
99.7 ft.
Depth to
limiting
factor
+98"
Remarks:
Boring #
1 0-1
5` 2 10-41 10 r5 4 none sil lcs mfr
-1f .2
none Tnf r if
Ground 3 1-51 L
C-1W .5
elev. 4 51-98 7.5yr4/6 none cos os ml na na .7 .8
99.05 ft.
Depth to
limiting
factor
+98"
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(R.05/92)
STEEL'S SOIL SERVICE
Gary L. Steel Greenwood Enterprises, Inc. 1554 200th Ave.
CSTM2298 NWgSEq S24-T29N-R19W New Richmond, WI 54017
MPRSW 3254 town of Hudson (715) 246-6200
4 lot #4-Wyldwood
N
1"=40'
BM= top of 12" pvc pipe @ el. 100'
Alt. Bm.= nail in tree C el. 104.00,
3 r
t~
12 .3
Gary L. Steel
10-15-96
Dave Fogerty Plumbing
SEWER SYSTEMS & PERK TESTING
FOGERTY HEIGHTS ROAD ROBERTS. W ONSIN 54023
(715 749-36
s/ode , y
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 pro ty" 1/4 Sr 1/4, Section,2:K,T_ar N-R jf_W
Township S.VA Mailing address _43~Z ZAt~,t
Address of site 1 L.
Subdivision name Lot no.
Other homes on property? Yes No
Previous owner of property
Total size of property
Total size of parcel s,f;C A7 71-1¢C bWd -T &4,s
Date parcel was created -
Are all corners and lot lines identifiable? ` Yes No
Is this property being developed for (spec house)? Yes 1/ No
Volume 1,Z3 and Page Number a2l 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. :5-a/g , 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.
gnature of Applicant C - ppl' ant
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
MAILING ADDRESS 7 1Gkrjb At . L~ W.41-PROPERTY ADDRESS /I G Z G~J~,, Lc~u~ed~ lA kif
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE , ~j` Gt~ cpt, Lc= S-J hV I X
1/4, Section 2 K T A P N-R_L_ _W
PROPERTY LOCATION 1/4, _C1
TOWN OF A4aedyr ST. CROIX COUNTY, WI
SUBDIVISION Gt/„ /~wo 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 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.
i
X SIGNED:'` -
r, DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
• . 558656 YOl1z'~6PACED
WARRANTY D®
3so~ FREGI5fER'S OTC
Document Number: ST. CR=CMvs
am rra"
• APR 3 0 1997.
Rehm Address: Ji DAVID J. ESTFEEN MN 55419 1t 3:30 P. M '
HUDSONLOCUW
. W1 54018
r
Pared I.D. Number:
020-1329-40
THIS DEED, made between Greenwood Eaterpriew, hr. a Wieoomfm aarpaea4iom, Grantor and Jason C. WaWM sad Margaret
E. WAMM, iudw d and wife ar survovaahif marital property, Grantee.
WITNESSBTH, that the said Grantor, for a vdm" consideration of cos do0w and other good and valuable cmudmadm COMM
to Grantee the folldr * described red estab is St. Croix County, State of Wisconsin:
Lot 4, of the Plat of Wyldwood, filed in the Office of the Register of Deeds lot SL Croix County, Wisconsin, on OCtobw 28, 1996
in Vobms 6 of Mats, d Page 72, as Document Number 551306.
This is not homestead property.
Together with all and singular the heed bnm is and appurtenances thwousto belonging: and Greenwood Enterprises, Inc. warrants
that ma tide is goad, indehmsWe in fee simple and free and clear of encumbrances except eawnmots, reebicdlom and reservations,
if any, of record and will warrant and defend the same.
Dated this Z=teary Mar* 1997. $ N R
GREENWOOD ENTBRPRM, INC. GREENWOOD BNTEMI PRISES
By:
B. ~its reddest Mary . Ra a
AU rHVMCATM AC.ZN0WLEDGEMF.NT
" h'1: M/Y~Sof'~L
Sigmtors James B. Ranch, its p mda+ STATE OF W )
suit mtica<ed We ;jnjpday 1997 (,(AI~A A'09 6- ) a&
COUNTY
• MEMBER STA vtRSCOxs>N f0°~y sums before me this a~
day of Aped, 1997 the above named Mary R. Rusci, do secretary to
no loomm to be dies person who awcoled the foregoing imhltmeat and
THIS INSTRUMENT WAS DRAFTED BY, ,pekppwbdv /J c ~a Q C,L~
Lois A. Murray
ZE, Estrous A Oglaod Notary P"c. Slab of Wisconsin
304 Lowd Sdreot My oo~edan 9qKf0@
P.O. Box 359
Hodson, Wi 54016
PAULA A. WWWORTH
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