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HomeMy WebLinkAbout020-1336-10-000 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER M 41« Z GZ' l ~ /Y14 iLA TO v 7 ADDRESS ;28 (,d1! l 1- _~IZ [-f. Ke 1`~ SUBDIVISION / CSM# BAbLA)IU 5 -?jet4/k If LOT SECTION T ? N-R / % W Town of > . ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM i f 7, ~ LL ~ H4J~f ~ Z t ~ Ice i~ . , 4,11 .7 k wo F NI $t~: /ou,C7v~ - - 4t -A--_, _ a°1 K L oT INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: Z VC 1 16c:, r C., 7 S ALTERNATE BM: ~I `C~ t C~ C IC l 1(., 0~- f I D SEPTICvTANK PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: DEC>~ Setback from: Well Cl---__ House '`7 Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM ~ r Width: Length o Number of trenches Z Distance & Direction to nearest prop. line: 1c, c-07/f e.-."7` JINN Setback from: well: 100 House ' Other k Helms 3,yo ~Oy, ELEVATIONS J Building Sewer ST Inlet: 4,.(,p r ST outlet: 7#OY%- l p0'~~ PC inlet PC bottom Pump Off Header/Manifold l~4sR A 9,y 1 ~ qC Bottom of system 10 W C) 7 Existing Grade Final grade (vo t'~ 2 ~b ~ ► ~ DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/93:jt Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST . CROIX Safety A Buildings Division (ATTACH TO PERMIT) Sanita 199046 GENERAL INFORMATION L Permit Holder's Name: Village Town of: State Plan ID No.: MILLER, SAM/STOUT, RICHARD 11k8bj8N CST BM Elev.: Insp. BM Elev.: BM Description: Parcel' a lalo_:13 36-10-000 p0' /06 1 TANK TANK INFORMATION LEVATION DATA A9700364 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic - / Benchmark / 00 0 Dosing A ' 3;L Aeration Bldg. Sewer Holding St/Ht Inlet 2' /ol,d3 TANK SETBACK INFORMATION St/ Ht Outlet o o . TANK TO P/ L WELL BLDG. Ae Intake ROAD Dt Inlet Septic 17 NA Dt Bottom Dosing NA Header/Man. 9,~0 9 b5' Aeration NA Dist. Pipe y3~ 9 9 g: y6 Holding Bot. System 39- y PUMP/ SIPHON INFORMATION Final Grade 05, Ll Manufacturer D nd 3~ ar oi/.Y3' Model Number GPM TDH Lift Friction System TDH Ft oss FHead In Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits inside Dia. Liquid Depth DIMENSIONS ` (00 ' 'L__ DIMENSIONS -9a -nu acturer: LEACHING SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREAM INFORMATION Type O CHAMBER Model Number: System: 3 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 G H Bed /Trench Edges _ b > Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON 27.29.19,NW,NW 781 OAKLEY ROAD LOT 41 ~ ~e~ ~-fi--,.ate C~~« r~ v' e ~t~.• ~ ~ a/ ' d~-~<~~ ~C,L~~ 6~6 '41 0 Plan revision required? ❑ Yes ET/No Use other side for additional information. 0 1/,0 117~ SBD-6710 (R 05/91) Date Inspe 'r's Signature Cert. No ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: Safety an Buildings stem Bureau of Building WaterlsY N 201 E. Washington Ave. PPLICATI MadBon79 953707 7969 SANITARY PERMIT A Wis. Adm. Code In accord with ILHR 83.05, County onl ) for the system, on paper not less y State Sanitary Permit Number lete plans (to the county copy ~ • Attach comp ;n size, °29 application than 8112 x 11 inches for completing this application vi See reverse side 414 ous Check it revision ro , Pre .for instructions O. ms. State Plan I.D-Number • government aY ~ g~ The information you provide may be used ot, 19 ~ ~ / j I ATION W PRINT ALL INFO RMpr party Lo a1/4,tS Z 7 T Z (Privacy Law, PLEASE s. 15.0411) (m)1" N~ Block Number I . APPLICATION INFOTRMATr ~ Number Prop I rty LO o-ner A Name S 60j SAM Lot 19~ I Mailing Address Subdivision Name o~SM Nu 2eA Pro artypwner J phone Number B,4 p L A N Nearest Road Q Zip code l ) '207 it~ 0A LC- City, State S® State Owned p vil age q 0 / Y F B ILDING: (check one) of bedrooms-~- Town OF OZ?. PE O~g• It?. !'g I. T it Dwellin - No. Parcel TaxNumber(s) 'D ll that apply) Public 1 or 2 Fam Z~ 1 "5 3 If building type is public, check a O iii. BUILDING USE: ( ! 1() ❑ Outdoor Recreational Facility / Nursing Home 11 ❑ Restaurant / Bar / Dining 1 ❑ Apartment I Condo 6 ❑ Medical Facility airs 12 ❑ Service Station / Car Wash 2 ❑ Assembly Hall ❑ Merchandise: Sales /Rep 130 other: specify 3 ❑ Campground 8 ❑ Mobile Home Park 4 ❑ Church /school 9 ❑ office/ Factory if applicable) C1 Repair of an S❑ Hotel / Motel Check box on line e, Ex►sting System only one box on line A. 4 Reconnection of 5. PERMIT (Check Replacement of Existing System Date Issued IV. TYPE OF 2 ❑ Replacement 3 - Tank Only--------------- A) 1. (New System " `System issued. Permi B) ❑ A Sanitary t Number Permit was previo~slY Experimental other Check only one) 410 Holding Tank V TYPE OF SYSTEM : ( pressurized Distribution 30 C1 Specify Type 42 ❑ pit privy Non-Pressurized Distribution 21 ❑ Mound 43 ❑ Vault Privy 11 ❑ Seepage Bed 22 ❑ In-Ground Pressure 12 50 Seepage Trench 1310 Seepage Pit 7. Final Grad S stem-In-Fill 6, System Elev. 14❑ Y YSTEM TION: Rate S.Perc. Rate Elevation INFORMp► 4. Loading IF Z„oo Fey Area Loading Rate (Min./Inch) Feet / 0 VI. ABSORPTIONS Area p Absorp. ft) 2. Absorp. ft) proposed (sq .0-W Ex 1. Gallons Per Day Required (sq- ' Site Fiber- plastic A S Prefab- Con Steel glass Capacity Total # of Manufacturer's Name Concrete strutted VII TANK in gallons Gallons Tanks ❑ ❑ ❑ C03 INFORMATION New Existin ❑ ❑ ❑ ❑ Tanks Tanks ❑ ❑ Septic Tank or Holding Tank n dersig n on the attached plans- pump Tank (Siphon Chamber e s stem show ,ft Phone Number: VIII. RESPONSIBILITY STATEMENT for installation of the onsite s ~P ~ RSW No . ~ 3la I, the un ned, assume responsibility Plumber"s Signature:(NoStam S) Poe 5 =035 ~ Plumber's Nam (Print) a !~D 1\(F,-LL- 0 state, zip Code),. 1400 / LAJ W''1; I ate Address (Street, City, Plumber's St Ps NTY / ssue Issuing Ag t Signature (No 0 70 N (Indude$Groundwater Permit Fee roved ~ Surcharge Fee) ! IT COUDEPARTMENT USE ON Sanitary ❑ Disapp d ❑Owner Given initial O pD Approve Adverse Determina REASONS FOR DISAPPROVAL: . CONDITIONS OF p1PPROVA Owner, plumber To: Safety & Buildings Di~rsion, Ori final to county, One copy nrcT~16UT10N: 9 INSTRUCTIONS 1- A sanitar t ` Y permit is valid for two ' r 2~ Your sanitary (2) Years- ` Wisconsin Y permit may be renewed before the expiration date, Administrative Code will be applicable All revisions to th and at a time of renewal 3- is permit must be approved by the p or lu permit issuing authority. county prior to installation tuber requires a SanitarY Permit Transfer/ Renewal Form Onsite sewage systems mustbe S (SBp necessary, -6399) to be submitted to the usually every 2 to 3 properly maintained. The sf~ years. 6. If you have ptic tank(s) must be Wisconsin questions concerning your onsite sews Pumped by a Licensed Safety and Buildin puml'erwhenever gs Division, 608-265-38 ,15. system, contact your local code administrator To be complete and or the State of accurate this sanitary permit application must include: 1- Property owner's na system is to be installed and mailing address. Provide the le IV Type of building gal description and parcel tax nu g being served. Check onl tuber(s) of wh Ill- Building use. If buildin only one and com l lei"e the IV. T g type is Public, check all p ete # of bedrooms a Ype of if 1 or 2 Family Dwelling- permit. Check only appropriate boxes that hat ppl V. Type of system. y one on line A. Com l y' Check a p ete line B if permit is for tank replacement, r VI. Absorption ppropriate box depending system information. Provide all information ore m type. econnection, o, repair. manufacturer' Fill in the cap quested for numbers 1 throu s name, indicate acity of ever through or existin VII. holding Tank information . this s P efab or site constr/ucted and tank DILHR. Ystem. 9 tank, list the total gallons, number of tanks and material- Check experimental approval only if tanks received experimental septic, VIII- address and Responsibility statement. y statement. Installing pump/s'p~ion and number. Plumber is to fill in name, license number Product approval from IX. County/Department Use Only tuber must sign application f onp- with appropriate prefix (e X. County/ Department Use Onl 9' MP etc.), y, Complete plans and specifications not smaller than 8 112 x 1 1 include the following: plot Ian tank(s) or other treatment tankp , drawn inches tanks; distribution to scale or with Complete Gist be submitted to the count . boxes; building Sewers; wells; water mensions, location of B) horizontal and eonabsorption s y The plans must vertical soil elevation differences; fr ctlos~ P reference ms; replacement rnains/water system areas- ervice; holding tank(s), septic streams and lakes; pump or siphon ion of the soil absor Points; C) completes and the location ption system if re P Performance curve; Peufications for of the buildin quPu by the count Pump model and pumps and controls; s served; y E) soil test data on a 1 15 fo m; manufacturer- p dose volume- olume; m; and F) all sizing )cross section information. I Wisconsin GROUNDWATER SURCHARGE Act 410 included the creation. of surcharges (fees) for a number of regulated stablishment of standadshese surchar practices which can ges are used for monitoring groundwater contamination investigations ~ L t ~ a 1 ' r r Z ~ n ~ t vs ~j w IA ,Q a ^ z w a i n CO O - ~ b y V {r, ~ o o 3 ~ A h ~ 1 R e O i. N O v z07~W a ~ 0 0 o tom. ch ~ 0 4 o 41 °oo S~e > a. n ~ . W I I CL I rlb,i ~ - I o 2 I tJ I W a ' t a k2 a I 9 Z ~ ~ z r a j W C/") I ~ I w ' a CL I o v I m t ~ O i w IE - . 411 Wisconsin Department of Industry, SOIL AND SITE EVALUATION Labor and-Human Relations Page 1 of 3 61vislon of Saflety and Buildings in accordance with s. ILHR 83.09, Wis. Adm. Code 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 St. Croix percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # l2U /0 - 96 APPLICANT INFORMATION - Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location Richard Stout Govt. Lot NW 1/4 NW 1/4,S 27 T 29 N,RI 9 (or) W Property Owner's Mailing Address Lot # Block# 4 Subd. Name or CSM# 1353 AWatukee Trail 1 Badlands Prairie City State Zip Code Phone Number ❑ City ❑ Village [ Town Nearest Road Hudson WI 54016 (715)549-6731 Hudson New Construction Use: H Residential / Number of bedrooms 3 - 4 Addition to existing building ❑ Replacement Public or commercial - Describe: Code derived daily flow 6 0 0 gpd Recommended design loading rate . 7 bed, gpd/ft2 8 trench, gpd/ft2 Absorption area required 8 5 8 bed, ft2 750 trench, ft 2 Maximum design loading rate - 7 bed, gpd/f12 -8 trench, gpd/ft2 Recommended infiltration surface elevation(s) 98.0 ft (as referred to site plan benchmark) Additional design/site considerations Parent material Glacial deposit Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank U = Unsuitable for system [2S ❑ U E~ S ❑ U ;Ps ❑ U R] S ❑ U ❑ S R] U ❑ S U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 1 1 0-1 7.5yr2.5 1 none mabk fr 2 14-48 10yr4/6 none s sg 1 s - .7 ..8 Ground 3 48-90 10yr4/5 none s s 1 s - .7 elev. 9 8 .0 ft. Depth to limiting factor 9 0 in. Remarks: Boring # 1 0-13 7.5 r2. 2 2 13-47 10yr4/ none MS osg ml cs - .7 .8 3 47-89 10yr4/ none cs osg ml cs - .7 -.8 Ground elev. 100.30. Depth to limiting factor 89_-_in. Remarks: CST Name (Please Print) Signature Telephone No. ` c.4 u yer4 PIZ -3/22 Address Date CST Number lQ7 o d ,E1c~d Sc.rl i D 4? ?~?y'4'C PROPERTYOWNER Richard Stout SOIL DESCRIPTION REPORT Page :2 of 3 r PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Structure G~Djft2 in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench 3, 1 0-1 7.5yr2.5 1 none 2mabk mfr s f .5 -.6 2 15-49 10yr4/ none s sg 1 ICS - .7 '.8 Ground 3 49-E9 10yr4/ none cs sg 1 s - .7 ;.8 elev. 1n1 - .0 Depth to limiting ; factor 9 in. Remarks: Boring # 1 -10 7.5 r2.5 none mabk fr s f 5 4 2 10-3 10yr4/5 none s sg 1 s - 7 .8 3 6-8 10yr4/6 none s sg s s - 7 ,8 Ground elev. 101 .6t0 Depth to limiting factor 8 9 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# 1 0-12 7.5yr2.5/1 none L mabk fr s f 5 .6 5' 2 12-43 10yr4/5 none ms sg 1 s - 7 '.8 3 43-89 10yr4/6 none cs sg 1 cs 7 A Ground elev. 9 9 ft. Depth to limiting factor 8 9 in. Remarks: Boring # Ground elev. ft. ' Depth to limiting factor in. Remarks: SBDW-8330 (R. 08/95) ,zc(~a ~I~S ae. lftl c Q p ~ 3 d ~ l UG c f e v GO_ B 41 ate, ' zef I S T C - 100 ' i 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 1 K S® ~/~/9tif GL Location of property S144-)114 A(4<-) 1/4, Section 27 , T_lf_N-P,/ ZIG Township H Ad .0 he Mailing address BC~~ ~ ~ S R V y)s a tj ( .S" `f O l t Address of site -7 go i - ~JI Lf"IZ~D 014 Subdivision name T~ A b L A N Q Al i f. Lot no. Other homes on property? Yes No Previous owner of property Nes e- 4, Total size of property `Z 40 C. Total size of parcel 4 / C.- Date parcel was created ,L... y -5 Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes No Volume and Page Number y~ 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. X.3 S 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. 9:5 gy 21k. Signat>re o Applicant Co-ApSTi nt Date of Signature Date of Signature ` y ,J R STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER IQ ( C H ( 1~ ~d v "T__.- Z-Z 44 r ,E MAILING ADDRESS lam, O N v 1) 0 / k) 11 ; PROPERTY ADDRESS I~ &Q A, (location of septic system) Please obtain from the Planning Dept. CITY/STATE HQ D Sp W W/ '00", V Q /4 PROPERTY LOCATION 1/4, 1/4, Section , T ~ 'r N-R W TOWN OF E} y.D S 0 N ST. CROIX COUNTY, WI SUBDIVISION MAA 044 X D ,.7 -?Riff i l jc. LOT NUMBER -4/ CERTIFIED SURVEY MAP C(01014; VOLUME 40 , 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. SIGNED: ' DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 ,r,~py„ir~•I WARRANIY 1)1:E1) n.+; rt r rlr, Yot P 't PACE 4 4 2 I his D),c(l, ...Itl, I,, The NGI. Cprpgrat ion,. ~ a 1\isct.nain curporltion,orginized Apr it I, 496 and t ii;:d with the Wi',consin Sec ret.lrv (if State kin t DEC Q r!' April 3, 1995 _ _ - lr.ulatr• ,d Richard 0. StOUL 3: 30 P. i t i Witnessed], III.:' Il'e .nu unwltur. fora .;tluahii ,t'I~ Idcraulul r.; t:.F •A flk,\l ny dc,t r,ht•d real (state In St. Croix TriS iPACE N_ iA/`L:I r4 'IV -.lillt'i the i Lt~,lll; l- 11,11:' ,I ~~IS. ttrl,ill ,AME ANJ. aET~AN A:,r;Fr Richard 0. Stout 1351 Awatukee Trail See Exhibit A hereto, Hudson, WI 54016 020-1074-80-000, 020-1074-90-000, 020-LQZ5_-__aQ-N0, 020_-111I-4fL-000 PARCEL :OENFF-GArI0N NVA'BE9 .F: Grantor also quit-claims to grantee any reversionary right, title and interest to the parcel described in Vol. 589, page 212, Doc. No. 354521, and in Vol. 588, page 214, Doc. No. 354522. i trl; is nut h. iii,-wad propene the hircdllalilt' nt, and altlturtinar.:rs :I rnum,t nrittr giii ; \II•I II !ci ,nnrli and . e and !,'M , nt um!11.1: See Exhibit B hereto M1,21 '..+U •va .old ;k' .unr i Isar: iu. 4th December w__96 l The NG Corporation _ iSFAU r'AI., Rebert Romer tSEAL) ACKNOWLEDGMENT Minnesota State of 13^isaiMIta, Count 1.r unally tank he Ettrc me this day tit December- 14-96__, the above named ._Robert Romeo, its VP nod Controller Ili; i. \I !I'EF>I.il[:f,1!?tt1',`I~C.:~r:~lN n, me known tit Ix the person KhO ixi.uted the Iore,Lomg mstniment and a.knt .rk 'fir the same M j a Yot 124 4 PArf 443 EXHIBIT A 1-egal Description The NGL Corp ration to Richard n. Stout The South Half of the Northwest Quarter, the Northwest Quarter of the Northwest and the West Half of the Southwest Quarter of the Northeast Quarter of Section 27,Quarter, .'ownship 29 North, Range 19 West, Town of Hudson, St. Croix County, Wisconsin. Except that portion of the Northwest quarter of the Northwest quarter of said Section 27 described as follows: Beginning at the Northwest corner of said Section 27; thence along the North line of said Section 27, South 88 degrees 23 minutes 58 seconds East 160 feet; thence, diagonally, South 29 degrees 07 minutes 38 seconds West 338.27 feet to a point on the West line of said Section 27; thence along said West line, North 0 degrees 54 minutes 02 seconds East 300 feet to the Northwest corner of said Section 27 and the point of beginning. Subject to the right of St. Croix Count for highway recorded in the office of the Register of Deeds for St pCroixeCount , Wisconsin inks I Vol•ime 257, page 118 and Volume 302, page 24; r Subject to the right of way grant to the Wisconsin Telephone Company, recorded in f~f the office of said Register of Deeds, in Volume 472, page 85, document 305105; I Subject to the existing town road along the North line of the Northwest Quarter of the Northwest Quarter of Section 27. i I i i r 220798-1 'e s y~ at FAD -114 Exhiint P- Liens and Encumbrances The NGL Corporation to Richard O. Stout (i) Municipal and zoning ordinances and agreements entered under them, (ii) recorded easements for distribution of utility and municipal services, (iii) recorded building and use restriction-, and covenants, and (iv) general taxes levied in the ycar of closing. I.t % i' i i, 'I 220798-1 i 9 Y