HomeMy WebLinkAbout020-1336-30-000
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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER j" r /y~ r c c£ 2
ADDRESS Pn)("
SUBDIVISION / CSM# EAj)LAkD S LOT ~(3
SECTION Z TZ-f N-R~ b(; Town of j-4 y 0W 6j
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM -
WILf ei t)
wet s
C y G~' Ln~c
t
Ile
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
[ t
BENCHMARK: ? Q/'"
ALTERNATE BM: ",9k" 'F'iC OT AD c'-1 / y Fc,
SEPTIC TAN PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: W c` i S f .e Liquid capacity: Setback from: Well '7- House Other
.J~
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location W.•-r---
SOIL ABSORPTION SYSTEM
1 i
Width: Length (a O Number of trenches
Distance & Direction to nearest prop, line: '`n 'oU`l tt.. Lei
Setback from: well: / S House Other
ELEVATIONS
Building Sewer ; ST Inlet: ST outlet: J01 PC inlet PC bottom Pump Off
le -P
Header/Manifold/q, e ~
Boof ttom of system-
Existing Grade ~ Final grade P, /a
DATE OF INSTALLATION:
PLUMBER ON JOB:
LICENSE NUMBER: { f.6 `!t>~
INSPECTOR:
3/93:jt
Wisconsin D4partmentof Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT 5T . CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 299043`
Permit Holder's Name: ❑ City ❑ Village Tov~ 'of: State Plan ID No.:
MILLER, SAM/STOUT, RICHARD HUDSON
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
f &0: 020-1336-30-000
TANK INFORMATION LEVATION DATA A9700360
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark Q v' , 6o IU . U
Dosing
Aeration Bldg. Sewer
Holding St/.JKlnlet p5 ' g
TANK SETBACK INFORMATION St/ K Outlet 9'
.9' I C1q, 0
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic S' > -7 $ ' NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pips
6Q
17,
Holding Bot. System ~1?1 f
110
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand 2zti-/!, r 5.l 8l
Model Number GPM
TDH Lift Friction System TDH Ft
oss ad
Force main Length Dia. Fi Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No.Of Tfenches PIT No. Of Pits Inside Di;. Liquid Depth
DIMENSIONS 'J & O ~J DIMENSIONS
SYSTEM TO P/ L BLDG WELL LAKE / STREAM LEACHING manufacturer:
SETBACK
INFORMATION Type 0 /Ap-,3 CHAMBER Model Number:
System S~ /o' 4A. 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 - G It Topsoil E] Yes E] No ❑ Yes ❑ No Q061 I
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON 27.29.19,NW,NW 789 OAKLEY RD LOT 43
Plan revision required? ❑ Yes ❑ No i
Use other side for additional information. 1/0 [11,?]?
SBD-6710 (R 05/91) Date In pe is Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH T f ,
SANITARY PERMIT NUMBER:
Yia~sm° ,"Riawun
Safety and Buildings Division
e`~•~I•■r,. SANITARY PERMIT APPLICATION Bureau of Building Water System:
201 E. Washington Ave.
In accord with ILHR 83.05, Wis. Adm. Code R.O. Box 7969
Madison, WI 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less County n
than 8112 x 11 inches in size. O
n f tvie
• See reverse side for instructions for completing this application State Sanitary Permit Num er
q o
4t
3
The information you provide maybe used by other gov W n t age aograms E] Check if revision to previous application
(Privacy Law, s. 15.04 (1) (m)]. 79q R~ State Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Property Owner Name Property Location
ke-44 At RD !9TA Jr SA Mj( 44 if /Z. w4 1/4, S Z I T 21 ; N, R 1'7 E (o W
Property Owner's Mailing Address Lot Number Block Number
3
City, State Zip Code Phone Number Subdivision Name or CSM Number
,fl 4 t.~! ,r l ( > Z to 9 MAd%) I F
II. TYPE F BUILDING: (check one) ❑ State Owned o Ityy Nearest Road
❑ Village E
Public 1 or 2 Family Dwelling - No. of bedrooms Town OF 14 U S rAn
Ill. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 027. a9- P?. /7g3
e
1❑ Apartment/ Condo /33(41_30
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. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
~<System System Tank Only 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 M 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
~t Required (sq: ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) / Elevation
dT- Feet 9 ~tb Feet
T -5'0
VII. TANK Capacity
gallons Total # of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existing structed
Tanks Tanks
Septic Tank or Holding Tank /coo 4c.1 Is
❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: (No amps) MP/MPRSW No.: Business Phone Number:
/ o L.C. S-Q3SOG 366 ?45 2 -
lumber's Address (Street, City, State, Zip Code):
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved San, ary Permit Fee (includes Groundwater ate Issued Issui g Agent Signature (No Stamps)
XApproved ❑ Owner Given Initial Surcharge Fee)
~y
7
Adverse Determination
I 1'9b
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Ruildings Division, Owner, Plumber
INSTRUCTIONS 7
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 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.
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 on 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. 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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Wiscogsin Department of Industry, SOIL AND SITE EVALUATION
1 3
Labor and Human Relations Page of
Civision of Safety 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. #
Dow 7
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
Govt. Lot NW 1/4 MW 114,S 2 7 T29 N,99 )f (or) W
Property Owner's Mailing Address Lot # Block# ~Subd. Name or CSM#
1353 Awatukee Trail 43 adlands Prairie
City State Zip Code Phone Number El ty Nearest Road
Hudson WI 54016 1(715)549-6731 udson village ® Town Badlands Rd
New Construction Use: Residential / Number of bedrooms 3 4 Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow 600 gpd Recommended design loading rate . 7 bed, gpd/ft2. _B_trench, gpd/ft2
Absorption area required 858 bed, ft2 75 0 trench, ft2 Maximum design loading rate . 7 bed, gpd/ft2_,$_trench, gpd/ft2
Recommended infiltration surface elevation(s) 9 3 . 9 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 ® S ❑ U 12 S ❑ U [kS ❑ U OS ❑ U ❑ s O 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 0-16 7.5yr2.5/1 none 2mabk mfr Cs 2f .5 .6
2 16-19 10yr3/ none sl 2mbk mvfr Es if .5 .6
Ground 3 39-$9 1 Oyr4/ none ms osg ml Cs .7 , . 8
elev.
100.4ft.
Depth to
limiting
factor
8 9 in.
Remarks:
Boring #
1 0-1 7.5yr2.5 1 none 2mabk fr s f .5 .6
2 2 16--':9 10yr3/4 none sl 2mbk vfr s if .5 ..6
3 39-S2 10yr4/6 none s sg 1 s - 7 .8
Ground
elev.
97.6W
Depth to
limiting
factor
in. Remarks:
CST Name (Please Print) Signature Telephone No.
-3-31 ;7-
Address Date CST Number
1,0d - al'IN -c-014rc Sye/c J~i a -A 7 g9 4'
PROPLRTY OWNER Richard Stout SOIL DESCRIPTION REPORT
Page 2 of 3
PARCEL LD.#
Boring # Horizon Depth Dominant Color Mottles Structure GCplft2
in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots
Bed Trench
3 1 -24 7.5yr2.5/ none mabk mfr cs 2f .5 .6
2 4-4 10yr3/4 none sl 2mbk mvfr cs if .5 .6
Ground 3 8-8 10yr4/6 none ms osg ml CS .7 .8
elev.
9 7--"t.
Depth to
limiting
factor
_8_9__in.
Remarks:
Boring #
1 0-24 7.5yr2.5/1 none L 2mabk mfr cs 2f .5 ,.6
2 24-48 10yr3/4 none sl 2mbk mvfr cs if .5 ,.6
4
3 48-9 10yr4/6 none ms osg ml CS .7 '.8
Ground
elev.
9 E--".
Depth to
limiting
factor
-9-9-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 0-16 7.5yr2.5/1 none 11 mabk fr s f .5 '
2 16-50 10yr3/4 none 1 mbk 1 s f .5 .6
-5
3 50-9 10yr4/6 none s s 1 s -
Ground
elev.
98.9Oft.
Depth to
limiting
factor
9 6 in.
Remarks:
Boring #
Ground
elev.
ft. '
Depth to
limiting
factor
in.
Remarks:
SBDW-8330 (R. 08/95)
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673
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STC- 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
O WNERIBUYER / ST C uT / s ff ~`I /f~ ~L ,EIL
MAII.ING ADDRESS B-o X 2 s( 't
PROPERTY ADDRESS '"I 8' ®I~~C. L`Q
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE H t1 0 -'c,,n V Uj t = yQ l ,m
PROPERTY LOCATION 1/4, N U) 1/4, Section ? 72 T 2! 9 N-R
TOWN OF KOOSOk/ ST. CROIX COUNTY, WI
SUBDIVISION 2AD t A N b 'S Q l e /E LOT NUMER 5.3
CERTIFIED SURVEY MAPS4 Ia1(c , VOLUME ~o , PAGE 1 , LOT NUMBER V--
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.
LfWc, 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.
SIGNCD:
DATE !
St. Croix County Zoning Office
Government Center
1101 Cannichacl Road
Hudson. AV'I 54016 11/93
STC - 100
x
This application form is to be completed in full and signed by the
owner(s) of the property I)eing developed. Any inadequacies will
only result. in delays of the permit ie,suance. Should this
development be intended or resale by (,,.iner/contractor, (spec
house), then a second forri should re;-a i reed and compl ited when
the property i sold and submit 2d 1.o this office with the
appropriate deet recording.
Owner of iroperty P- Ir-N 4AD S7-,Ou- " -Swltl /e-41e& .
Location of propertyA/k-,* 1/4 1V LO 1/4, 3e4 t on 7,T_gjLN-RW
Township -Mail. rr addr( <:s B40K Ff2
L-0 S go/ G
Address of rite aAK L € OZIzz,A D
Subdivi:,_k)n name D C A. A I K 1 Lot no. !Y-3_
Other home:.; on property"' Yes 1.o
Previous owner of propert, IV r'y L G.O,
Total s i z u of property (.o A c
Total size of parcel "2. Date parcel was created 6 C ~ G>,
Are all corners and lot lines identifiable? X-Yes No
Is this property being developed for (spec hou !2)? Yes No
Volume 21 and Page Number ? is recorc'~d with the Register
of Deeds.
7""CLUDE WITH THIS APPLICA'1'LON THE FOLLOWING:
A WARRANTY 111'ED which includes a DOCHMENT NUMBER, VOLUME AND PAGE
NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a
certified survey, if available, would be het pful so as to avoid
delays of the reviewing process. If thc~ deed description
references to a Certified Survey M;p, 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 inform,ltion form, by virtue of a
warranty deed recorded in the offi of the County Register of
Deeds as Document No. S'l' 35' , and that I (we) presently
own the proposed site for the sewa,je disposal system or I (we)
obtained an easement, to run the above described property, for the
construction of said system
and the -;ame has been duly recorded in
the office of the County Register of Deeds as Document No.
~ C
r _
a4tur&e of Applicant pplic ~~t
Date of Signature Date o' f (indture
f
`J S4
i<SI i IQH2
«ARRAN I l DIA-1)
Vot 12114PAGE44
I his D-, ed. the NG1. Corporation,
a l+is(onsin corporation, orgi!n;zed April 1, 996 and
[r;:1 w.rh the Wi,ccrnsin Secret.,rv of State on
Ar ri1 1995 _ )C~
I Richard 0. Stout 3:30 P.
. linesselh, i!t,:, and t ::uu+n. t,a a ~afuahir "'I'L'idcl.wor
+)cd „"a;,;tarc rn St. Croix _
Richard 0. Stout
See Exhibit A hereto, 1351 Awatukee Trail
Hudson, Wl 5401b
020-1074-80-000, 020-1074-90-000,
020-107.2700-Q00- 420-1074-40-000
.,`c97 A-i _'N N-:NBE:
.A-JSZER
Grantor also quit-claims to grantee any reversionary right, title and interest to the
parcel described in Vol. 588, page 212, Doc. No. 354521, and in Vol. 588, page 214,
Doc. No. 354522.
is not ~nnr>[e.id i~:.,ncrr,
A, and . , ,un! "-if
a
See Lxhihir H hereto
4th da': December
- - I~ 9_
SI_:qL` The NG Corporation SEAL1
Rob2rt 'Omen i
SEAL! 1
- Its. 1LP__ & _.CnnLr a ll er.
ACKNOWLEDGNILM'
Minnesota
Sole of Mg1ranna,
Court,
[\i,i.aC% ._n, kk•'+,•, :::c ti :s dac.+t
_De.~Qm]?eI _ W 46 _ the ih,+%c named
ROher} ROmeo, its VP and _Controller
;;ic kiio«n To !x ,Itc perso❑ who rtie. wed the I„regwr~~{
and a.,:, hr 5
YOt 1?1•'~PA~c-~~~
EXHIBIT A
Legal Description
i The NGL Corp-ration to Richard n. Stout
The South Half of the Northwest Quarter, the Northwest Quarter of the Northwest Quarter,
and the West Half of the Southwest Quarter of the Northeast Quarter of Section 27,
".bwrship 29 North, Range 19 West, Town of Rvdson, St. Croix County, Wisconsin.
Except that portion of the Northwest quarter of the Northwest quarter of said Section
27 described as follows: Beginning at thv 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 County for highway purposes as established by deeds
recorded in the office of the Register of Deeds for St. Croix County, Wisconsin, in
Vol-ime 257, page 118 and Volume 302, page 24;
Subject to the right of way grant to the Wisconsin Telephone Company, recorded in
the office of said Register of Deeds, in Volume 472, page 85, document 305105;
Subject to the existing town road along the North line of the Northwest Quarter of the
Northwest Quarter of Section 27.
220798-1
} -
'it T? ! PACE 414
Exhibit E
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
1 restrictions end I-venants, and (iv) general taxes levied in the year of closing.
}
220798-1
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