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HomeMy WebLinkAbout020-1314-20-000 i STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER 'E;\q V-N S yr~4 r fl a r ADDRESS SUBDIVISION / CSM# S CR o i S (j LOT # a SECTION Zkg T N-R W, Town of 1IV n S 0tJ ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 8-xG-7 N~1_e ; ~1pr~~ IP Rey) I S UU P~ ~ i Guy ~e~ ~~pt'' o I I .L CQ1 i I N INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. L c BENCHMARK: I p b Cj \1 S 1 1 i C2Q I U J' ''J ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: (,J e e ~1 Liquid Capacity: poo q~) Setback from: WellOVRf, S~ House Other a Q' Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location b SOIL ABSORPTION SYSTEM Width: O Length Number of trenches Distance & Direction to nearest prop. line: sy u' 11 Setback from: well: ~ae~ iv House Other I~~~nl 9-?- lD rN - I -T14 N 51-Y4 - 1' y 1 ELEVATIONS Building Sewer ST Inlet: 10 3•15 ST outlet: U 3 PC inlet PC bottom Pump Off Header/Manifold Bottom of system 5 O Existing Grade S~tY Final grade (60 g° DATE OF INSTALLATION: PLUMBER ON JOB: 5Z,f,'Y''--::ice' LICENSE NUMBER: 3 YU y INSPECTOR: 3/93:jt Wisconsin Oepartment of Industry, PRIVATE SEWAGE SYSTEM County: Labor a Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 289363 Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.: BJORNSTAD HOMES, INC. HUDSON CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: / Q l U ` _ /{jy y 020-1314-20-000 TANK INFORMATION ELEVATION DATA A97010181 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic ~O Benchmark f r ~We If '4_ Dosing Aeration Bldg. Sewer Holding St/}fit Inlet b_ ' TANK SETBACK INFORMATION St/ heft Outlet S6 /b 515.;2 TANK TO P/ L WELL BLDG. Airi to ntake ROAD Dt Inlet Ar I Septic "/6 50r ' NA Dt Bottom Dosing NA Header/Man. y 9?,~ Aeration NA Dist. Pipe , Holding Bot. System ~ 6, 5 PUMP/ SIPHON INFORMATION Final Grade 54% 100,66' Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft mead Forcemain I I Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED /TRENCH Width I 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 1YL&,V Ll ` > r CHAMBER model Number: System: OR UNIT 1J t~V 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 'r Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON 28.29.19,SW,NW 770 CROSBY DRIVE LOT 2 6/7/ Plan revision required? ❑ Yes ❑v1V0 Use other side for additional information. 1/0 1/5 ?1 SBD-6710 (R 05/91) Date Inspe or's Signature Cert. No. V ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: Safety and Buildings Division ~•■~r■r,t 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 1 than 8112 x 11 inches in size. T ~'t0 • See reverse side for instructions for completing this application State Sanitary Permit Number X85 3~3 The information you provide may be used by other government agency programs ❑ Check it revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Pr y Owner Name Property Location l E(or r C, Spj 1/4 1/4,S 4Y T 4 ,N,R G Prop yOwner's Msiiling Address Lot Number Block Number ftv City, State Zip Code Phone Number Subdivision Nam or CSM Numb r II. TYPE OF BUILDING: (check one) ❑ State Owned Lufn Nea st Road ge /i ❑ Public 1 or 2 Family Dwelling- No. of bedrooms of It t... /'OS 111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 7~. lob 5 1 ❑ Apartment/ Condo ©c7 o - ` ,3 / e l 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 ew 2. E] Replacement 3. ❑ Replacement of 4. E] Reconnection of 5. E] Repair of an - System________System_____________TankOnly______________ExistingSystem 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 1 1,15,Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ 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 r, V Requjre ~ d~q. ft.) Prop~o~ d~(~ ft.) (Gals/d~y/sq. ft.) (MS inch) S_ Elevation p S U Feet 00• Feet VII. TANK Capacity in gallons Total # Of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App New Existing strutted Tanks Tanks Septic Tank or Holding Tank tot ❑ ❑ ❑ ❑ ❑ 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. Plu er's Name: Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number: in A1,& A-,V- 11/Z 9 11) Plumber's Address (Street, City, State, Zip )de): /07b ~4W, S IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issue Issuing Agent Signat Sta S) rApproved Surcharge Fee) ❑ Owner Given Initial Q/g. d3 ~ /l 17 7 Adverse Determination /g DITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Divi ion, Owner, Plumber INSTRUCTIONS `t 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, 608-266-3815. 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, purnp/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; Q 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. L U I A H i I U% I-1, 1 1~ 1\1 N A M E U a r-ey- N A M E M 1ok rr. c f R O LO C A I o s.fi:_. 1=~i C ENS E ?Ay P L II 11 aI~ • L7 ^ Ix~rZ4 h v 1 P S y,~ ~ k L 7l~ 6s\ We-kl a ay' 8' • l,J-e 11 s ~rcfl ~a~~"1-gin `"►x, r~ l / I S/a~,~ ~j • 3~ fK-U • 1 r& 4 n loo =r~E' Sfi-eel ~*Nce ~ ~IeV=10.3. 8~•, . r - i. .f I p Y~.q ~ :s. C R o S FRESH All'. INLETS -AND OBSERVkYION PIVE ciZO~S SECTION Approved Vent Cap Minimum 12" Above Fr Final GraijG'---~ 4" Cast Iron Above Pipe Vent Pipe To Final Grade! Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT f, 3 Labor and Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COI! TY • e. Attach complete site plan on paper not less than 8 1 /2 x 11 inches in size. Plan must include, but st. Croix N, $a u~ not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PAR'C,L I.D. dimensioned, north arrow, and location and distance to nearest road., ' APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DAT PROPERTY OWNER: PROPERTY LOCATION John Rauchnot GOVT. LOT SW 1/4 NW 1/4,S28 1 ?,9 f i 4490. r) W PROPERTY OWNERS MA!I.ING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # 527 Co. Rd. #W 2 na St. Croix Estates CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE E ]TOWN NEAREST ROAD Hudson WI. 54016 t715)386-3052 Hudson rob d. [x] New Construction Use [x I Residential / Number of bedrooms 3 ( ) Addition to existing building j ) Replacement [ ] Public or commercial describe Code derived daily flow 450 and Recommended design loading rate . 3 bed, gpd/0 trench, gpd/ft2 Absorption area required 900 bed, ft2 750 trench, ft2 Maximum design loading rate • 5 bed, gpd/ft2 •6 trench, gpd/ft2 Recommended infiltration surface elevation(s) 96.50 It (as referred to site plan benchmark) Additional design / site considerations na Parent material outwash Flood plain elevation, if applicable na it S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable for system ® S ❑ U ®S ❑ U ®S ❑ U [2S ❑ U ❑ S ®U ❑ S ® U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourxiary Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Tmr& " 1 0-12 10yr3/4 none 1 2msbk mfr cs if .5 .6 1 2 12-30 10yr4/6 none sil lfgr mfr gw If .2 .3 Ground 3 30-84 7.5yr4/6 none f s Osg mvfr 9W na .5 .6 elev. 100 JE5 Depth to limiting factor +84" Remarks: Boring # 1 0-9 10yr3/2 none 1 2msbk mfr gw If .5 :1.6 k 2 2 9-21 10yr4/4 none sicl lfsbk mfr gw if .2 .3 3 21-84 7.5ry4/6 none Co s Osg ml na na .7 .8 Ground elev. 99.5ft• Depth to limiting factor +84" Remarks: CST Name:-Please Print Gary L. Steel Phone: 715-246-6200 Address: 1554 2 th. Ave., ew R' hmond, WI. 54017 Signature: Date: 11-2-95 cstm 02298 PROPERTY OWNER John Raucbnot SOIL DESCRIPTION REPORT Page 2 of 3 PARCEL I.D. # pending Boring # Horizon Depth I Dominant Color I Mottles Texture Structure Consistence ~eourbary I Roots GPD/ft in. Munsell Gu. Sz. Cont. Color Gr. Sz. Sh. Bed iTre & 1 0-8 10yr3/3 none 1 2msbk mfr gw if .5 .6 3" 2 8-21 10yr4/4 none sicl lfsbk mfr gw if .2 .3 Ground 3 21-36 7.5ry4/4 none sl 2msbk mfr gw na .5 .6 elev. 4 36-84 7.5ry4/6 none co s Osg ml na na .7 .8 99.9x. Depth to limiting factor +84" Remarks: Boring # 1 0-15 10yr3/2 none 1 2msbk mfr gw if .5 .6 4 2 15-27 10yr4/4 none sicl lfsbk mfr gw if .2 .3 3 27-80 7.5yr4/6 none S Osg ml na na .7 !.8 Ground Depth to limiting factor +80" Remarks: Boring # 1 0-12 10yr2/2 none 1 2msbk mfr gw If .5 ';.6 5 2 12-26 10yr4/4 none sicl lfsbk mfr gw If .2 :::.3 3 26-35 7.5yr4/4 none is Osg mvfr gw na .7 .8 Ground elev. 4 35-82 7.5ry4/6 none S Osg m1 na na .7 .8 99.3 ft. Depth to limiting factor +8211 Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: STEEL'S SOIL SERVICE Gary L. Steel John Rauchnot 1554 200th Ave. CSTM2298 SMINW4 S28-T29N-R19w New Richmond, WI 54017 MPRSW 3254 town of Hudson (715) 246-6200 lot #2-St. cRoix Estates T N 1"=40' BM.= top of 1" steel pipe C el. 100' Alt. Bm.= top of steel fence post C el. 103.3' ke k10 10 60 141 q6 Gary L. Steel 11-2-95 t S'I'('- 1115 Sl-'I "l'l(: TANK MAIN'1'I;NAN(:I, nc-;It1,I.n11:N'1' St. Croix (.ounly OWNERAMYEIR MAILtNC ADDRESS PROPERTY ADDRESS (location of septic system) Please obtain from the I'lanning; Depl. CI'T'Y/STATI--, PROPEIRTY LOCATION 1/4, 1/4, section '1' TOWN of ~U~SOn~ el-01 / S'1'. C1iOIX COUNTY, \\,I SUBDIVISION 5/ V) CAS i4eS LOT NUMBER 2 CERTIFIED SURVEY MAP , VOLUMr //941 AGE, I,o-I'NUMBER 2 Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out (lie 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 I, 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. 'llic property owner agrees to submit to St. Croix Zoning a certiIlca(ion 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 condilicm ;111(1 (2) alter inspection and pumping, (if necessary), the septic lank is less than 1/3 full of sludge and scum I/We, the undersigned have read the above requirements and ag;rce to maintain Ilse private sewage disposal system in accordance with the standards sc( forth, herein, as set by the \1r;sconsin DNIZ Certification stating that your septic has been maintained nnrst he conipleted and returned to the St Croix County /.oning, Officer within 10 days of the three year expiraliun dale Sl(;Ni:l) )A 1'1:- ~ `I ('ruts ('urtnly l.uttirlg, (Mice (;Itveltllll~'nl Centel 1 101 1':11ntrcltarl Road 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. Owne r of property Oil ~v'~ ffDmeS _Z;J G Local ion `u:f p76&~wj perty :514) 1/4 /UGcJ 1/4, Section Z T 29 N-R W Township Mailing address Address of site Subd i vision name S7( ~r_ ~ Ojx, ZS fa1ZS Lot o. 2 Other- homes on property? Yes No Previous owner of property rn,OQ4 " /i~ Total size of property ZZI~Cre Total size of parcel 2,ZZ cse.rt Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house) ? _X Yes No Volume .1142 and Page Number as recorded with the Register of Deeds:. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRAHTY 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 refr►•ences 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 (ate) 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. 5y753_1 and•that I (we) presently own the proposed site for the sewage disposal system or'11 (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 ot.. Deeds as Document No. 5y~S5/ r Sigr ture of Applicant Co-Applicant I).it~ of . i~~I vi t ure Dato of Signature DOCUA4ENT NO. STATE BAR' WISCONSIN FORM. 2-1982 THIS SPA :ESERVED FOR RECORDING DATA WARRrI--. fY DEED w 547551 vol 11 q~)Pw Q BS OFRCE Bri ggland Development Company a Minnesota coWration ~~yy// ~M{/ //~~fipp~/~~V4 VI7VIA V I iy RiGidlOt'F1e001l1 . JUL' 31! 1996 conveys and warrants to Michael C. Lundberg - - lI. ,wA-0:30 AM 44Q. -h Oka, acmes RETURN TO the following described real estate in St. Croix County, State of Wisconsin ~f TAX PARACEL NO. Lot 2 , St. Croix Estates in the Town of Hudson, St. Croix County, Wisconsin. $ T N 'ER This is not homestead property. (is) (is not) Exceptions to Warranties: Dated this 23day of M L,, 19 96 (SEAL) (SEAL) * * (SEAL) (SEAL) * * AUTHENTICATION ACKNOWLEDGMENT Signatures authenticated this day of STATE OF MINNESOTA 19 Dakota County Personally came before me, this 23 day of * May, 1996 the above named TITLE: MEMBER STATE BAR OF WISCONSIN Neal Krzy_zaniak (If not, authorized by 706.06, Wis. Stats.) This instrument was drafted by to me known to be the person who executed the Bridgeland Development Com=j foregoing instrument and ackno ledged the same. 17799 Kenwood Tr. # 265.Lakeville. MN 55044 chE-a~ (Signatures may be authenticated or acknowledged. *Darla J Bauer Both are not necessary.)