HomeMy WebLinkAbout020-1319-10-000
S~
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER fie,) c~ C a s
ADDRESS/aa d
~Gc aQS'd,.~ l,~ ~ `
SUBDIVISION / CSM# S7` ~Vd % K SST LOT #
SECTION q_T a Q N-R ~Q W, Town of
ST. CROIX COUNTY, WISCONSIN
GYos 6 ~Y
PLAN VIE
SHOW EVERYTHING WITHIN 1 0 FE T OF SYSTEM
J 41~
flea s e
35
oa o
ft
~O ~y,e.JGLs
a_s
x
a o
INDICATE NORTH ARROW
-r
Pr*vide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
RECEIVED MAR 0 4 1W
BENCHMARK: _15 a w
ALTERNATE BM: -W ~J
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: , ejesT~ey Liquid Capacity: /mod d.
Setback from: Well House 3Q' Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: Length ,6"d Number of trenches
Distance & Direction to nearest prop. line: lod S4G~7~1t
r
Setback from: well: House O~ fi Other
ELEVATIONS
Building Sewer ST Inlet: ST outlet:
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION:
e
PLUMBER ON JOB:
LICENSE NUMBER: 1y1,%~~3~2
INSPECTOR:
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor il Human Relations
S INSPECTION REPORT ST. CROIX
Safety fety and Btiildings Division
(ATTACH TO PERMIT) Sanitary Permit No-:
GENERAL INFORMATION 284239
Permit Holder's Name: ❑ City ❑ Village own of: State Plan ID No.:
LACASSE, R.W. HUDSON
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
d r 60 020-13197-
TANK INFORMATION ELEVATION DATA /
TYPE MANUFACTURER CAPACITY STATION BS HI FS
Septic M-`faleS,1141-CQ I.Y~ Benchmark
Dosin ~~ri11 Ib.r71,
Aeration Bldg. Sewer
Holdin St/e Inlet 3,1`1
ANK SETBACK INFORMATION St 11W Outlet
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom
Z
Dosing NA Header / Man.
Aeration ANA Dist. Pipe 40'3 y
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand {"P 0,,1s.T '
o C~r~-~r` 0 0' S ld~
Model Num er GPM l0f
tv.r$~ E rc:,~C , 9a 14 9 7
TDH Li Friction Ft
oss
For emain Length Dia. Dist. To well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width ) Length / No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS S &,12 02. DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACH
SETBACK BER
INFORMATION Type O A yw1C CH Model Number:
System: -A~r!U OR UNIT
DISTRIBUTION SYSTEM
Header / I/ Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
i
Length Dia. Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade System
Depth Over Depth Over xx Depth Of eded /Sodded xx Mulche
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HUDSON 28.29.19W NW,SW. CROS Y RIVE
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I V/" -'~`/'~~f/~'/ (3.
/V~}J(\// •y.A ~y/ j ..-~['~~1. A ..SAL.
111/// C O~ / U
1 ~~iY►~1. C*
Plan revision required? ❑ Yes B-No
Use other side for additional information. 02 f
SBD-)6710 (R 05/91) Dat Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
r
SANITARY PERMIT NUMBER:
Safety and Buildings Division
V•;`j; ; SANITARY PERMIT APPLICATION Bureau of Building Water System!
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 n " %
"tT
gglip
than 8 1/2 x 11 inches in size-
• See reverse side for instructions for completing this application State Sanitary Permit Number
54APAWM4 12 YLI X39
The information you provide may be used by of n agent pr gr 5 ❑ Check if revision to previous application
(Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
1. APPLICATION INFORMATI • FORMATION
Property Owner Name Property Location
/ t /4 5 Lii 1/4, S T N, R E (or)~
Property Owner's Mailing Address Lot Number Block Number
X 12 __2 G 11 1 1__y c ti
City, State Zip Code Phone Number Subdivision Name or CSM Number
X
II. TYPE F BUILDING: (check one) E] State Owned !tr Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms Towage OF F ~ti!~' 2 ~a Gl ,ri
II1. BUILDING USE: (If building type is public, check all that apply) Parcel Tax.Nu er(
q. /t? a
1 ❑ Apartment/ Condo -
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. m New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
System System Tank OnlyExisting 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 i 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) Elevation
70 Feet 16S, ~T Feet
VII. TANK Capacity Total # of Prefab. Site Fiber-
App
INFORMATION in g Gallons Tanks Manufacturerrs Name Concrete Con- Steel glass Plastic Exper.
New Existing strutted
Tanks Tanks
Septic Tank or Holding Tank f -C1 Pv ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VI11. 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 Stamps) P/MPRSW No.: Business Phone Number: A7
's
C
Plumber's Address (Street, City, State, Zip Code :
/Z -7
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issue Issuing Agent Signature (No Stamps)
roved Surcharge Fee)
pp [:1 Owner Given Initial V" pf)
Adverse Determination (f I 1" 0
X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05194) DISTRIBUTION: Original to Counly. One copy To: Safety 8 Buildings Division, Owner, Plumber
INSTRUCTIONS
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 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 8 112 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.
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Wisetnsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3
~►t.abo; and Human Relations
Division of Safety 8 Buildings in accord with ILHR 83.05, Wis. Adm. Code
. COUNTY
c
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but St. Croix
not limited to vertical and horizontal reference point (BM), direction e, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to neares pending
APPLICANT INFORMATION-PLEASE PRINT ALL ATI REVIEWED BY DATE
PROPERTY OWNER: LT7 PER C TION
Brid eland Dev. Com an GOVT. LOT 1/4 SW 1/4,S 28 T 29 ,,R 19 :R (or) W
.40
PROPERTY OWNER':S MAILING ADDRESS = Lo # B # SUBD. NAME OR CSM #
11736 117th St.S ix , addn
CITY, STATE ZIP CODE PHONE R ; r v CITY GE 0 NEAREST ROAD
Lakeville MN. 55044 (612 Pamela Ln.
[x] New Construction Use [ Residential / Number of bed" Addition to existing building
[ ] 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) 102.00 ft (as referred to site plan benchmark)
Additional design / site considerations alt. area system el.= 101.17'
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 ®S ❑ U ®S ❑ U 0S ❑ U [!3 S ❑ U ❑ S U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Consistence Bour>dary Bed Trertdi
y''...1.. 1 0-10 10 r3 3 none 2rpl mfr cog if np -9.
2 10-19 1Qyr4/4 none -'il 2mcjr mfr 9W if -9 -1
Ground _
elev.
105.7 ft.
Depth to
limiting
factor
+82"
Remarks:
Boring #
1 0-16 10 r2 2 none 1 2f l mfr C1W if n .3
2::::::: 2 16-35 10 r4 4 none sil lfsbk mfr if .2 .3
Ground 3 35-84 7. r4 6 none
elev.
105.7 ft.
Depth to
limiting
fac+tor
Remarks:
CST Name: Please Print Phone:
Gar L. Steel 715-246-6200
Address: 1554 200th-Ave., New Richmond WI. 54017 m02298
Signature: Date: CST Number:
6-24-96
le X'tjLZ---
PROPERTYOWNER Bridgeland Dev. Cn_ SOIL DESCRIPTION REPORT Page 2 of 3
PARCEL I.D. # mending Lot #15
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ftl
in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
1 0-14 none
2 14-27 10 r4
Ground 3 127-37 7.5 r4 4 none Is 0&1 mvfr Qw na -7 .8
elev.
105.0(1. 4 37-82 7.5 r4 6 none s os fr na n
Depth to
limiting
factor
+82'1
Remarks:
Boring #
1 0-14 10 r3 3 none 1 2c 2l mfr
2 14-25 10yr4/4 none sil lfsbk mfr w if .2 `.3
3 25-80 7.5 r4 6 none s os mvfr na na i.8
Ground
elev.
103.4 ft.
Depth to
limiting
facto
0"
Remarks:
Boring #
1 -15 10 r2 2 none 1 2msbk mfr C1w 1f .5 i.6
2 15-29 10 r4 4 none sil 1f r mfr Crw 1 .2
Ground 3 29-38 7.5 r4 4 none is
elev.
103.2ft 4 138-82 7.5 r4 6 none s os
.
Depth to
limiting
factor
+82"
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
STEEL'S SOIL SERVICE
Gary L. Steel Bridgeland Dev. Co. 1554 200th Ave.
CSTM2298 NW4SW4 S28-T29N-R19w New Richmond, WI 54017
MPRSW 3254 town of Hudson (715) 246-6200
4 lot #15-St. Croix Estates First Addn.
I
N
1"=40'
BM.= top of SE lot stake C el. 100' r
~pZ
r -2
1~►vlC:~ ~ ~ ~1.
Gary L. Steel
6-24-96
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER Llta►SS~
MAILING ADDRESS >aw4ks w1
PROPERTY ADDRESS _ 73 w e-
( location t
(location of septic systems) Plev a obtain from the Planning Dept.
CITY/STATE a_ r /a
PROPERTY LOCATION l 1/4, f-ZJ 1/4, Section T_2.~;N-R1~7_W
'OWN OF ST. CROIX COUNTY, WI
SUBDIVISION _ Croy X S 6d 4:4
LOT NUM13ER _
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 verit;,ing 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:
~t,
DATE: 9 - za q
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
STC - loo
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 e e
s ; l ~52
Location of property 1/4 5CL' 1/4, Section ;Z Z- ~ l N-R- /ct W
Township l -,A _j Mailing address I 'Z Zo 64K 1-m Address of site OF21 br1Subdivision name Lot no.
Other homes on property? -Yes No
Previous owner of property
Total size of property D CZ)
Total size of parcel ~7 .
Date parcel was created
Are all corners and lot lines identifiable? t/ Yes No
Is this property being developed for (spec house)? Yes No
Volume Uj eZ and Page Number -'y5-Z-_ as recorded with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION TILE 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
war.ranty'deed recorded in the office of the County Register of
Deeds as Document No. _-,S- / 7 Z/ 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.
S ' gnhotIir of Applicant Co-Applicant
I 2-8 Z9
-
hato of F Sirinat-iirP
at 1?07mA58
5 ai.IS r3
y DOCUIv1ENT NO. STATE BAR OF WISCONSIN FORM 2-1982
WARRANTY DEED
P,:a IL;SCrr.Cc
Brideelanr Devel rt~°nt COnLin+nr ST. CROIX CTI.l W1
-gA a [L inr~Ac~,a n~r~r,i-i~~111r~: b Vacrr!
{ Nov _b 1996
conveys and warrants to at 1:30 P.
Richard W LaCaccr and Gracx r t s(accr hu~i- ~.Jt 3 '~k .'•k
f ;:'wat:Ma
I
the following descnbed real estate in St. Croix County, State of WLco sin
Lot 15 • St. Croix Estates First Addition in the Tow+t ; i r'udson
St. Croix County, Wisconsin
Wk0jr4rica Beak Hudwn
600 SecaW Sbreet
P.O. Boot 71
$TRA%FER HudFon. Wl 54016
This is not
(d) 6. -homestead property.
Exceptions to Warranties:
Dated this _ 28W day of mod, 19 96 •
(SEA1-)
•
• (SEAL) (SEAL)
•
AUTHENTICATION ACKNOWLEDGMENT
Signatures authenticated this elay of STATE OF M;.4NESOTA
19 Dakota county
• Pam ally came before me, this h day of
TITLE: 11g1~1BER STATE BAR OF WISCONSIN 4apber_ 1996 the above named
Nea! Krtyraniak
(if
authorized by 706.06, Wis. Stats.)
This instrument was drafted by
to me known to be the person who executed the
Bridgdand Catty foregoing insirnment and acknowledged the same.
20141 Iconic Tr 4,np B °tittLlle I~Q+I 55044
(Signatures may be authenticated or acimowledga • CZGC~~/
Both are not necessary.) path 1 Bauer
Notary Public DAM County, MN
my commission expire January 1, 2000.
QARA I
NOW x#41
iitt[tleaootasmr
~ott~w3~sla 11.1DOE
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