HomeMy WebLinkAbout020-1111-90-000
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
ADDRESS wn 3$
l~ZedSQ~i Lc.j/~
SUBDIVISION / CSM# LOT #
SECTION /-Z TAN-R Za W, Town of Hoc ~S67i
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
we61 ~/"t7
Af4...,E gds
cL n'36
6v1/, ~,c~,fo •
1
yam,
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK:
ALTERNATE BM: ;
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: 6,, ,e,,ks e,4 Liquid Capacity: /zoo
Setback from: Well 9o House y3" Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: Length 71 Number of trenches
Distance & Direction to nearest prop. line:
Setback from: well: 6 S' ' House 35' 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:
PLUMBER ON JOB:
dq~i /,.~r.►~
LICENSE NUMBER: Iq//,7 3 22'/
INSPECTOR:
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT
Safety and Buildings Division Oro % ,574 . GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.:
I -la
14, 1
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
/ Qe
Iro
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark $ • U~
Dosing
Aeration Bldg. Sewer
Holding St/Ht Inlet 95y' t q
TANK SETBACK INFORMATION St/ Ht Outlet gY,19
Vent
TANK TO P / L WELL BLDG. Air Ito ntake ROAD Dt Inlet
Air
Septic >dS" D - 3~ r- NA Dt Bottom
Dosing NA Header / Man. 9" 3 y
Aeration NA Dist. Pipe 01 36~ 94! a
Holding Bot. System A -331 93,,2,S`
PUMP/ SIPHON INFORMATION Final Grade
41
Manufacturer Demand 61 444 caw 33' 98 '
Model Number GPM
TDH Lift Friction System TDH Ft
Forcemain Length Dia. Dist. To Well
Fi
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS /:p , 71/ ' / DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type 0 CHAMBER Model Number:
System: >/00 ' 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 Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
„
- ®C~CtLi`C~~~ ~ltr~sor~ -l01-~29-4o-1t1,E-SI,) 04 "'3/STH435-
O 1- ~
Plan revision required? ❑ Yes EeNo
Use other side for additional information. q
a g
SBD-6710 (R 05/91) Date 1 ' pe is Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
I
i Safety and Buildings Division
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
than 8112 x 11 inches in size. . ~o`
• See reverse side for instructions for completing this application State Sanitary Permit Number
7
The information you provide may be used by other government agency programs ❑ Check if revision to previous application
[Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Property Owner Name Property Location
-T L& t/I' t n/£ 1/450 1/4,S I Z T Z`f , N, R ZD k(oro
Property Owner's Mailing Address Lot Numbey Block Number
1008 35 Y't Co IF _3
City, State Zip Code Phone Number Subdivision Name or CSM Number
14
5 40 1 1(-7/6 ) b i
II. TYPE F BUILDING: (check one) ❑ State Owned ❑ it Nearest Road
❑ Village 1~~/
❑ Public 1 or 2 Family Dwelling - No. of bedrooms Town OF #V V
111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) Z , . 4 S~{'
1 ❑ Apartment /Condo 02.0- 1 I qd
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. M 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 CR 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
Required (sq. ft.) Pro osed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation
b 0 ~19 H4 471 .7 - 9 3 Feet 9-/. 3 Feet
VII. TANK Capacity
INFORMATION in gallons Total # of 's Name Prefab. Site Fiber- Plastic Exper.
Gallons Tanks Manufacturer Concrete Con- Steel glass App.
New Existing structed
Tanks Tanks
Septic Tank or Holding Tank 9§ ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ 1 1:1 1 E]
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) r Plumber's Signature: (No tampS) rMPRSW No.: Business Phone Number:
Plumb 's Address (Street, City, State, Zip Code):
312-8 dQ)"h / vVf 16A 1-50n ~4
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issue Issuing Ag nt Signatu
Surcharge Fee)
XApproved ❑ Owner Given Initial
Adverse Determination pd Y
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
. SBD-6398 (R. 05/94) DISTRIBUTION: Original to County, 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 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 8 112 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.
JOB Duy Cctwtw~~1
TIMM EXCAVATING SHEET NO. OF 2
Route 1 Box 192
WILSON, WISCONSIN 54027 CALCULATED BY DATE zo-
(715) 772-3214 (715) 386-5443
MPRS #3224 WI MPCA #696 MN CHECKED BY DATE l4o
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PRODUCT 915-1 Inc., Groton, Mass. 81471. To Order PHONE TOLL FREE I-8DD-2255388
JOB C'ca.w»~ e'"4
TIMM EXCAVATING
L Z
Route 1 BOX 192 SHEET NO. OF
WILSON, WISCONSIN 54027 CALCULATED BY DATE /
(715) 772-3214 (715) 386-5443
MPRS #3224 WI MPCA #696 MN CHECKED BY DATE
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PRODUCT 205-1 ! Inc., Groton, Mass. 01471. To Order PHONE TOLL FREE I-BOD-225-6380
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 1)407J C6Lw..►• "•y
Location of propertFNW. 1/4 1/4, Section a T~ N-R01)_W
Township -H 1i A( 6 A Mailing address 0-61) (o ~U Hydsm
Address of site
subdivision name rn Q Lot no.
Other homes on property? _ No Yes No
Previous owner of property J-, DQ V i L CU M m A) r
Total size of property
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? ?X Yes No
Is this property being developed for (spec house)? Yes k' No
Volume 11 and Page Number Y3 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. '~L` IL , 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.
4
V V\ w\A- -
Signat re of Applicant Co-Applicant
Date of Signature Date of Signature
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
MAILING ADDRESS D, 4619 X 62 y ( S tic l
PROPERTY ADDRESS 1009 f '/l Phraay~S M VA0n, ►
(location of septic system) Pleas obtain from the Planning Dept.
CITY/STATE
PROPERTY LOCATION 1/4, SIa/ 1/4, Section ) QL_, T 9 N-R d W
TOWN OF T~I)~S'dY1 ST. CROIX COUNTY, WI
SUBDIVISION ft) ) + LOT NUMBER
CERTIFIED SURVEY MAP , VOLUME /I Q'I, PAGE 9-~ , 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: >M
DATE: 7 a 10 ~1 to
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
794FA,~~ 93 30cuMrr)T NO WARRANTY DEED ;v, E Hr, «,VtO ..•R R! MIaN.
STATE BAIL OF WISCONSIN FORM 2-1982
431,20T
RL-GiSTERS OFFICE
Marylee W. McMillan, a widowed unremarried '-7• G;OIX CO., WIS.
woman wbc'd. ~4x Recofcl th;s 19th
oy of Oct. A.D. 1987
con%c•>s and %c.;rr:nt3 to James D. Cumming and Carol J. ► 40 AA~
Cumming, husband. and wife as marital.
survivorship property Mw. N~
R1 TUFIN TO
the following described real estate in ..St... Croix ..............County,
State of Wisconsin.
Tax Parcel No
See attached description
0
This .._1S homestead property.
(is) (is not)
Exception to warranties: TOGETHER WIM AND SUBJECT TO any other easements, covenants,
reservations or restrictions of record, if any, but this shall not be deemed to extend
any such other recorded encumbrances beyond the term established by law therefor.
Dated this 16t:h.-.... October
-(SEAL)
• . Marylee V. McMillan.
-.(SEAL) .(SEAL)
AUTHENTICATION ACHNOW LEDCUKE11
• O
Signature (s) A------------------------------------•-••---------• STATE OF WISCONSIN
St.-.CXroix--------------- County.
authenticated this .-----..day of--------------------------- 19.---.. Personally came before me this ....16th ....day of
to r 19..87.- the above named
Mary----------------------------------
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not,
by § 706.06, Wis. Stats.) to me known to be the person who executed the
foregoing instrument and acknowte~ge the same.
A parcel of land containing 1.65 acres in Government Lot "3", Sect?on 12.
Township 29 North, Range 20 West, described as follows- Beginning at a point
453.0 feet W and 176.2 feet North of the Southeast corner of said Government
Lot "3'; thence 1437°211W a distance of 200.0 feet, thence N39°351E a distance
of 61.2 feet, thence 1473,1091E a distance of 254.3 feet, thence S320U4'E a
distance of 245.0 feet, thence S7600VW a distance of 300.0 feet to point of
beginning; together with a non-exclusive easement for ingress and egress over
an access road I8 feet wide frog above described parcel Easterly to the
private road running to state Trunk Highway "35", thence over said private
road as now opened and travelled to said State Trunk Highway 1135"; together
with the right to cut trees other than pine or birch, on lands to the
Northwest of said parcel, so as to provide a view of the St. Croix River from
the parcel, subject to the restrictions and covenants running with the land
dated June 28, 1960 and recorded in Vol. "369", Page 465 of the records in
the office of the Register of Deeds for St. Croix County, Wisconsin.
AND
P" 94 PA
A parcel of 1.5 acres located in Government Lot "3" and the` N6rtheast
Quarter of Southwest Quarter of Section 12, Township 29 North, Range 20
West further described as follows: Commencing at a point 453.0 feet West,
thence 176.2 feet North of the Southeast corner of said Government Lot "3",
thence N760041E a distance of 300 feet to point of beginning, thence N570301E
a distance of 250.0 feet, thence N340411W a distance of 292.8 feet, thence
S460141W a distance of 241.7 feet, thence S320041E a distance of 245.0 feet,
along boundary of parcel neretofore conveyed, to point of beginning; together
with an easement for an access road from the above described parcel Easterly
to State Trunk Highway 1135" as now opened and traveled.
c. • . ~
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT 7RE labor and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point (BM), direction and % of slope,
scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY E
PROPERTY OWNER: PROPERTY LOCATION
C4 ~Zo CU R7 ,t t GOVT. LOT 3 NF_ 1/4~1/4,S ii T Z N,(or) W
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBO. NAME OR CSM #
/60's 14)61Jt ;1 y S -
CI ,.STATE ZI COD PHONE NUMBER [:]CITY OVILLAGE [-]TOWN NEAREST ROAD
1U~sa"~ 'vJi S DI ( ) ~u~d>J s~~E. 4' 1Ch".;I
[ ] New Construction Use [Xf Residential / Number of bedrooms [ j Addition to existing building
Replacement [ ] Public or commercial describe
Code derived daily flow 4,00 gpd Recommended design loading rate 0.7 bed, gpd/ft2 O, % trench, gpd/ft2
Absorption area required 'RS% bed, ft2 7S 0 trench, ft2 Maximum design loading rate ~A .7 bed, gpd/ft2 6~~ trench, gpd/ft2
Recommended infiltration surface elevation(s) C~ 3•~ It (as referred to site plan benchmark)
Additional design / site considerations
Parent material Flood plain elevation, if applicable ft
S = Suitable for system CEO IVENTIONAL MO ND IN-GROUND PRESSURE AT-GRADE SYSTEM _!N ,FILL HOLDING, T~wK
U -Unsuitable fors stem 14S ❑ U L S ❑ U j4 S❑ U KS ❑ U ❑ S f 4 L ❑ S M U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bcu ~ lry Roots GPD/ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench
0-S 1 3/1 - L /h v rir C, s Z r O•A n.
E3 91 1 1~ - /'9 /6 Y9 3tZ SL n
Ground /S -3r2- 7 i YrC q 4 S ;Y 0.7 -
elev.
I ft $3 3Z-117- Y,F 414 S n, - 6 ~6
Depth to
limiting
factor
}
/617
Remarks:
Boring #
S Al
13
Ground l3/_1Z0 Y►E S r- ' 6.7 Cl6
elev.
1C.3 ft
Depth to
limiting
factor
Remarks:
CST Name:-Please Print Qv Y .)oNN ~ Phone:
Address: a ,
uflSoti ~
Signature: Date: CST Numbe^ f
`1 ~~Gtr
U C)
4C CUalAl„oe, SOIL DESCRIPTION REPORT Page of
,PROPE
1w pq?6n Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed rend,
J
GeV.
ft
Depth to
limiting
factor
Remarks:
Boring #
1'h Cr- ;-t-g1;-
L (3
:ar
Ground
elev. k-lr3 /6"MN A i S (3 0, 7
O.n
q1,L ft
Depth to
limiting
f ter,
7•b~
Remarks:
Boring #
Ground
elev.
It
Depth to
limiting
factor
Remarks:
Boring #
13
Ground
elev.
ft
Depth to
limiting
factor
Remarks:
SBD-8330(R.05/92)