HomeMy WebLinkAbout026-1004-50-000
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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER US c, e .0
ADDRESS
/1l~..J~[ f57~cL ~ ~ ~ 5 HOC
SUBDIVISION / CSM# LOT
SECTION-_~_T 0 N-R_ZL_W, Town of R/c kwL~cj
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW E ERYTHING WITHIN 100 FEET OF SYSTEM
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\ Ste.
\ INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK: A) 4`1
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: W LQ-- ~ Liquid Capacity:
Setback from: Well House other
Pump: Manufacturer Model# Size
Float seperation / Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: Length Number of+
Distance & Direction to nearest prop. line: -j/Q
Setback from: well: House Other
ELEVATIONS
Building Sewer ST Inlet: /At V ST outlet: /05,9
PC inlet PC bottom - Pump Off
Header/Manifold Bottom of system /.4-
Existing Grade_ 7 S, Final grade 9S",
DATE OF INSTALLATION:
PLUMBER ON JOB:
LICENSE NUMBER: 15(o,
INSPECTOR:
3/93:jt
Wistonrsin De0artment of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No-:
GENERAL INFORMATION 299038
19.
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
REEKS, ASA RICHMOND
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
x 026-1004-50-000
TANK INFORMATION LEVATION DATA A9700355
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic , Benchmark /0 1-3 DO- C)
Dosing
Aeration Bldg. Sewer
Holding St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
Vent
ir Ito ntake ROAD Dt Inlet
TANK TO P / L WELL BLDG. A
Septic 5 r 8 r~ - NA Dt Bottom
Dosing NA Header / Man. 7 7 Ga 93
Aeration NA Dist. Pipe ~Cr ~g
Holding Bot. System Q'/, 7y'
PUMP / SIPHON INFORMATION Final Grade
Manufacturer Demand ry✓~ M.~ , (o g p 6~
Model Number GPM
TDH Lift Fricti System TDH Ft
Forcemain ngth Dia. f Dist. To Well
Head
SOIL ABSORPTION SYSTEM
BED/TRENCH Width 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 CHAMBER Model Number:
System: D a 134 ( x)1A 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 a Bed /Trench Edges --34 N Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: RICHMOND 1.30.18.16C,SE,SE 1472 COUNTY ROAD GG
Plan revision required? ❑ Yes [1KNo
Use other side for additional information. `exl - SBD-6710 (R 05/91) Date I e is Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH ,
SANITARY PERMIT NUMBER:
l f l
Safety and Buildings Division
Visconsin SANITARY PERMIT APPLICATION 201 E. Washington Ave.
In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
Department of Commerce Madison, WI 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 1/2 x 11 inches in size. St C ro i
• See reverse side for instructions for completing this application State Sanitary Permit Number
`~'39
The information you provide may be used by other government agency programs ❑ Ghec If evi Ion o previous application
[Privacy Law, s. 15.04 (1) (m)]. 3 r2Xh4& State Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION
Prope y Owner Name Property Location
1/4 1/4, S T36 , N, R/,,~-!0or) W
PFC, , y Owner's Mailing Address Lot Number Block Number
City, Sta Zi Code Phone Number Subdivision Name or CSM Number
11. TYPE F BUILDING: (check one) ❑ State Owned o City Nearest Road It Village Public 1 or 2 Family Dwelling - No. of bedrooms
29 A9 own OF td107 d72 4V ce
Cv G
111. BUILDING USE: (if building type is public, check all that apply) Parcel Tax Number(s)
3 0.-1$- n0 c, le) - c7
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. ❑ New 2. X'System Replacement 3. ❑ Replacement of 4_ E] Reconnection of 5. E] Repair of an
------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)
No Distribution Pressurized Distribution Experimental Other
11 Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 eepage 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
Requi d (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) evvation
06 3 , ~l. 4 Feet /"y'i? Feet
VII. TANK Ca clt
in gallons Total # of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existing strutted
Tanks Tanks
Septic Tank or Holding Tank rm ❑ ❑ ❑ ❑ ❑
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 Nam . rint) Plumber's Sign ur (NoSamps) WMPRSWNo.: Business Phone Number:
Plun;ies . Ac dress ~et, Ci State Zip Code): ,
9 6
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (IndudesGroundwater Date Issued Issuing Agent Signature (No Stamps)
Approved Surcharge Fee)
❑ Owner Given Initial
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD•6398 (R.11/96) 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 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, 608-266-3151.
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; replacerent 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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PAGE OF
CrvSS Sec~Ion o~ SYs~-en-1
Fresh Air InI416 And Obcervallon Pipe
Q+ Approvad Vent Cap
Allnlmum 12' Above
Final Grade
20- 42' Above Pipe _ 4' Coat Iron
To Final Grade Vent Pips
Marsh Hoy Or Synlhelk Covering
wtn. 2' Aggregate
Over pipe
Dlitrlbutloe -Tee s
Pips _ 0 0 0 0
i 6' Agiltegals
th Pi a Pertoralsd Pips Below
Benleoath Plpe
o _ Coupling Terminating At
Bottom of Syilem
~~cJ•:T ton .
SOIL• FILL.
OISTRIBUTIOU PIPE
' APPROVED S~WTNETIC COVER
"'--MATERIM. OR 9" OF STRAW
2w co gGGREGAIE OR totmsw HAy'
Ie.OFl2-21/2 AGGREGATE
CV. .
15
>
DIS-rRI5UTI0►J PIPE TO BE AT LEAST INCHES BELOW ORIGIMAL GRAOE
AIJU AT LEASTLO IIJCHES BUT..IJO MORE THAN 42 MCHES BELOW FINAL GRADE
MIMUM WTH OF F-XOt4VAT100 FRoM OKI&V AL 65KAK WILL BE IMC 14ES
MINIMUM geprtt of EACAVATIOM f.Ro1M. CA141 SAL jRADF WILL. BE INCHES
SIGIJEO: '
LICENSE DUMBER: .
c
a
DATE: ~
Wisconsin Deportment of Industry, SOIL AND SITE EVALUATION
Labor and Human Relations Page / of
Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis.
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must County
include, but not limited to: vertical and horizontal reference point (BM), direction and S fi C r `
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
0a~_~ao~-so
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
ka _S Govt. Lot SE 1/4_5 1/4,S T ~(S N,R Cor) W
Property Owner's Mailing Address
Lot # Block# Subd. Name or CS M#
/ 7 / (C) X47 _
city ~ Stat Zip Code Phone Number Nearest Road
S, J2 c~ b ❑ City ❑ Village Town C r r G
1 V(211,~, ~tC T SY~~ 7
❑ New Construction use: Residential / Number of bedrooms 1~11- Addition to existing building
'1 Replacement ll''C ❑ Public or commercial - Describe:
Code derived daily flow '7`✓~ gpd Recommended design loading rate i bed, gpd/fit _#g trench, gpd/ft2
Absorption area required bed, ft2 trench, ft2 Maximum design loading rate 1 bed, gpd/fi2 , trench, gpd/ft2
Recommended infiltration surface elevation(s) 171 to ft (as referred to site plan benchmark)
Additional design/site considerations
Parent material S Flood plain elevation, if applicable V _ft
S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank
u= unsuitable for system So u ~(S ❑ u 5Q S❑ u ~ 1 s u ❑ S U ❑ S A U
SOIL DESCRIPTION REPORT I) e X
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
2- -30 -,S,. MS u) t
Ground 3 043 D S/ Ic S
elev
95-Z ft
I --J
Depth to
limiting
factor
7-0 in.
Remarks:
Boring #
,dim" r
J.,L C2 &-y r
Ground
elev.
7 ft• ,
Depth to
limiting
factor
QLin. Remarks:
CST/~am (Please Pri t) Si nature Telephone No.
1r0.~ V %,VN I 7 / C--~L Y6 -5 / _::i~S
Address 09 Date CST Number
92
S 4~ SOIL DESCRIPTION REPORT Page V? of`
PROPERTY OWNER
PARCEL I.D.# Oa(. -j" j " S O
Boring # Horizon Depth Dominant Color Mottles Structure Consistence 2
g in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Boundary Roots
S Bed Trench
l 7 . k
n 1 -Ib /G1 S C9
6 -S
09b Ground
elev.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
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 #
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
SBDW-8330 (R. 08/95)
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER C~
4 I
in I
MAILING ADDRESS n
' PROPERTY ADDRESS SQ vy~~ h4 -7 A. cm G.,
(location of septic system) Please obtain om the Planning Dept.
CITY/STATE 0(
PROPERTY LOCATION- 1/4, 1/41 Section W ,
TOWN OF K ~11ty~,p ry,c~ ST. CROIX COUNTY, WI
=
SUBDIVISION LOT NUMBER
-
CERTI IED SURVEY MAP 9 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 verifying that (I',
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 undersign6d 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: P~ tA (2 Q.
DATE: GI L
St. Croix County Zoning Office
Government Center
1101 Carmichael Road -
Hudson, WI 54016 11/93
STC - 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. ,
-------------------------------------------------------------a.....--
Owner of property ASCL N11
Location of property_S~C 1/4 S E 1/4, Section ,T3_3N-R W
Township ` Mailing address C, C-.
0l
Address of site JAj.? C.~v A
Subdivision name ti A- Lot no.
Other homes on property? Yes No
Previous ownef of property 4 14
Total size of'property
Total size of parcel
Date parcel was created _ 7 _ -(p Cy
Are all borners and lot lines identifiable? _ Yes No.
Is this property being. developed for' ('spec house).? Yes r No
Volume and Page Number 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 n the office of the County Register of
Deeds as, Document No. 'd 7 (gg-7 0 , 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.
Signature of Applicant 7
Co-Applicant
Date of Signature Date of Signature
VUl q r 1105 232
r „Xo, S- I. Quitclaim Deed-Common Form (STATE OF WISCONSIN) Published by Eau Claire Book & Stationery Co,
276870
i
Us .10CITturt, Made this 2nd day of July , A. D., 19 64
between Fritz No Asplund and Violet Asplund, his wife .
parti e s of the first part
and Asa E. Weeks and Amanda L. Weeks, husband and wife, as
joint tenants
parties of the second part.
Miitntf 000, That the said part ies of the first part, for and in consideration of the sum of
Four Hundred and No/100ths ($100.00)-,* Dollars,
to themin hand paid by the said part ies of the second part, the receipt whereof is hereby confessed
and acknowledged, havigiven, granted, bargained, sold, remised, released and quitclaimed, and by these
presents do give, grant bargain, sell, remise,-. release and quitclaim unto the said parties of the
second part, and to their heirs and assigns forever, the following described real estate,
- situated in the County of St. Croix State of Wisconsin, to-wit:
Commencing at the Northwest corner of the Southeast Quarter of
the Southeast Quarter (SEA of SE4) of Section One (1), Township
Thirty (30) North, of Range Eighteen (18) West; thence East
275 feet; thencehSouth to highway as now traveled; thence West
along North line of said highway to--West -line of said fort-.y_;_.____
thence North to point of beginning:-xAlso commencing at the
Southwest corner of said Northeast Quarter of the Southeast Quarter
(NE4 of SEf); thence North 70 feet; thence East 65 feet; thence
South 70 feet; thence West ;Do place of beginning, located in
Secti n One (1), Township Thirty (30) North,-of Range Eighteen (1$)
West;-'together with a right of way to Willow River across the
Vest y pprt'on of ro ert np wne the first ti's, and
ecor~dseatine14ea°sronN~O4 ~ 22in Vo~ume1 0
x
irst partieages reserve a : gHf of way a ong the West side of the,
above described premises.
8~11
(.i
Zo babe anb to DOW, the same together with all and singular the appurtenances and privileges thereunto
belonging or in anywise thereunto appertaining, and all the estate, right, title, interest and claim
' whatsoever of the said part ies of the first part, either in law or equity, either in possession or
expectancy of, to the only proper use, benefit and behoof of the said part ies of the second part,
their heirs and assigns forever.
Jn t iffitoo Obertot, the said part ies of the first part ha ve hereunto set their hands and
seal S this 2nd day of July , A. D., 19 64 .
Sig e d Se ed in Pre nce of C-2 Seal
~r4~~ (Seal)
Via el t; Asplund
Joseph W. hes
_.W(Seal)
-
-(Seal)
_ • Raced fUF oral s='
Ruth A_ Tohngnn day OL-11LlY A.D. 19__4
at__ :00 A$ M.
Statt of Moronofn, ss. 44
St. Croix County. Register - Personally came before me, this 2nd day of July , A. D.,19 64 ,
Fritz No Asplund and Violet Asplund, his wife
the above named - - -