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HomeMy WebLinkAbout026-1114-20-000 STc - 104 S AS BUILT SANITARY SYSTEM REPORT OWNER . 1 rv ECF~V~D t,{ 1A ADDRESS__ ~B~lC NTY SUBDIVISION--/ -CSM SAT ~ ~ , SECTION.- T7C> /jr Town of ST..CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEE_.OF_..SYSTEM . J. r} , L2 ~o INDICATE NORTH ARROW /CA Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: $ ALTERNATE BM: A. 641tc.Z SEPTIC TANK Y-UMPCHAMBER D Manufacturer; l,c) Liquid.Capacit . ~ /a Setback-from': 1el x~ • ~ 4 30 .rte: ...F Pump: 'Manufa-ctumr- Modell ize Float seperation - Ga11,on - - Alarm TiO 4 cation rz i ; x y# as x^' 1. .`j SOIL ABSORPTION SYSTEM Width: ~o;2 Length Number.of trenches i Distance & Direction to nearest prop. -line: ,S ` $a Setback from: well.: /U House. Other - ' ELEVATIONS Building Sewer ST Inlet: k, 7 ST outlet: ~~..3 PC inlet AJ PC bottom Pump Off Header/Manifold 97, Bottom of system 9~ . Existing Grade IJ~do" Final grade / DATE OF INSTALLATION: ,PLUMBER ON JOB: Crum-~--o LICENSE NUMBBR:! INSPECTOR: ; 0575 3/93:jt Wischnsin Department of Commerce PRIVATE SEWAGE SYSTEM County: Safety and Buildings Division ST. CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) SanitaryP2e5r§itW§ Personal information you provice may be used for secondary purposes [Privacy La s.15.04 (1)(m)]. y y 1 is 7 P81or' r& JO T VENTURE ❑i`yC~~ 7 ❑ Town of: State Plan ID No.: WlL~ r ' if CST lev.: Insp. ITM Elev.: BM Description: Parcel Tth'-1114-20-000 16U S C a k t, fl ~Va~ , TANK INFORMATION ELEVATION DATA A9700506 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Sep i to Z~ Benchmark 5 _ (oD Apr Dosing , _ - All, tv Zq$~ /p2 co2~ Aeration Bldg. Sewer Holding ~9?,w Inlet C1 3,F 5- TANK SETBACK INFORMATION 3 t , , f~S Outlet 1"f g~ y2 TANK TO P/ L WELL BLDG. AVvKt ir Intake ROAD Dt Inlet NA Dt Bottom Dosing - NA Header/ Man. _ -.$Z 917 Aeration - NA Dist. Pipe -7,9-7 9 7. ~13 Holding Bot. System 2"C/S- -j(,-&S- PUMP / SIPHON INFORMATION Final Grade S-00 /DO- (oD Manufacturer Demand's S 00,/7 Model Number GPM I Loss Friction. System TDH Ft TDH Lift Forcemain Length Dia. H Dist. To Well S BSORPTION SYSTEM E TRENCH Width 2 r Length -77, No. Of Trenches PIT No. Of Pits Inside Dia. Li uid Depth EN I N DIMENSIONS SYSTEM TO P / L BLDG WELL SETBACK LAKE /STREAM LEACHING nuaztu INFORMATION Type Of 11 r Number. Systemeanv[~;~! v n? CHAMBER OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s; r x Hole Size x Hole Spacing Vent To Air I-nnttake Length ~ Dia. Length 1= Dia. Ir Spacing L Z'f lbw 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.) LOCATION: RICHMOND 1.30./18,N/E,SW 1752 144TH STREET ~ Gr~ L:1r(~l ~?/~d t l..Gt~1C F ✓ L r ;r r. 1;~4 r / ~Cwf 14 ~ 7p 5 C' , / c I ~y,A,~ f •s 9~ Plan revision required? ❑ Yes ® No Use other side for additional information. SBD-6710 (R.3/97) Date Inspector's Signature rt ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: SANITARY PERMIT APPLICATION 201eE.Wand ahnllgtonAve sion `VIsconsin 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 v2 x 11 inches in size. S~ (b t • See reverse side for instructions for completing this application State Sanitary Permit Nu ber 29?/6 The information you provide may be used by other government agency programs p Check it revision to pre4ious application [Privacy Law, s. 15.04 (1) (m)). V"'-^ NR R State Plan I.D. Number 1. APPLICATION INFORMATION-PLEASE PRINT ALL`IINF RMATION Property Owne ame IM I&ItAX& Property Location o :Q # C p Sr9V CAM7 N Q14 SU.-)1/4, S T , N, R fir) W Property Owner's Mailing Address Lot Number Block N ber I-Sos City, State Zip C de Phone Number Subdivisi Name or CS~y rber ff~~ -7 \1 5 N ry\ II. TYPE F BUILDING: (check one) ❑ State Owned ❑ Ity Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms Vown of 1 ~Vk• arcel Tax Number(s) III. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apartment/ Condo 1-30. 18-45,5 © a 10 ` I I ! 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_____________TankOnly 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 RSeepage 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 (s . ft.) Proposed (sq. ft.) (Gals/dal/sq. ft.) (Min./inch) Elevation 60® cb 6 Feet Feet VII. TANK Capacity site in gallons Total # of Prefab. Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existing structed Tanks Tanks ❑ Septic Tank or Holding Tank I oiSc~ ~`t QS.a fJ 0-1 El E I [H] Lift Pump Tank /Siphon Chamber ❑ ❑ 1 1:1 VI11. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for' stallation of the onsite sewage system shown on the attached plans. Plumber's Na (Print) tuber's ignat : (No Stamps) /MPRSW No.: Business Phone Number: r- L-1-5- r l to -71 s Plumb er'] Ac dress (Street, City, State, Zip Code): NP- L Ct (0, C? -kl IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue issuing Agent ignature (No Stamps) A roved Surcharge Fee) Approved E] Owner Given Initial I S(~~° j~ 42 • S q-7 Adverse Determination O X X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: SBD•63M IRA 1/96) 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 ata 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; 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. r 1- - 6 ~ 71- Pot) d L~ 97 4 17 It _ i L 7 y ` s . L&u) ~12J'1 PAGE OF rvSS S~r~'1un o~ ~ ~rl~ S~ st~e~ Fr~►A Ali Well, And 0b►6iv0llo4 Pip, Uwmum 12'Abavo ~Approvid Vonl Cap final Gfade 20- t2' Abovo P19p V Coll Ir°e To fnnol Orodo ~Vonl Pipe - IrwrA Nov Of SintMlb Corofln MIA 2 OrofPip$YfaOola Olwrlb~llon ~ . ~Ipa ° ° Too 1 6' AYYropolo 6onaalb Plpo ° Porlwalod Pipe b6lav ' ° Co'0In r' i Twminoliny AI Ballbm 01 $r/lam ' i ~,Icv•.~' l on ~ SOIL FILL DISTItIBUTICIfl PIPE APPROVED ySIMP{CTIC COVCit, 2" OF AGGREGATE OR 9" OF STRAW OR AKSN HAy ELEV. OFFEET IO,~OFIrz-21/i AGGREGATE v '7 IL t -L~ DISTRIBUTIOU PIPE TO BE AT LEA5T C? AUU AT LEAS7L0 IIJCH[S E BUT LIO MORE THAW 42lljCHES BELOW FINAL GKA0r t • i MAXIMU/' DEPr11 OF EXcAVAT1 D" FAOM OR16WAL 6RADa WILL BE 1'UKlMVM pEPT}i 0F EXCAvATImN INCHES RO~t 'DAI61NAL GRAPE WILL BE INCHES SIGLIEO; LIGEIJSC UU/A BE11: ISM -3- 97 DATE : . Ila Wisconsin Qepartment of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3 Labor and Human Relations Division of Safety 8 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 St. Croix not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distanc9 ttQ~aa~ t road. 026-1114-20 APPLICANT INFORMATION-PLEASE P T ALL INk ION R VIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION GOVT. LOT NE 1/4 SW 1/4,S 1 T 30 AR 18 E (or) W Derrick Construction IN . PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # 1505 Hy. #54 1 '997 3 na Willow River Meadows CITY, STATE ZIP C PHOWINLIMF-R ❑CITY ❑VILLAGE []TOWN NEAREST ROAD New Richmond, WI. 5401 (715~a82320 Richmond 144 th. st. [x] New Construction Use (:4 Residen KT' rpber of bedrooms\b 4 ( j Addition to existing building j ] Replacement Public or co rcial describe Code derived daily flow 600 gpd Recommended design loading rate • 7 bed, gpd/ft2 .8 trench, gpolft2 Absorption area required 858 bed, ft2 750 trench, ft2 Maximum design loading rate ___,7 bed, gpd/ft2 .8 trench, gpolft2 Recommended infiltration surface elevation(s) 96.60 ft (as referred to site plan benchmark) Additional design / site considerations na 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 ZS ❑U 7S ❑U ®S ❑U RIS ❑U ❑S ®U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft Boring # Horizon in. Munsell Clu. Sz. Cont. Color Gr. Sz. Sh. Bed Trertcft 1 0-11 10yr3/3 none 1 2msbk mfr gw 2f .5 .6 1 2 11-25 10yr4/4 none sicl lcsbk mfr gw if .2 .3 Ground 3 25-38 7.5yr4/4 none sl 2mgr mvfr gw na .5 .6 elev. 100.4ft 4 38-84 7.5yr4/6 none ms Osg ml na na .7 .8 . Depth to limiting factor +84" Remarks: Boring # 1 10-13 10yr3/2 none 1 2msbk mfr gw 2f 1.5 .6 .......2_ 2 13-30 10yr4/4 none sicl 2msbk mfr gw if .4 .5 3 30-84 7.5yr5/4 none ms osg ml na na .7 .8 Ground elev. 100.3 ft. Depth to limiting factor +84" Remarks: CST Name:--Please Print Gary L. Steel Phone: 715-246-6200 Address: 1554 200 ve. New Richm d W154017 Signature: e. - Date: 11=19--97 CST Number: m02298 PROPERTY OWNER Derrick Cosnt., IncSOIL DESCRIPTION REPORT Page 2 "of 3 ' PARCEL I.D. # 026-1114-20 4 Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourd3y Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 1 0-14 10yr3/3 none 1 2msbk mfr gw 2f .5 .6 2 14-27 10yr4/4 none sicl lcsbk mfr 9w if .2 .3 Ground 3 27-37 7.5yr4/4 none sl lcsbk mfr gw na .5 .6 elev. 100.6ft. 4 37-84 7.5yr4/6 none ms Osg ml na na .7 .8 Depth to limiting factor +84" Remarks: Boring # 1 0-15 10yr3/2 none 1 2msbk mfr gw 2f .5 .6 4 2 15-28 10yr4/4 none dUl lcsbk mfr gw if .2 .3 3 28-48 7.5yr4/4 none S1 2cgr mvfr gw na .5 .6 Ground elev. 4 48-84 7.5yr4/6 none ms Osg ml na na .7 .8 100.6 ft. Depth to limiting factor +84" Remarks: Boring # 1 0-10 10yr3/2 none 1 lcsbk mfr gw 2f .4 .5 5 2 10-24 10yr4/4 none sicl lcsbk mfr gw if .2 .3 3 24-32 10yr5/4 flf 7.5yr4/4 M na gw na np .2 Ground l -ebev6 ft. 4 32-84 7.5yr4/6 none ms Osg ml na na .7 .8 Depth to limiting factor +84" Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) STEEL'S SOIL SERVICE Gary L. Steel 1554 200th Ave. CSTM2298 Derrick Construction, Inc. New Richmond, WI 54017 MPRSW 3254 NE4SW1j S1-T30N-R18W (715) 246-6200 town of Richmond lot #3-Willow River MEadows I N 1"=40' BM.= base of elec. transformer C el. 100, Alt. BM.= top of tel. ped @ el. 101.50' a qO ~L Zd 2n" 3 d ~ ' 80 2+ 4", 7',k `1~4 4~ G°,glbls-x h Gary L. Steel 11-19-97 STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER l ► ~``cS MAILING ADDRESS c.► ry~1: t' 'W r r4., r'-1 PROPERTY ADDRESS (location of septic system) Please obtain from the Planning Dept. CITY/STATE C-" k iv'' &a C> V T PROPERTY LOCATION 1/4, 5W 1/4, Section T N-R W TOWN OF V21 C-iA rti%= N Q ST. CROIX COUNTY, WI SUBDIVISION LN iu. cam.. I?.cy I = = LOT NUMBER 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 ;t 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 ^d scum. [/We, the undersigned have read the above requirements and aorL% to maintain the private sewage disposal system in accordance with the standards set forth, herein. set by the Wisconsin DNR. Certification stating that your septic has been maintained must be comp,-::d and returned to the St. Croix County Zoning Officer within 30 days of the three year a iration data. t SIGNED: DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11193 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. \M P i-l -'o\ f ,G("T \/EH"t-t, 1t Owner of property G,%G M iL+A66tr R-- `_,7'~w=Vlz~l4 S Location of property 1/4 `wV 1/4, Section T "3® N-R 19 W Township Mailing address ~t~° o X A gz:w \441 Address of site 1-15 L i~}4-~t~ ` =Z.v ~lu-rnnoNta P +3 E subdivision name Lot no. Other homes on property? Yes No Previous owner of property Total size of property Total size of parcel 2 14~-~~ Date parcel was created Are all corners and lot lines identifiable? X Yes No Is this property being developed for (spec house) ? A Yes No Volume <~%4 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 in the office of the County Register of Deeds as Document No. '4SZ.`1~--' -1 , 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. Signa ure f Appl' ant Co-Appiica:. l~rL ` `3- v BW)YxRRRR 462'767 GUARDIAN'S DEED REGISTER'S OFFICE This Deed, made between ST. CROIX CO., WI Gertrude E. Schmit by Beverly Buckner,. Guard.i.a Recd for Record 00 2131989 . Grantor, and..-..Michael.-R-.---Stevens.,.,.Will_iam-H•.___Derr•ick,.•.•••-..... at 8.00 A. ~Mn I Can ........-_Wil1.i-am..M ...Derrickhomas..-E-. _•Derr•ick and...... Rona~,d_• L_._.•Derr_ck-_a- tenantsD common I RegTaterofDeeds Grantee, Witnesseth, That the said Grantor, for a valuable consideration...... Gertrude E. Schmi-t by. Beverly Buckner ' nrim rr i r, conveys to Grnntee the following described real estate in r... C.r V.iA . . County, State of Wisconsin: Southeast Quarter of Northwest Quarter and Northeast Quarter of Southwest Quarter of Tax Parcel No: Section 1, Township 30 North, Range 18 West. This deed is given pursuant to the Order to Sell, dated October 16, 1989, and the Confirmation of Agreement and order, dated October 19, 1989, both duly authorized by order of the Court and whereas the undersigned, Beverly Buckner, is authorized to sell the same by Letters of Guardianship certified on October 22, 1989. 't`FtAiv;~F u_x Ym. This i is not homestead property. (is) (is not) - Together with all and singular the hereditaments and appurtenances thereunto belonging; And..... Ger.tr-ude---E.....S.chmit-_-by...Bever.ly...Buckn.er.................................. warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements, restrictions and rights-of-way of record, if any. and will warrant and defend the same. . iv Dated this t'day of _........October.........................................., 1989.... . (SEAL) (SEAL) }4. tyG Gertrude`E. Schmit by Beverly • ...sUo1rner~ ..GUa-rd3•an (SEAL) (SEAL) „ AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN Beverly Buckner as'