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HomeMy WebLinkAbout026-1022-60-000 r STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ADDRESS 1210 SUBDIVISION / CSM# / LOT # f SECTION Ca T~ N-R~~W, Town of Gf7fj~~~?4` / ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM v r` 34 y ►a ~ v i INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. ti R I la ,7 ~G. /,~V Z GI Iii' 75- Ile / rl'1 le ~p ~ro 1, r~172i. Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor ztnd Human Relations S Safety ty and Buildings Division INSPECTION REPORT ST. CROIX (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 284307 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: STEPHENS, MARK & LORI RICHMOND CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: /C/0, G~ S G!s 026-1022-60-000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic S 2) Benchmark 1- 1 _D 5/p' Uv. Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic so, NA Dt Bottom /g9 Dosing NA Header/_Dhw:t-" (A g'jp 3' p9" Aeration Dist. Pipe 6,19' 7~ Holding Bot. System PUMP / SIPHON INFORMATION Final Grade i Man Demand Model Number GPM TDH Lift Friction System TDH Ft mead Forcemai n Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width / Length No. Of Drenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSION oZ / DIMEN I N SYSTEM TO P / L BLDG WELL LAKE / STREAM LEAC anu adurer. ham, SETBACK MBER INFORMATION Type O Mode Number: System: ~ oO/T. OR UNIT DISTRIBUTION SYSTEM Header / IVIAP.4~ Distribution Pipec((ss) Hole Size x Hole Spacing Vent To Air Intake Length _L' Dia. Length / Dia. Spacing w SOIL COVER x Pressure Systems Only xx Mound Or A - de Systems On y Depth Over Depth Over (i1 xx Depth xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges To i ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) owa"o, LOCATION: RI MOND 6.30 18. A,SE,SW 9 TH TREET LOT 4~k, .fro - 'Jl Plan revision required? ❑ Yes 01-No Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: - t Safety and Buildings Division SANITARY PERMIT APPLICATION Bureau 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 t than 8 112 x 11 inches in size. Gr^o~ • See reverse side for instructions for completing this application State Sanitary Perrylit Number 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)]. 967 .f a State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Owner Name - Property Location O/"/ =/4 1/4, S T , N, R/5 Propert~ Owner's mailing Address of Number Block Number Ci , Statt , Zip Code Phone Number Subdivision Name or CSM Number 3031 6 II. TYPE F BUILDING: (c eck one) ❑ State Owned El Ity earPS1 Road Public 1 or 2 Family Dwelling - No. of bedrooms Vown of III. BUILDING SE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/Condo 10. is. gaA 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.eplacement 3. E] Replacement of 4, E] Reconnection of 5. E] Repair of an System 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) Non-Pressurized Distribution Pressurized Distribution Experimental Other 1 1~eepage 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.) Proposed (s q. ft.) (Gals/day/sq. ft-) (Min./inch) Elevation -e-v -45'` j ~l Feet ;s- Feet VII. TANK Capacity Total # of Prefab. Site Fiber- Exper INFORMATION In g Gallons Tanks manufacturer's Name Concrete Con- steel glass Plastic App New Existing strutted Tanks Tanks Septic Tank or Holding Tank [I ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ F1 E] 1:1 ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plum is Name: (Print) Plumb ' ignature: (No Stamps) MP/MPRSW No.: Business Phone Number: /'o /'7 w ! l Plu er's Address (Street, City, State, Zip Code): 173.1o, 42 45 100~ -e '0-'CW- IX. C UNTY / DEPARTMENT USE ONLY ❑ Disapproved San tary Permit Fee (Includes Groundwater Date Issue Issuing Age t Signa r (No amps Surcharge Fee) Approved ❑ Owner Given Initial /p 1? 9 Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SRD-6398 (R. 05/94) DISTRIBUTION: original to County, One copy To: Safety & Buildings Division, Owner, Plumber t 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 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 rrionitoring groundwater contamination investigations and establishment of standards. 217 PROJECT Gt/"e ~ 5 ADDRESS ®`~clll~no j~~14 j~ 1/4/S /T N/R/IKW TOWN " COUNTY rolc "MPRS 'Byron Bird Jr. 3?8 DATE - BEDROOM CLASS PERC CO NTIONAJ,~I 7- ~N- ROUND PRESSURE CONVENTI NAL LIFT MOUND HOLDING TANK SEPTIC TANK SIZE LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE ABSORPTION AREA " PERC RATE' BED SIZE X~~ Benchmark V.R.P. Assu e. Elevation 100' - Location of Benchmark * H.R.P. 0 Borehole Q Well Scale Feet 0 Perc Hole System Elevation 1 Uent 1'2• TYPAR COVERING 2" 12' 3- 6.1 31 6 , Sewer Rock l 12 s WiscOn'sin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page of Bureau of Integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # 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 f'` to Govt. Lot.S~ 114S~ 1/4,S T'%V N,R E (ooD Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# tom? S~ 7 5:51 city tate Zip Code Phone Number ❑ City ❑ Vil~la'ge P? T Nearest Road lw Cr O/ /din v S 5 S New Construction Use: Residential / Number of bedrooms Addition to existing building Replacement L_J Public or commercial - Describe: Code derived daily flow gpd Recommended design loading rate ;7 bed, gpd/fF a trench, gpdfft2 Absorption area required r bed, ft2 C~ trench, ft2 Maximum design loading rate =bed, gpd/ft2_,_'~Ltrench, gpd/ft2 Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design/site considerations L Parent material Flood plain elevation, if applicable S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank U = Unsuitable for systeml 51 S❑ U S❑ u Os ❑ u ID'S ❑ U ❑ s JR u ❑ s U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/f12 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Ground elev. f~ft. Depth to limiting factor ~!?Z' in. Remarks: Boring # G p r c- ¢ sn 100, El 14 lo, Ground elev. De~to limiting factor in. Remarks: CST Name (Please Print) r Signature Telephone No. Gil ~j^G '*7- Addrpwe6 Date CST Number -oo PROPERTY OWNER OiL DESCRIPTION REPORT Page of. PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench E-W Ground ft. Depth to limiting fact r in. 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 # ; L Ground elev. ft. Depth to limiting factor in. Remarks: Boring # 13 Ground elev. ft. Depth to limiting factor 'n. Remarks: SBD-8330 (R. 07/96) ~ f /~~G~v` G~ c.~iind~~ 7 G%! i Gym ~y~T-~`-~ .~j~ limo .>c G© . 0 ~T ~141 0 40o C 0 rd 6 r ~I ~a ev ° ~cH G -cam ~ efi z c .P ~ 53'788. a ~ FILED CERTIFIED SURVEY MAP DEC z a 1995 ► MTALEEN WAM Located in Part of the Southeast Quarter of the Southwest Quarter Section 6, PSAU 01 Township 30 North, Range 18 West, Town of Richmond, St. Croix County, Wisconsin!" NORTH 1/4 CORNER SEC. 6 (TO BE RECORDED) r Owner : Mary Norman 'a D Prepared for and at the request of o Gary Baillar eon cV 00 Century 21 Premier Group UNPLATTED LANDS \ 2 3 'I1 1237 North Knowles Avenue - - - - - - - - - - - - - - - - I I : \1 New Richmond, WI 54017 I 355.97' Drafted by. James M. Brault N 87'53'07" E \ \ I } _ r la;x-X-_322.97 sis X °ri % '1;g Ind x -fio x '~a F 1 X\ I M i is I:.> t :s 'crtmittee \ _ DCU6_Aa..1• ' TOTAL AREA x co ZAHLER , ; , 287, 559 sq. ft. 3 j6.60 acres I I 0 days of o U) if date shall be 00 AREA EXCLUDING R. 0. W. I r n 9. 0 w N 250,028 sq. ft. SEPTIC AREA Z z I 5.74 acres Ir- Qi I w J I WELL- -G uWi: W F z I o: 33' 33' I J C) SHED::. ' LLJ r-) U H I W I I \ z o QI I w = J Iwi Z I 0 SHED; Z I Q ~ w i SILO J I W I c°n I Q Z 0 I SHED I C p I W C5 0) NO TH _ :SHED::: I I N I p z W :2 co N cn I o < LO m o Q Co 00 ° I W N I I 01 GRAPHIC SCALE r 0 25 50 100 150 200 1 LOT 1 I ° I o 1 I M ZI LO < 00 I I I ( IN FEET) J I 1 inch 100 ft. r I F-~I I C II j N I I WI II J1 I f -r- 100.00' I I a I LEGEND Z SETBACK I ~iI ~ I County Section Corner Monument I °a II of Record (Aluminum Monument) ' 00 1 • Set 1" x 24" Iron Pipe weighing SETBACK LINE - o toll a minimum of 1.13 pounds per linear foot. O Set Railroad Spike • • • • • • • 66' R.O.W. 33' 33' -x- Denotes Fence ' I \ I I -100' SETBACK b rl 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 Location of property Si 1/4 C 1/4,Section W Township ( EMailing address 17 24 qs !52Z Address of site Subdivision name -123/ Lot no. Other homes on property? Yes No Previous owner of property _ H y J)I6rj-14- rz Total size of property . Total size of parcel i Date parcel was created -7 Are all corners and lot lines identifiable? _ Yes No Is this property being developed for (spec house) ? Yes _,2!~_No Volume Ste' and Page Number _5~ 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 t office of the County Register of Deeds as Document No. S 3~, 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 Co-Applicant /,S- 9 7 Date of Signature Date of Signature r STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County Q rK Lt)r 3efJhen S OWNER/BUYER MAII,ING ADDRESS ~7 q 54 h 3'4 r (f e-4 PROPERTY ADDRESS ~ "71 Q S 4h of e e-F (location of septic system) Please obtain from the Planning Dept. CITY/STATE /V 2. u) ei d- A m o n d( 0-T 5140 1-7 PROPERTY LOCATION 114, 1/4, Section , T~N-R ST. CROIX COUNTY, WI TOWN OF SUBDIVISION >T `7 , LOT NUMBER CERTIFIED SURVEY MAP , VOLUME 1 , PAGE 3a 3 , LOT NUM 3ER 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 plun#~!i-,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 mus completed and returned to the St. Croix County Zoning Officer within 30 days of the three year tion datne. SIGNED: DATE: `7 6 5 g St. Croix County Zoning Office Government Center 1101 Carmichael Road 11/93 Hudson, WI 54016 vAv -)OA State Hal A Wic,,,n.in 1 I,rm 1 1782 NVAItKAN'TI DEED DOCUMENT NO I (()Lt1,~8PAi1 ry G. Norman, f/k/~ Vary ?.ot: ri^~, JAN 1 7 1996 n single ner-.nn,- - - 1:45 P. Ll % con,rks and ,warrants to nrk A. Ste-hens and ' orrpi-rte C. i, „t~~.)hens tus,I.-ind ands Trlfe, ScACE rrE SE RV F.D r'1n RECOrr p'N . oAtA _ . MANE A,•n HETlIr1N ADnnESS , - is BANK OF NEW RICHMOND - - - - 5 SOUTH KIvOWLES AVENUE 35 the following described real estate in St. Croix Countv, State of Wisconsin: - t NEW RICHMOND WI 54017 - ,I (Parcel :deatification Number)- - Lot i of Certified Survey ?tap fiiec? in Vollne 11 of Cert'_`lF~' SI-Irvey on i Page 031 as Doclunif-rt No. 537881, being ,.art of the So._theasr 1/4 of t'-v` S rout`v ost C,70 1/4 of Section e, oc:•nship 30 Z4ort.h, ?an-e 18 .est, -o,:.+► Of :?ica~lond., o~`r County, `disconsin. i w, ;1 T AHSFER ~i ll l 7his_ _-_-ls homestead property. II Ii (IS) II ( i Exception in warranties: S,-aSerlEntS, "r°StiCt10:IS and riziltS-Of-Way Of record, if ''11V. i' ! h q ~I _ - - J?I:u - - Dated this 3rd day of ary- 19 . I' m (SEAL) - (SEAL) ,I i' G 'Norman, f/k/a Mary G. Roterin - (SEAL) (SEAL) - ff ~ ~ ~j II AUTHENTICATION ACKNOWLEDGMENT STATE OF WISCONSIN I' Signature(s) - - - - St. CrOiX Countv. 19 Personally ome before me this - 3rd day of i authenticated this day of - - - - - - --JeZuary- - - , 19910 _ the above named - - - Mary G. 'lor-i-:3nz a sin). a :er , - - t