HomeMy WebLinkAbout026-1078-70-130
t•. " Fr°n
STC - 104 ~pRp~X
AS BUILT SANITARY SYSTEM REPORT `~V1hG
OWNER ~AR1 ~QK~ ADDRESS a U~
SUBDIVISION / CSM# LOT #
SECTION a-1 T 30 N-RW, Town of PN) CA MU)1 b
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
IS D C. ao.
a as
3S
N~fi~ ; I~I~Nho~1P ) S
OV Pr- OKAfi Ifl~
f o? ~ I~Nc I,P f r
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
f
BENCHMARK:
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer:
Liquid Capacity: ) (J0( :1)
Setback from: Well,,,,,,, House
Other
Pump: Manufacturer
Model#Size
Float seperation
Gallons/cycle: ~
Alarm Location
:SOIL ABSORPTION SYSTEM
Width: Length S
Number of trenches a
Distance & Direction to nearest prop, line: `-7
Setback from: well•OVRR 5U 1 5
~•House 0~ R f- Other
n12vr ~7 ~y - 9757
NO ELEVATIONS
Building Sewer
ST Inlet ; U .U3 ST outlet
PC inlet
PC bottom Pump Off
Header/Manifold
Bottom of system
Existing Grade Sigy°W ,1:0
Final grade 1' ' I~1-Su 95.80
DATE OF INSTALLATION:
PLUMBER ON JOB:
13
LICENSE NUMBER:
INSPECTOR: 'I
3/93:j t
Wisconsin Department 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 284295
Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.:
ALBERT, DANIEL AND BRENDA RICHMOND
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
026-1078-70-130
TANK INFORMATION ELEVATION DATA to <.3p 19
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark w,& led, &~J,
Dosing
Aeration Bldg. Sewer
Holding St1W Inlet /U
TANK SETBACK INFORMATION St/ l~f Outlet
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom
z,z9
Dosing NA Headed---
Aeration NA Dist. Pipe
d-e
Holding Bot. System /3 y 3
PUMP/ SIPHON INFORMATION Final Grade
Man Demand Z
A e a ~ 4-7,.
Model Number GPM
TDH Lift Lriction 5vste Ft
ead
Forcemain Length Dia. H Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT Pits Inside Dia epth
DIMENSIONS DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE /STREAM LEACHI u acturer:
SETBACK CHA BER
INFORMATION TypeO Model Numer:
System: >Sb ' 1 OR UNIT
DISTRIBUTION SYSTEM
Header /f#twT fofd- Distribution Pipe(s) H i x Hole Spacing Vent To Air Intake
Length Dia Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Gra ystems 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..27.30.18W,NW,NW 140TH AVE LOT 3
~Cs~ cy~•)Ccy~n u f L)a C.0
Plan revision required? ❑ Yes ❑ 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: '
Safety and Buildings Division
SANITARY PERMIT APPLICATION Bureau of Building ater 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
than 8 112 x 11 inches in size.
C~.O
• See reverse side for instructions for completing this application State Sanitary Permit Number
a ¢1g9s'-~
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
Pr erty Owner Name Property Location
X01/4 W1/4,S,)7 T 30 ,N,R to E(or)W
Property Owner's Mailing Addrjass Lot Number Block Number
f ve
Cit , Sta ''j Zip Code Phone Number Subdivisi0 N e or CSM tuber
II. TYPE F BUILDING: (check one) E] State Owned ❑ fit( J~' Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms -3 Town OF 6NV /a 0+l)
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 Apartment/ Condo (Z) 07P 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. ISa New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5_ ❑ 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
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 Weepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 43 ❑ Vault Privy
14E] System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. Syjjrq elev. 7. Final Grade
Required sq. ft.) Proposed (sq. ft.) (Gals/da /sq. ft.) (Minnch) 14 dd Evatio
S, 0 ~P a 9-7, ~ 0 Feet 1 a e'a~Feet
VII. TANK Capacity
in gallons Total # of r Prefab. Site Fiber- Ex er.
INFORMATION New Existing Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic Appstructed
Tanks Tanks
Septic Tank or Holding Tank 1000 ❑ ❑ ❑ ❑ ❑
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 Name: (Print) Plumber's Signa rec o Stamps) 7/MPRSW No.: Business Phone Number:
u n _~v 3D 1S~ -90a0
Plumb is Address Street, CJiY State, Zip Code): '•l
1 ~70 W ath OIJ W.J . ~I
IX. COUNTY / DIEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issue Issuing Agent Signature (No Stamps)
Surcharge fee)
Approved ❑ Owner Given Initial
Adverse Determination /C I _ /49
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SOD-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 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.
I1. 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.
P. B.L- 67 PLOTA 1111
I-ROSS S
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ci;Oss SECTION
npprDved Vent Cap
Hinimurn 12" Above
Final r,tl~______• ~U3 5 V
Ufa" lh 14 x
Above Pipe ; Cast Iron
To Final nr.nArv- Ve1 l Pipe
r
STEEL'S SOIL SERVICE
ry L. Steel 1554 200th Ave.
STM2298 Richard W. Hopkins New Richmond, WI 54017
NWkNW4 s27-T30N-R18w, (715) 246-6200
PRSW 3254
town of Richmond
lot #3
110=40,
-4- Aue,
I BM.~ top of SE lot stake 0 el. 100'
(i
r ~
Aot
10° N
off`' .
I
100%t 3t01 . l~
Garb .:Steel
12-15-95
Labor and Human Relations a v I L h 11 u 71 1 C C V A L U A I I U N K t: N U H I Page Of
oivisionotsafety 8 9uildngs in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 81/2 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 distance to aid. pending
APPLICANT INFORMATION-PLEASE PR N REVIEWED BY OATS
PROPERTY OWNER: °ROPERTY LOCATION
(0y LOT 114 1I4,S 27 T 30 N,R 18 (or) W
PROPERTY OWNERS MAKING ADDRESS ~ 14T # BLOCK # SUBD. NAME OR CSM #
1369 120 th. St. j -1
na csm pending
CITY, STATE ZIP C BER , r ❑VILIAGE MOWN NEAREST ROAD
New Richmond, WI. 54017 1r ~45-59 Richmond 120th. st.
[ New Construction Use [x] Residential "ul ",olt `3
j ] Replacement Public or comma 6 Adctitiort ~ existing building
Code derived daily now 450 gpd Recommended design loading rate • 7 bed, gpd/ft2 - 8 trench, gpd/ft2
Absorption area required 643 bed, ft2 563 trench, R2 Matdmum design baling rate • 7 bed, gpd/ t2 •8 trench, g XVII2
Recommended infiltration surface elevation(s) 98.10 f< (as referred to site plan benchmark)
Additional design / site considerations trenches @ 99.201--97.601--97.101--95.80, if used
Parent material stream terrace Flood plain etevation, if applicable na It
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL
HOLDING TANK
U=Unsuitable for system DU faS OU ®S OU fR S DU DS tgU 13S laU
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistertoe Boundary Roots GPD/ft
in. Munsell OU. Sz. Cast Color Gr. Sz. Sh. Bed tactic
4.v4.}n
1 1 0-9 10 r4 3 none 1 1 2msbk.-... mfr LAZ- -if .5 -6
2 9-23 10yr4/4 none sicl lfsbk mfr gw if .2 .3
Ground 3 23-40 7.5yr4/4 none sl lmsbk mfr gw na .4 .5
102.4 IL 4 40-90 7.5yr4/6 none co s Osg ml na na .7 ;.8
Depth to
limiting
factor
*90„
i
Remarks:
Boring #
1 -9 10yr3/3 none 1 2msbk mfr w if .5 .6
2 2 9-18 10yr4/4 none sicl 2msbk mfr gw if .5 .6
3 18-36 7.5yr4/4 none sl 2mgr mvfr gw na .5 .6
Ground
10 2ft 4 36-55 7.5yr4/6 none is Osg mvfr gw na .7 `.8
5 55-86 7.5yr4/6 none co s Osg ml na na .7 .8
Depth ID
limiting
factor
+8611
Remarks:
CST Name:-Please Print Gary L. Steel Phone: 715-246-6200
Address: 1 200t Aye, /kew 12-15-95
Richmond WI. ;4097 Signaw Date: CST Number.
PROPERTYOWNER Richard W. Hopkins SOIL DESCRIPTION REPORT 2 3
Page r_ of
PARCEL I.D.E pending
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bw-d y Roots GPD/ft
in. Munsell Qu. Sz. Coat, Color Gr. Sz. Sh. Bed ITrmndh
1 0-9 10yr3/3 none 1 2msbk mfr gw 2f .5 i.
3
2 -22 10yr4/4 none sicl lfsbk mfr gw if, .2 .3
Ground 3 22-36 7.5yr4/4 none sl lmsbk mfr Crw na .4 .5
100.61t 4 36-86 7.5yr4/6 none co s Osg ml na na .7 .8
Depth to
limiling
facbr
+86"
Remarks:
Boring #
1 0-8 10yr4/3 none 1 2msbk mfr gw if 1.5 .6
:.n
4 2 8-15 10yr4/4 none sici lfsbk mfr gw if .2 .3
v 3 15-24 7.5yr4/4 none sl 2mgr mvfr gw na .5 .6
Gmund
4 24-8q 7.5yr4/6 none co s Osg ml na na .7 .8
elev. 99.7 ft
Depth ID
IlMng
factor
+8411
Remarks:
Boring # 1 0-8 10yr3/3 none 1 2msbk mfr
gw 2f .5 .6
51 2 8-16 10yr4/4 none sici lfsbk mfr gw if .2 ~.3
y
3 16-26 7.5yr4/4 none sl 2msbk mfr gw na .5 `.6
eleN. 4 26-80 7.5ry4/6 none co s Osg ml na na .7 .8
G
980 ft
Depth to
uniting
fRCtor T-1
Remarks:
Boring #
YrK
<X
Ground
elev.
ft f
Ito.
limiting
factor
F-T-
Remarks:
STEEL'S SOIL SERVICE
Gary L. Steel 1554 200th Ave.
CSTM2298 Richard W. Hopkins New Richmond, WI 54017
MPRSW 3254 NW4NW4 S27-T30N-R18w (715) 246-6200
town of Richmond
lot #3
N
111=401
BM.= top of SE lot stake @ el. 100,
0
100 N
a psi
Lel
40 .
5,
Gary Steel
12-15-95
1
FILED
9 MAR 4 1996 12
KATHLEEN H. WALSH
SLgCrolx Co.Wj
540396
CER T I F-1-ED UP VE Y MA P
Located in the Northwest quarter of the Northwest quarter of Section 27,
Township 30 North, Range 18 West, Town of Richmond, St.Croix County,
Owned by: Richard Hopkins Wisconsin.
1369 120th
New Richmond, Wi.
LOT_2_OF CERTIFIED SURVEY
I ! LVIAP IN YOL_ 8 LPG. 2207E
133' 33r-•,." R X ED
I S 00018'020E 495.00'
I 33.11 461.89 , n ,
I 01 50
I N °I T X C '.JtjTy
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zl I CO co Including right-of-way. R Q I
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CHOR = N67 17'30"E \ SETBACK LINES /O/ w
226.67' in
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S T C W5
SEP'T'IC'T'ANK MAIN E,,NANCE. AGRE'EME.NT
St. Croix County
O~'1'N1:It/►3t,Y1?IZ ..,_~./mil /~D
MAILING ADDRESS _-ILL_-~Qm P"r St-L~
/ /nom
PROPERTY ADDRESS IAO
(locatiorof septic sys(cm) Please obtain from the Planning; Dept.
CITY/S'T'A'T'E,
1'ROPEIR T'Y LOCA'T'ION _ 1/4, 1/4, Section T 3(~ N'Il
I'ONN'N 01' {~pnA ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
CERTIFIEDSURVEY MAP VOLUME, PAGT? _ DOl' NUM13I R
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.
'llrc properly 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 systcm 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
/We, tits undersigned have read the above requirements and ag;rcc to maintain the private sewage
disposal systcm in accordance with the standards set forth, herein, as sct by the Wisconsin Wit
Cerlification statinE; that your septic has been maintained must he compleled m►d retunted to the St Croix
County Loning; Officer within 30 days of the three year expiration date
S1c;NH I Er" f CJ
Dnl l . 4s~' 7
tit Cloys l aunty l.oning; t lllirr
l iovenuncnt ('c•nlc•r
1101 t'cnrntch.n•1 Ito;rd
Ilndson. \\'I V1016 ll/43
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 ~DaAJiP_l _ re da s5.. 4,lbepf
Location `oaf prope.rty_A)U) 1/4~ 1/4, Section ,,2~_, TAN-R _ _W
Township
address
Ajq
' d s s o e _`v C~ 1 /'I1 t )Qy e. A)e Lu r' S~OC
Subd i vision name V~ Lot no. RIP,
IJ
Other- homes on property? Yes ,,,,_No
Previous owner of property ^ j _
Total size of property ~o, adL
Total size of parcel _
Date parcel was created
Are all corners and lot lines identifiable? ~_Yes No
Is this property being developed for (spec house) ? Yes _X_No
Volume and Page Number 31654 as recorded with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRAV.PY 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. and • that I (we) presently
own the proposed site for the sewage disposal system ors~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 o.£ Deeds as Document No.
S' nature AfAp~plic~ant Co-Applicant A
Pitt, of i Gnat ure Date of Signature
i
545907 STATE BAR OF WISCONSIN FORM 2 - 1982
i _„yVARRAppNTY DEED y `
DOCUMENT NO. VOL 1106PAG.364
F ER'S OFFICE
Richard W. Hopkins and Wanda D. Hopkins, OIX CTl(., WI
husband an wi e, edforRecord
25 1996
conveys and warrants to Daniel W. Albert and Brenda S. 11.00 A.M
Albert, husband and wife, •R G~.3eN.
Register of Deeds
THIS SPACE RESERVED FOR RECORDING DATA
NAME AND RETURN ADDRESS
the following described real estate in St. Croix County,
State of Wisconsin: A IS ~ / , rem ~ . I A
PARCEL IDENTIFICATION NUMBER
Part of NWT of NWk of Section 27-30-18 described as follows: Lot 3 of
Certified Survey Map filed March 4, 1996, in Vol. 11, page 3067, as Doc.
No. 540396.
$22LER
This is not homestead property.
(is not)
Exception to warranties: Easements, restrictions and rights-of-way of record, if any.
Dated this 14th day of June , A.D., 19 96
i
r (SEAL)
(SEAL)
Richard W. opkins Wanda D. Ho kins
(SEAL) (SEAL)
*
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) State of Wisconsin,.
St. Croix SS.
.qt - crni x Countv.