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HomeMy WebLinkAbout026-1080-10-100 STC - 104 i AS BUILT SANITARY SYSTEM REPORT 1997 rrri i` OWNER o Y.`.✓ Y C' YY~`G' re ADDRESS 2 SUBDIVISION / CSM# LOT # SECTION T N-R W, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM lJsr v~ 4a x ~v J I. INDICATE NORTH ARR W Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. i BENCHMARK : S'm fy,. S % l ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer:i,,~' Liquid Capacity: Setback from: Well 37V ~ House Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: S Length,04:~1&1 Number of trenches :~2- Distance & Direction to nearest prop. line: Setback from: well: House 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: LICENSE NUMBER: INSPECTOR: 3/93:jt Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Label?,and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division _ (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 284254 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: DERRIK LOREN RICHMOND CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 1d.; ?f 026-1080-10-000 TANK INFORMATION ELEVATION DATA A9700010 16197 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic sfrrt Cc ~.t ? / Benchmark Dos 3.16 ' 99 70' Aeration Bldg. Sewer y/ ~(P y~ f Holdin St/ Inlet 9 791 TANK SETBACK INFORMATION St/ Outlet 77~ ' Vent TANK TO P/ L WELL BLDG. Airito ntake ROAD Dt Inlet Septic >a as NA Dt Bottom Dosing NA Header/Man. 97, 685',5 QG,45' 6 Aeration NA Dist. Pipe Hold' Bot. System (a ~ S. / PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand p (off' Model Number GPM TDH Lift Lriction System TDH Ft For main Length Dia. H Dist. To Well SOIL ABSORPTION SYSTEM BED /TRENCH Widths / I Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMEN 1 SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING acturer: SETBACK CHAMBf INFORMATION Type O rr t,, i , Model Number: System:Cc,-Ll.4/_-4 /Q d, S t~ OR UNIT DISTRIBUTION SYSTEM Header / chi. IVWws4eld /r Distribution Pipe(s) / x Hole Size x Hole Spacing Vent To Air Intake Length Dia_ Length Dia. Spacing _LA SOIL COVER x Pressure Systems Only xx Mound Or ade Systems On y Depth Over Depth Over xx Dept xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges To i ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) au.;,A ilavkfsll~ LOCATION: RICHMOND 27.30.18.423.SE.SE 130TH AVENUE, fr7 y: %'1+ /_/P j ,,.'-u',,,. i ,t F /t1' ..Er^ Plan revision required? ❑ Yes No Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert No. s ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: Safety and ButIdin s Division SANITARY PERMIT APPLICATION Bureu 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 8 112 x 11 inches in size. Cm! • See reverse side for instructions for completing this application State Sanitary Permit Number The information you provide may be used by other government agency programs ❑ Check it 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 1/4, S,4 fBlockNum , N, RE (or)0 Property Owner's Mai ing Address Lot Number b er City, State Zip Code Phone Number Subdivision Name or CSM Number Ale- IJ /9412A A115 J1_1 11:~"11KO/Z (7rj^)r? G 9-9?5' II. TYPE F BUILDING: (check one) ❑ State Owned ita~ Nearest Road p VII ge Public 1 or 2 Family Dwelling - No. of bedrooms Town of Ill. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 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. NL New 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 & rSeepage 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 (sq. ft.) (Gals/day/sq. ft.) (Min./inch) lQ 4/, 7 Elev tion ~el e CL Feet / Feet VII. TANK Capacity in gallons Total # of Prefab. Site Fiber- Ex per. INFORMATION New Existin Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App strutted Tanks Tanks Septic Tank or Holding Tank a ~Q _ i, a° r y~ f K El ❑ El El El Lift Pump Tank /Siphon Chamber El F1 ❑ ❑ ❑ ❑ 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 Signature: (No 5 a s) P PRSW NO.: Business Phone Number: 02 sxg - -1 4Z Plumber's Address (Street, City, State, Zip Code): / 4 70 51C 0 -n;" -lot? lot IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issue ssuing A nt Sign ture (No mp ~L~,/~~ Surcharge Pee) / A pp ❑ roved Owner Given Initial a Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SOD-6398 (R. 05194) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS a. 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. 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. 11. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family'Dwelling. Ill. 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. L. 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 phor)e 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. -------------------------------------------------7-------------------------------------------------- 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. o q-:e ,~I er-~'%~ '~~1 S d? ~ T.~ l 4l G~J~v Olt ~ `C`i Yn o..~el o v u N 3 Gb o .t Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3 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 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 nearest road. 026-1080-10 APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION Loren Derrick GOVT. LOT S E 1/4 S E 1/4,S 2 7 T 3 0 AR 18 Ekr) W PROPERTY OWNERS MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # 1310 H 65 na na na CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE [MOWN NEAREST ROAD New Richmond, WI. 54017 (715 246-5425 Richmond 130th. ave. :k:k New Construction Use Residential / Number of bedrooms ~4 [ ] Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow 1600 gpd Recommended design loading rate . 5 bed, gpd/ft2 .6 trench, gpd/ft2 Absorption area required 1260 bed, ft2 1006 trench, ft2 Maximum desig.00q rate . 5 bed, gpd/ft2 .6 trench, gpd/ft2 Recommended infiltration surface elevation(s) 104. 7 & - -10 3o h (as referred to site plan benchmark) Additional design / site considerations alt. area= 101 .6 5 ' Parent material pitted glacial d i r f t Flood plain elevation, if applicable n a ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable for s stem 121 S ❑ U E3 S ❑ U [as ❑ U ® S ❑ U ❑ S ®U ❑ S [211 SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 1 1 0-11 10 r3/3 none 1 2msbk mfr gw if .5 .6 2 11-23 10 r4 4 none sicl 2msbk mfr gw if .4 .5 Ground 3 23-44 7.5 r5/4 none fs osg mvfr gw na .5 .6 elev. 108 it.5 4 44-84 7.5 r5/4 none sl 2msbk mfr na na .5 .6 Depth to limiting factor +84" Remarks: Boring # 1 0-10 10yr3/3 none 1 2msbk mfr gw if .5 .6 2 2 10-29 10yr4/4 none sicl 2msbk mfr 9w if .4 .5 Ground 3 29-66 7.5 r5/4 none fs osg mvfr 9w na .5 .6 elev. 4 66-84 7.5 r4/4 none sbk mfr na na .5 .6 108.2 ft. Depth to limiting factor +84" 1 S` ras Remarks: CST Name:--Please Print Gary L. Steel P : 715-246-6200 Address: 1554 200th. Ave., New R' hmo d WI 54017 Signature: Date: 11-1-96 CST Number: m02298 PROPERTY OWNER Loren Derrick SOIL DESCRIPTION REPORT Page 2 ofx PARCEL I.D. # 026-1080-10 - 4 Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft Boring # Horizon in Munsell Ou. Sz. Cont Color Gr. Sz. Sh. Bed Trend `ti...3.... 1 0-14 10 r3 3 none 1 2 114-31,10yr4/4 none sicl 2msbk mfr crw if .4 .5 Ground 3 31-52 7.5 r5 4 none f fr 9w .5 -6 elev. 104.9ft. 4 52-84 .5 r5/4 none ms os mvfr na na .7 .8 Depth to limiting f+c Remarks: Boring # 1 -15 10yr3/3 none 1 2msbk mfr Crw .5 .6 4 2 115-36 .5 r4/4 none sicl 2msbk mfr if .4 .5 3 k6-78 .5yr5/4 none fs os mvfr 9w na .5 .6 Ground elev. 4 68-84 r4/4 none scl 2msbk mfr na na .4 .5 104.8ft. Depth to limiting factor +84" Remarks: Boring # if .5 .6 1 -13 0 r3 3 none 1 2msbk mfr Crw 2 13-29 .5 r4/4 none sicl 2msbk mvfr if .4 .5 3 9-69 .5 r5/4 none fs os mvfr 9w if .5 ':.6 Ground elev. 4 9-80 r4 4 none scl 2msbk mfr na na .4 .5 104.4ft. Depth to limiting factor +80" Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) r STEEL'S SOIL SERVICE Gary L. Steel Loren Derrick 1554 200th Ave. CSTM2298 SE 4SE a S27-T30N-R18w New Richmond, WI 54017 MPRSW 3254 town of Richmond (715) 246-6200 r N 111=401 BM= top of tel. ped @ el. 100' Alt. BM.= top of 1211 pvc pipe @102.801 s 90 tr) t Gary L. Steel 11-1-96 STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER t ogI of4'9 &-n~ CG MAILING ADDRESS / 10 9W COS f c`v I'CtC4*A40"_0 EV6177 PROPERTY ADDRESS oZ Sr $ 1-3© v+ 4~s, . 1 YkW le 44M,0 A Q Y-f (location of septic system) Please obtain from the Planning Dept. CITY/STATE PROPERTY LOCATION 5c 1/4, S4E- 1/4, Section ""Z 7 , T 30 N-R g W TOWN OF N ST. CROIX COUNTY, WI SUBDIVISION 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 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 St. Cro~xJ~ County Zoning Officer within 30 days of the three year a piration date] / u SIGNED: DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 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 LoP,467;j ~ 6 4C-AJj4, le, Location of property SE 1/4 5G 1/4, Section 'Z , T 0 ~"N-R le W Township /C!t/K~oi4o Mailing address /31o /4wvy (os , &-Uj IC-44 040 &W at .5 VOi-7 Addressof site /,RS'$ ~30Tlf AVE,, 'Lyf 4'/ CH A4 0 &193 Subdivision name Lot no. Other homes on property? Yes No Previous owner of property L SC)M %~'L lCl-6 Total size of property Total size of parcel VO /4clLc'S Date parcel was created Are all corners and lot lines identifiable? X Yes No Is this property being developed for (spec house) ? Yes No Volume jWdu 3'And Page Numbercv3.1g 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. s3 a o i() a, , 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. nature f Applicant Co-Applicant J--/3-~7 -21-3-17 Date of Signature Date of Signature + DOCUMENT NO. STATE BAR OF WISCONSIN- FORM 2 c J(t~( WARRANTY DEED 320102 eoolc 507 PA~i: 2H THIS SPACE RESERVED FOR RECORDING DATA R • j REGISTERS OFFICE BY THIS DEED, Erna Miller, Special Administrator of the Estate of Wanda Sommerfeld, ST. CROIX CO.. WIS. II 1 Recd for Record this-_2th day of_ 44PRzry_--A.D.19 Z4 II Grantor conveys and warrants to Loren D. Derrick and Rose H. Derrick, husband and wife, et___1+9- P. h1. _ - Registz,r of ;,eeds Grantee- for a valuable consideration One Dullar and other valuable RETURN TO L.R. REINSTF& consideration 127 W. 2nd Street the following described real estate in ST. CROIX County, State of Wisconsin: New Richmond, WI Tax Key # This is not homestead property. The Southeast One-Quarter (SE 1/4) of Section 27, Township 30, Range 18. FEE EXEMPT This deed is given in satisfaction of a land contract between Carl Sommerfeld and Wanda Sommerfeld and Loren D. Derrick and Rose H. Derrick, dated September 6, 1957, recorded September 12, 1957, in Volume 344 of Deeds, Pages 327 & 328, Document No. 251853 in the St. Croix County Register of Deeds Office. Exception to warranties: Executed at New Richmond, Wisconsin this 31St day of December 19 73 (SEAL) SIGNED AND SEALED IN PRESENCE OF + /L ~ 4'1/4-4 Erna Miller, Special Administrator of the Estate of Wanda Sommerfeld (SEAL) (SEAL) (SEAL) Signatures of Erna Miller, special administrator of the Estate of Wanda Sommerfeld, authenticated this 31St day of December 19 7 wm w. Ward Title: Member State Bar of Wisconsin ar :RerlY 4t~t#FcRzFg~tirt8~f~~d~Q6~