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HomeMy WebLinkAbout030-1010-60-000 r STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER C'2)V'- Z-dV-e- ADDRESS SUBDIVISION / CSM# LOT # SECTION T -27 N-R Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM or f~ks c INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. s BENCHMARK: Sa `r+ c~ y / / S ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: /fop Setback from: Well S-4 ;c House Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: f Length -'-If Number of trenches f Distance & Direction to nearest prop. line: S-4 Setback from: well: 404' House yo ` 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: <Z//tf PLUMBER ON JOB: iy`rr'~ ~y~r---- LICENSE NUMBER: ~'a7>Yd INSPECTOR:- 3/93 : jt Wisconsip 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 289357 Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.: COREY, CARL ST. JOSEPH CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: i YtLi %~sc./ 030-1010-60-000 TANK INFORMATION ELEVATION DATA A97 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic C;b © _ Benchmark q$ 0 , Dosing Aeration Bldg. Sewer - Holding St/Ht Inlet 54 ' TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Airlntake Septic ra Jr rsU NA Dt Bottom Dosing NA Header/ Man. 4 Q ' Aeration NA Dist. Pipe IL, 79 Holding Bot. System 5' S. S PUMP/ SIPHON INFORMATION Final Grade , Manufacturer Demand Model Number GPM I Loss Friction System TDH Ft TDH Lift mead Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length 7 No. OVrenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS g, y,f DIMENSIONS SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK CHAMBER INFORMATION Type O Model Number: System: 410 X 1127A * q/3 h- r ')p ' 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 " Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: ST. JOSEPH 3.29.19.52B,NE,SE 1149 CTY RD I Plan revision required? ❑ Yes :,No Use other side for additional information. /n, 9 SBD-6710 (R 05/91) Date 5"_ p or'sSignature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: Safety and Buildings Division ~~i~'■•ir~'i SANITARY PERMIT APPLICATION Bureau 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. • See reverse side for instructions for completing this application State Sanitary Permit N4mber ~ 17 The information you provide may be used by other gove^rnm nt a ency programs ❑ Check it revision to previous application (Privacy Law, s. 15.04 (1) (m)]. I~ O~ 0 State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Property Owner Name Property Location V 114 $Z,- 114, S T ef , N, R E (or l Property Owner's Mailing Address Lot Number Block Number City, State Zip Code Phone Number Subdivision Name or CSM Number i II. TYPE F BUILDING: (check one) ❑ State Owned ❑ cityy Nearest Road ❑ Village Public 1 or 2 Family Dwelling - No. of bedrooms Town OF 111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo C9QtyX1_ a 30 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-~P~ew 2_ jK Replacement 3. ❑ Replacement of 4. E] 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 ❑ 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 S. Perc. Rate 6. System Elev. 7. Final Grade Required (s ft. Prop sed . ft.) (Gals/day/sq. ft.) (Min./inch) Elevation 4011105 76 1 A/Q- VS1.2 Feet 97-7 Feet VII. TANK Ca acit in gallons Total # Of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App New Exist in strutted Tanks Tanks Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite se age system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: No Stamps) MP MPRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip ode): 7 a , .s C a r el t L/ ~ IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issue Issuing Agent Si n Approved ❑Owner Given Initial Surcharge Fee) C'O Adverse Determination /U A. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SRO-6398 (R. 05/94) DISTRIBUTION: original to county, One copy To: Safety & Buildings Dive ion, Owner, Plumber r 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 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. ~ ~g x y~/3a~ ~ ~ 2 ti~ Is~~p1~ ~ ,o;2 161.1,1 ,OA ,Oa `ir ` dMR =rrisinDdpartmentofIndustry, SOIL AND SITE EVALUATION REPORT Page of 3 Labor and Human Relations Divi n of Safety 3 WIdrogs 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 Ste' CRU lX 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. O 3o - - \z 10 , APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTYL9CATION tie- SF RNp C.PrQ.`„ CORE( eew.5E 1/4 K)1/4,S 3 T V° N,R lq E( W PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # 141 ttwj)"f ` V - - CITY STATE ZIP CODE PHONE NUMBER ❑CM( []VILLAGE MOWN NEAREST ROAD vDS 1 wl sum. (-)IS) 3$6- 23 to ST. ~s~N C, U)'_" [ ] New Construction Use,(] Residential / Number of bedrooms [ ] Additign to existing building Replacement [ ] Public or commercial describe Code derived d94 flow b 0 O gpd Recommended design loading rate bed, gpd/ft2 - 6 trench, gp"2 Absorption area required a Sg bed, ft2 -I's 0 trench, ft2 Maximum design loading rate bed, gpd$ - 3 trench, gpo1ft2 Recommended infiltration surface elevation(s) °I S - Z ft (as referred to site plan benchmark) Additional design / site considerations REC am h e\-,D \%'Y- 48' Bzb . Parent material st ~`t`Y S ~A 1~,,T ov ~It S'k~+o`/ oj`tu+ft S N Flood plain elevation, if applicable fy • A . It S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING 7TAW U = Unsuitable for stem 10 S ❑ U ® S ❑ U WS ❑ U 12 ❑ U ®S ❑ U ❑ S SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/fta:~ in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed rttdl 1 A` o-~ gyp`t~- z! z 1- m sV mu <t S Z \z-31 Vo`1tt- 31y ~g o S-) mv~ A X"' Ground 3 31-9B 113y ti 3~6 - S O s9 elev. S fL Depth lo limiting fact tour ~Remarks: Boring # o_~Z to %z Z1 L lMSbk Muif - ck, ,<< .S Z 2 ~z-36 ~o~ltZ 31y - ~s o sg o! ~ •g 3 36-9D ~0`~2 ~6 - S Ogg `1 . a Ground elev. 99.OfL r' Depth to ti "g j c factor Remarks: CST Name.-Please Print Arthur L. We erer~ 715-425-0165 egerer Soil Testing & Design Service-P.O. Box 74 River Fa11s,WI 54022 Stnahue: Date: CST Nmber: M00576 PROPERTY OWNER SOIL DESCRIPTION REPORT Page of 3 PARCEL I.D.# D3~ 1 t)lp- b0 ` Boring # Horizon Depth Dominant Mottles Texture Structure Consistence Boundary Roots GPD/ft Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 3 o_fo ~o~~ Zli - L ~~►-,Sb MU-G, cw - 04 .S Z 13 Ground 3 36 -a`l l0 R 3 / S $ 6t- elev. 98•b ft. Depth to limiting factor E i Remarks: Boring # 13 Ground elev. ft. Depth to limiting factor i Remarks: Boring # i Ground elev. ft. Depth to limiting i factor i Remarks: Boring # .13 Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(R.05/92) r of PLOT PLAN Page 3 3 SCALE 1"= 30 ' ?\p 11 03o- WOO- to Z3M Z- EL- M04' otv 301"MM O'F S101)u6. - ti sT L4AJE. OF 01 40-4= 1'Rl-c - 13 > So' Y--;~ZOM Ba-P a3 a.z. ; ao''o~n. t8' a•a e'kVIMTQ C. SEOZIC 8M ~ Z d ~ •H ~ I k ~~sT. 41 rv I 0, 4 FI t / v` V t q 9 I i 011-S) h (715 ) 425-01 69 1400576 CST Signature Date Signed Telephone No. CST # STC- 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County O WNER/BUYER C b cc r MAILING ADDRESS PROPERTY ADDRESS Sk- vy~ (location of septic system) Please obtain from the Planning Dept. CITY/STATE ct- 0,~ C PROPERTY LOCATIONW,-r-- 1/4, 1/4, Section 3 T N-RW TOWN OF 411 ST. CROIX COUNTY, WI SUBDIVISION `-7 451-ele- e s LOT NUMBER r1? w 7`S /3" ,/,a 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. UWe, 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 the St. Croix County Zoning Officer within 30 days of the three year expiration date. SIGNED: DATE: 5 17 - St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI S4016 I I /o "s Thic appltcaCLorn corm is Lo ne c:0mN4c4cu ,L,. LMi.& 6"0- 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 4 , 19 iv Location of property N C 1/ 4-56 1"/4, Section T_ j_ N-R Township 5-- $~e&h .mailing address 11yg ~ l &d5on w 1 5 ~/o to Address of site _ y9 Cvvn r j-tvdson w 1 5 yo IL Subdivision name Lot no. Other homes on property? Yes __2( No Previous owner cf property _ S~ e_ioien 4 o.~e l Lab;C Total size of property Qx rif 5 Total size of parcel Date parcel was created Are all corners and lot lines identifiable? K_Yes No Is this property being developed for (spec house) ? Yes No Volume Ila and Page Number 396o 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. , 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 o pplicant Co--Applic nt S/ c Date of Signature Date of Signature Z0 39hd Vd9f LS 05:0Z L66T/ET/50 * n Y C~Or161 State Bar of Wisconsin Form 2 - 1982 J ! WARRANTY DEED vOL 1128PAGE39~ t DOCUMENT NO. t v 'G ~u~ r.;....:. - J U L 3x.996 Stephen W. Mabie and Jonel M. Mabie, g•00 A j formerl husband and wife, now_ single !I personsy - I ~'I j conveys and warrants to Carl A. Corey and- Mar K. l Corey husband and wife as survivorship- I _ marital property, - ~ THIS SPACE RESERVED FOR RECORCING DATA - _ ii !I NAME AND RETURN ADDRESS j G~ II the following described real estate in St. Croix - i~ County, State of Wisconsin: (Parcel Identification Number) ii PARCEL 1: Part of the NE 1/4 of SE 1/4 of Section 3, Township 29 North,!i Range 19 West, Town of St. Joseph, St. Croix County, Wisconsin described as; (follows: Commencing at the NE corner of said SE 1/4; thence West 20 Chainsll }to the NW corner of said NE 1/4 of SE 1/4; thence S69°E 21.37 chains to the (!East line of said NE 1/4 of SE 1/4; thence North 7.54 chains to the point of !beginning; EXCEPT commencing at a point 452 feet West~and 211.1 feet South' of the NE corner of said NE 1/4 of SE 1/4; thence S77 48 E (magnetic variation 2°201E) 178.85 feet; thence S16°37'W 135.35 feet; thence N69°19'W 178..75 feet; thence N16°37'E (previously erroneously recorded as S16°37'E) 108.9 feet tol point of beginning. '',PARCEL 2: Part of the SE 1/4 of NE 1/4 of Section 3, Township 29 North,' Range 19 West, Town of St. Joseph, St. Croix County, Wisconsin described as! follows: Commencing at the E 1/4 corner of said'Section 3; thence West along;l the E-W 1/4 line, 715 feet; thence N01°00' 15"E, , 130.00 feet; thence East, it '715.00 feet to the East line of the NE 1/4 of said Section 3; thence; S01°00'5"W,.;along said East line, 130.00 feet to the point of beginning. This-is homestead property. (is) (is not) 1 RM. Sa, Exception to warranties: O Subject to easements, reservations and restrictions of record. June 15~ 95 Dated this e 0 day of (SEAL) `6~ ! (SEAL) ;I * JO M. MABIE * _STE HEN W. MABIE ~I (SEAL) - (SEAL) ,I :i , i AUTHENTICATION ACKNOWLEDGMENT j of Jonel M. Mabie STATE OF }~/I~Q~ JAN ALASKA Signature(s) ~ ,f Q'1'L} l- r~~R-n KS 1Var