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HomeMy WebLinkAbout032-2004-30-200 V N0 11 I2. 03 RECEIVED STC - 104 AS BUILT SANITARY SYSTEM REPORT APP ' is ? 5T CFOX OOUNVTY OWNER ~ IQ Z2G ZONNf30PRCEr.,': _ 19 V1 I ADDRESS 27 Gr f l ~Y d~~ SUBDIVISION / CSM# LOT # v W, Town of SECTION T-N-R -4?- ST. CROIX COUNTY, WISCONSIN PLAN VIEW, SHOW EVERYTHING WITHIN 100 FEET OF SYST J ~ ig 4 n o L.iYe, INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. . ~ ~ q6- /yam 9G 7~ q o y t ~ ~rL G~ 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 284300 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: GOSSO, RONALD SOMERSET CST BM Elev.: , Insp. BM Elev.: i BM Description: Parcel Tax No.: 032-2004-60-000 TANK INFORMATION ELEVATION DATA 2( 9 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosi n Aeration Bldg. Sewer 96, Ho Ing St/ Inlet (o, 3S~ TANK SETBACK INFORMATION St/10t Outlet 5oPq Vent TANKTO P/L WELL BLDG. AirIto ntake ROAD Dt Inlet Air Septic NA Dt Bottom 7 Dosing NA Headert g, 75 Aeration - NA Dist. Pipe ' 9 /7 Ho Bot. System 77'tf PUMP/ SIPHON INFORMATION Final Grade Man uqurer Demand Model Number _ PM c n TDH TDH Lift Lri o!rs ea Forcemain L th Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width 7 * Length / No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS S0 DIMEWSHM RING acturer: SETBACK SYSTEM TO P / L BLDG WELL LAKE /STREAM CHAMl3 INFORMATION Type of We i q Moe u r. >S(~~ >Sbi ( OR UNIT System: croo,-, 1,4 DISTRIBUTION SYSTEM Header L M&n+fefd Distribution Pipe(s) x Hole Size x Hole Spatirrg Vent To Intake Length Dia. _C Length Dia. Spacing l0 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, etc1 S LOCATION: SOMERSET 1.30.19.479A,W,NW 82ND STREET Plan revision required? ❑ Yes No pr P1 Use other side for additional information. aoZ S-- U SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: ` stems vp : SANITARY PERMIT APPLICATION BuSafetyreau anofd Building Water Sy Sy 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 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)]. ( `'YL& State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Own Name IPr erty Location 17a/ JVX E~1/4,5` T O ,N,R/ E( Property Owner's Mailing Address Lot Number Block Number / nc~ city, State~ r Zip Code Phone Number Subdivision Name or CSM Number ( >vT E /C r ~a► J-001 7 I. TYPE F BUILDING: (check one) ❑ State Owned ❑ city L Nearest Road ❑ Village Public 1 or 2 Family Dwelling = No. of bedrooms Town of III. BUILDIN USE: (If building type is public, check all that apply) Parcel Tax Number(s) d,~v7"'~o O 1 ❑ Apartment/ Condo a 0. 4 7 9 /9 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 online B, if applicable) A) 1. lew 2. De Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an ___ystem _____ystem 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 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 (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation 1? 15-v 6 4 Gc - _ Feet Feet VII. TANK Cap city allons Total # of Prefab. Site Fiber- Ex per. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existin strutted Tanks Tanks Septic Tank or Holding Tank V I / I lgJ'G-~ ❑ ❑ ❑ ❑ ❑ 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. Plum is Name: (Print) Plumber's ature: (No Stamps) MP/MPRSW No.: Business Phone Number: Plu er's dress (Street, City, State, Zip Code)- jJ2 DPW IX. UNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing A nt Sig nature (No m Surcharge Fee) Approved ❑ Owner Given initial Adverse Determination CJ T X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: S1,10-6398 (R. 05/94) DISTRIBUTION: Original to Counly. One copy To: Safety & Buildings Di--ion, 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- 11. 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. J~x &M um dov Ags r i~ :C`'. toe; 17 Ir. G` ~Pb~ Esy►;~.t 6G t,-1k ~i b L~v a- I 3° ~J 3a` a 0 0~~ ~'ru• L7 ~ J< 47 116 i~ J Grp r s Wisconsin Department of Commerce SOIL AND SITE EVALUATION Division of Safl3ty 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 81/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and f ~y.y 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 3 Ca Gad Govt. Lot dl, jg~ T N,R E (o& Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# Ci State Zip Code Phone Number El ~ 7 Nearest Roa City El Village Town New Construction Use: 12flesidential / Number of bedrooms Addition to existing building ❑ Replacement ~f^ ❑ Public or commercial - Describe: Code derived daily flow /<'OV gpd Recommended design loading rate 7 bed, gpd/H2 -5 trench, gpd/ft2 Absorption area required ?bed, ft2 75 ~ trench, ft2 Maximum design loading rate, bed, gpd/ft2_ trench,gpd/ft2 Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design/site considerations Parent material .-Z- ~ Flood plain elevation, if applicable A'-.~r ft S Suitable for system Conventional Mound In-Ground Pressure AT Grade System in Fill Holding Tank U = Unsuitable for system S ❑ u [WS ❑ U I S ❑ u ~Rs ❑ u ❑ S ©•u ❑ S G~ U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench e)-3 16W Ground elev. Depth to limiting factor Remarks: Boring # Ground elev. el1 azft- D pth to limiting factor ;7/2pvin. Remarks: CST Nam (Please Print) Signature Telephone No. Address Date CST Number SOIL DESCRIPTION REPORT PROPERTY OWNER Page ° of PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots QVD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Kr 36 G v~ c A-4 Ground elev. ft. f , Depth to limiting factor Remarks: ' . " ,7' Boring # &Ou elev. Depth to~ , limiting factor 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 # ; Ground elev. ft. Depth to limiting factor 'n. Remarks: Boring # 13 Ground elev. ft. , Depth to limiting factor in. Remarks: SBD-8330 (R. 07/96) I7 K`f ell \ I r 3° sp r ® 3.1 r r0 ~rj-h.«~s Sao f ~~yc! L 9 f ~c~55 P` t k0 ' ,r1fL~ V 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 fzah " s„ Location of property 1/4 j Township 5, „Sa.~-~eHf Maili address 17z Address of site Subdivision name Lot no. Other homes on property? Yes____L-'_No Previous owner of property Tod„ Total size of property Total size of parcel Date parcel was created, e /,~y3 Are all corners and lot lines identifiable? _ Yes No Is this property being developed for (spec house) ? Yes -_Z No Volume /jol Z 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. a/ o -T/ , 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. Si nature of Applicant Co-Applicant t l Date of Si nature Date of Signature STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER MAILING ADDRESS PROPERTY ADDRESS (location of septic system) Please obtain from the Planning Dept. CITY/STATE PROPERTY LOCATION G~1 1/4, IZV 1/4, Section T :30 N-R ,,~W TOWN OF S. j o r•-~ .e -5 f 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 the St. Croix County Zoning Officer within 30 days of the three expiration date. SIGNED: DATE: i ) 1! - St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 DOCUMENT NO. WARRANTY DEED THIS SPAC[ R[S[RVID POR R[G0001140 DATA !I STATE BAR OF WISCONSIN FORM 2-1"2~I _ Y 501081 rq 1017PacE 5 h~ j , ST. - Reed tct R~cc:d John H. Kimberly and Amy Lewis, husband and wife JUN 2 2 1993 t f Ronal d F Gosso and -Penny, L,•_ Goss4,~•, d [~seda conveys and warrants to huban4 a".4..ife RiTURR TO .M the followint described zeal estate in it....rx.Mix .....................County, i State of Wisconsin: Ta= Parcel No: Attached "EXHIBIT AN hereto made a part thereof. { mkNSF E I is not This homestead property. (is) Xx Zzeeption to warranties: q Jane Ist43..... . Dated this day of ---._(sswL) K• mbar'(........ qleo4n. (SZAL) (SEAL) . • AUTRANTICATION AC=MOW LSDOURNI ` a sisuatne(s) STATZ OF it Ninnes a ».Wa~hingi4!~...... county. 4- authentieated this --day oi!».....».---»_...»....., lf»... PeesonaQ7necaame woes ; t4h3b the above named ...0.4-wifs...._--.... TITLE: YEYBER STATE BAR OF WI8GON8IN - ' » (It -f 706.06. Wis. StatsJ to me known to be the person » .»w>so executed the t sekao tke same. THIS i wAS °.Y._» EXHIBIT .4 r0L 1017PAGE 5j- Part of NW4 of Scction 1-30-19 described as follows: Commencing at the Northeast corner of Section 1; thence North 89'08'03" West (true bearing) (previously recorded as North 87'46' West) 2641.21' along the centerline of State Trunk Highway "64"; thence South 0'31' West 110.00' to the Southerly right-of-way line of said S.taLe''1'runk Highway "64"; thence North 89°08'03" West (previously recorded as North 87.46' West) 486.24' along said right- of-way line; thence South 89°57'24" West (previously re- corded as North 88'42' West) 499.13' along said right-of- way line; thence North 0°02'36" West 50.00' along said " right-of-way line; thence South 89°57'24" West 64.30' along said right-of-way line to the point of beginning; thence South 34'11140" West 962.78' along the Southeasterly right-of-way line of an existing town road; thence South- ; westerly 176.09' on a 500.00' radius curve concave South- easterly whose chord bears South 23'23'33",West 175.05' along said Southeasterly right-of-way line; thence South 12035' 26" West 120.90' along said Southeasterly right-of-way line; thence Southwesterly 192.88' on a 383.00' radius curve con- cave Northwesterly whose chord bears South 27°01'03" west 190.85' along said Southeasterly right-of-way line; thence South 41'26'40" West 82.00' along said Southeasterly right- of-way line; thence North 48'33'20" West 66.00'; thence North 81033'20" West 125.00'; thence South 69'37'39" West 145.31'; thence South 31'37'13" West 120.90'; thence South 5'40'00" East 129.35'; thence South 70026'00" East 94.05'; thence South 0'31'00" West 634.53'; thence South 89'31'00" Fast 100.00'; thence South 0'31'00" West 604.80' to the South line of said NA; thence North 89049'56" West along said South line to the West line of said NWT; thence Northerly along said West line to the Southerly right-of-way of said State Trunk Highway "64"; thence Easterly along said Southerly right-of-way line to the point of beginning. It:; d and swo May before me our= • 0 Mq4Q101, Attorney's Title of Stillwater 1940 S. Greeley. St. ARTruwcoaoTnsR Stillwater, MN 55082 SAL MAW OR MAL (OR o77IRR 77Th OR M