HomeMy WebLinkAbout032-2055-60-000 1
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER -a #"e:2
f/C , y ~G
ADDRESS
`mod sN• ~ ~'~i' .G/ !~i(O r ` ,~~'a a~s
s
SUBDIVISION / CSM# LOT #
SECTION_T~N-RW, Town of ~o C/'Sc
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
li
~~-`-may • y
~ J
~a
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
.dr. ~rl
r
~K.t ~c(' .~r~y ~c~t.~r~- G=~y ~l~• ..Z~ /~J~ y.7 /~as~ `i~ fir/, ~
r
lo2 7,r
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and'HumanRelations INSPECTION REPORT ST. CROIX
fafety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 284297
Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.:
RIVARD, JAMES A. SOMERSET
CST BM Elev.: Insp. BM Elev.: BM Description: n// n Parcel Tax No.:
/Z,-) ) /%1, )0671 032-2055-60-000
TANK INFORMATION ELEVATION DATA A9700066 Co /,3 z
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic S "6n_ Benchmark
Dosin
Aeration Bldg. Sewer 7?
Holdi St/ #9 Inlet a 9.7f
TANK SETBACK INFORMATION St/ Outlet 99, 7'
Vent
ir Ito ntake ROAD Dt Inlet
TANK TO P / L WELL BLDG. A
Air
Septic NA Dt Bottom
Dosing NA Header / 8 p/
Aeration NA Dist. Pipe 53 fl, 771
Holding. Bot. System , ~(o
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand ° &f<> -)~l~ DI
del Number GPM
TDH Lift Lriction m TDH Ft
For ain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Liquid Depth
DIMENSIONS DIME I
SYSTEM TO P / L BLDG WELL LAKE / STREAM L G Manu acturer:
SETBACK CHAMBER
btu,.
INFORMATION Type Of
system: it, 6x. / OR UNIT
DISTRIBUTION SYSTEM
Header / Manifold Distribution Pipe(s) le Size x Vent To Air Intake
Length Dia. Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or -Grade Sys s Only
Depth Over Depth Over xx Depth xx Seeded/Sod xx M ed
Bed /Trench Center Bed /Trench Edges Topsoil' ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION; SOMERSET 16.30.19.712,NE,NW 160TH AVE
ae / 4.<-f
ovto~i4 R - -ft -It f,-'
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
f ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
Safety and Buildings Division
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 t
than 8 112 x 11 inches in size. 6171-, rd 4
• See reverse side for instructions for completing this application State Sanitary Permit Number
v7l~~o2~~
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 e P perty Location
/4 /4, S ~j T N, R 19E (oRO,,/
Property Owner's Mailing Add Ass Lot Number Block Number
Cit tate Zip Code Phone Number Subdivision Name or CSM Number
"l - v I;,- /
4 e,0
II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ city Nearest Road
❑ Vll age S,0,1,S A-s-.e p(
Public 1 or 2 Family Dwelling - No. of bedrooms own of
III. 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 online B, if applicable)
A) 1. ('New 2. ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. Q Repair of an
"System System Tank OnlyExisting 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 5. Perc. Rate 6. System Elev. 7. Final Grade
Requi.". ft.) P oposed (sq. ft) (Gals/day/s ) (Min./inch) Elevation
5~0 ~6O ?Feet Feet
VII. TANK Ca acct in gallons Total # of Prefab. Site Fiber- Plastic Exper.
INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass App.
New Existin 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 sewage system shown on the attached plans.
Plumber' gnature: (No Stamps) MP/MPRSW No.. Business Phone Number:
Plumb( ame: (Print)
All
Plumber' ddr ss (Street, City, State, Zip e
IX. COUNTY/ DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agep(t Si ature No St
A Surcharge Fee) /
pproved ❑ Owner Given Initial
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6396 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Div.,ion, Owner, Plumber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit maybe 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.
V1. 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 compfete dimensions, tuca#on 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.
r
1IZ.1f
"1J
149
I V~
I~ l
70
rY p e-
0
jr/ / I
J~1
Wicconsin Department of Industry, SOIL AND SITE EVALUATION
LaSor and Human Relations Page of
Division of Safety and Buildings 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 Dat
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner - Property Location
Govt. Lot 1/4 /I/o/4,S /✓6 T E (W
Property Owner's Mailing Address Lot # Block# Subd. Name or CSM#
City State Zip Code Phone Number
❑ City ❑ Village Town Nearest Road
t&New Construction Use: 5 esidential / Number of bedrooms Addition to existing building
LJ Replacement L 1 Public or commercial - Describe:
Code derived daily flow 4J O gpd Recommended design loading rate bed, gpd/ft2---19-'-' -trench, gpd/ft2
Absorption area required bed, ft2 Qom- trench, ft2 /Maximum design loading rate - gibed, gpd/ft2^-~trench, gpd/ft2
Recommended infiltration surface elevations ri 2/r 7 ~~fT f+ ft (as referred to site plan benchmark)
Additional design/site considerations
Parent material Flood plain elevation, if applicable dl/ ft
S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank
U = Unsuitable for system ~]C S❑ U S0 U A S ❑ U s0 u ❑ S ~a U ❑ s Wu
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
/ in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
I B! rJ^ rw " .7 ~
Ground
ft.
Depth to
limiting
J ` Remarks:
Boring #
den,
Y 'l
Ground
c
~D th to
limiting
fac o
/~7 in. Remarks:
CST Name (Please Print) Signature Telephone No.
Address Date CST Number
SOIL DESCRIPTION REPORT
PROPERTYOWNER 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
O` z _f 5
Ground r /
~e -v ft.
Depth to
limiting
factor
Remarks:
oring #
+ !
i5
lk'= d
Ground
Depth to
limiting
n.
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 #
r 6:,e
~r ,
Ground
el v
Depth to
limiting
,t~c~or
6~+ in. Remarks:
17-
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in.
Remarks:
SBDW-8330 (R. 08/95)
Soil Test Plot Plan
Project Name James Rivard Byron Bird Jr.
Address 1645 Co. Road I `
Somerset Wi 54025 CSTM #3479
Lot Subdivision Date 10/5/96
NE 1 /4 NW 1 /4S 16 T 30 N/R 19 W Township S. Somerset
❑ Boring ()Well PL Property Line County ST. CROIX
BM or VRP Assume Elevation 100 ft. Top of 1/2" Steel Rod with Orange Ribbon
System Elevation 94.3/93.2 * H R P Same as Benchmark
o3
Bedroom
g House
a
5'
700' B-1 1_155- 15' -4
0'
80' Pri A Rep A
0'
10% -3
Slope
B-2 -5
30'
5'
.M.
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 :J a in e-S k-0 A.~
Location of propertyfle_1/4 A )W 1/4, Section 16 , T 36 N-R & W
Township ro V, e~ Mailing address i6 c/7 _r
Address of sites q /`O f~
Subdivision name Lot no.
Other homes on property? Yes_ No
Previous owner of property 4 ~ .e.
Total size of property tip A-.4 e
Total size of parcel _ /e e cr~~
Date parcel was created Z /g' lfrjS
Are all corners and lot lines identifiable? _ X Yes No
Is this property being developed for (spec house) ? Yes __Z No
Volume 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 o fice 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.
D
ignature of Applicant Co-Applicant
Da e of Signature Date of Signature
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER c~a. r,~ e S .A R l i v ac rd
MAILING ADDRESS #3- 00
PROPERTY ADDRESS. (location of septic system) Please obtain from the Planning Dept.
CITY/STATE a k), t- Ve--Ir Wt"'
PROPERTY LOCATION A) f 1/4, JV w 1/4, Section r (o T -70 N-R_jy _W
TOWN OF S O m e 1''S -c T ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
CERTIFIED SURVEY MAP - VOLUMEr ,SAGE ; 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
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 year iration date. /I
SIGNED:
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
* DOCUMENT NO. STATE BAR OF WISCONSIN FORM 2-1982 THIS SPACE RESERVED FOR RECORDING DATA
W R ANTY DEED
529104 VOL 7 '
^;sE. ~ ST. CROIX
Redd iu;
~rN~ 1 d 1 I'C' E d eer mc~i-rfe MAY 18 1995
LJ'e r5' o rv.S
4T}y} 9:30 A
co eyes and warr is to Ac m 'e C_' J ' rU /U r ~v' ^
S '4 P- V l~ e"✓
r '
RETURN TO ~
/lo qS C:t~&Z
the following described real estate in r f V County, ( ~m11)-'~Q~~, (.L,117
State of Wisconsin: r
F Tax Parcel No:
ctN
i/'~
F
C~c vn~r$~!~ z..~ SY
dd
fe- et
~T
This homestead property.
(is not)
Exception to Warranties:
y~l)
.Dated this - day of
19.
X (SEAL) (SEAL)
r N l pD B e e Y •!YJ z 1~ 1J
(SEAL) Zj 1*0'y11'A;r_..1 (SEAL)
• Ce kJ eeY (D
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN
ss.
County. ov
l /