HomeMy WebLinkAbout032-1031-50-300
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AS BUILT S STC - 104
ANITARY SYSTEM REPORT
OWNER /ADDRESS 176c)
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SUBDIVISION / CSM#
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SECTI LOT
ON
T-t2l N-RZLW
, Town of
ST. CROIX COUNTY, WISCONSIN
SHOW EVERYTHING WILTHINIEpp FEET OF SYS / -
TEM
2 ~b ~5
i
/Spy
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i
INDICATE NORTH ARROW
Provide setback and elevation information on rev
Provide erse of this form.
2 dimensions to center of septic tank manhole cover.
BENCHMARK:
J 1 ~z `
ALTERNATE BM:
EPT K / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: ~A~0_k Liquid Capacity: ~G a
Setback from: WellNd w House Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle.-
Alarm Location
SOIL ABSORPTION SYSTEM
Width: /oZ Length Number of trenches/
Distance & Direction to n~ef~/est prop. line:
S&-e~
irL
Setback from: well: House Other
~ 50
ELEVATIONS
Building Sewer ST Inlet: 9.r- ST outlet:
PC inlet PC bottom Pump Off
Header/Manifold 0.2 Bottom of system
Existing Grad e~~a Final grade /e o~
DATE OF INSTALLATION:
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR:
3/93:jt
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 289362
Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.:
WISHARD, BRADLEY SOMERSET
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
/00/ (00 r 032-1031-50-300 zt, ILL TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septicz Benchmark
6.
Dosing
Aeration Bldg. Sewer o yg, q?,; 7'
Holding St/ Ht Inlet 3. 1~5 q10
TANK SETBACK INFORMATION St/ Ht Outlet y b ' 75
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic -,&-I C,12D 15 NA Dt Bottom
i
Dosing NA Header/Man.
Aeration NA Dist. Pipe ~fZ 15, p
Holding Bot. System 7d--
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand✓ y~ 33
Model Number GPM
TDH Lift Friction System TDH Ft
oss Head
Forcemain Leng Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width 1 1 Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSIONS
LEACHING Manufacturer:
SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM
INFORMATION Type O CHAMBER Model Number:
System: fit' a 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: SOMERSET 11.31.19,SE,NW 625 LAKESIDE LANE LOT 3
*
`f.
Plan revision required? ❑ Yes O/o
Use other side for additional information. V
SBD-6710 (R 05/91) Date I or's Signature Cert. No.
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 4
than 8 112 x 11 inches in size. ~St• ~1 ~ cc 1
• See reverse side for instructions for completing this application State Sanitary Permit Nu ber
,2gw~
The information you provide may be used by other government agency pro teams ❑ Check it revision to previous application
[Privacy Law, s. 15.04 (1) (m)]. &A5 Z C~~ty~f/ e Z~ State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Property Owner Name Property Location
T _3/, N, R E or&
Property Owner's Mailing Address Lot Number Block Number
State Zi Code Phone Number Subdivi' n Name or C 5M Number i Ar
a l , (/S V- U-32 38 Vm I 2 Y
II. TYPE F BUI ING: (check one) ❑ State Owned Ity Nearest Road
El e
Public 1 or 2 Family Dwelling - No. of bedrooms ,-2) Vows OF CL
III. BUILDING US : (If building type is public, check all that apply) Parcel Tax Number(s)
1 E] Apartment/ Condo L3 / 1500- ~3
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) 1.19New 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
11eepage 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: ev
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Fin a] Grade
R qu'red (sq. ft.) P~posed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation
0 j~ :/y ivy Feet Feet
Capacity
VII. TANK 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 sewage system shown on the attached plans.
Plumber's Name: (Print) Plu is Signature: (NO Stamps) MP/MPRSW No.: Business Phone Number:
Plu ber's Address (Street City, State, Zip Code)
IX. COUNTY / DEPARTMENT USE ONL
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issue Issuing Agent Signatur No Stamps)
Surcharge Fee)
Approved ❑ Owner Given Initial ZZ j I ~ b/ n~
Adverse Determination V 7
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 1 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of
Wisconsin, Sa ety a )o B.-J' dinys L)W;Siorl, 608-166-3815.
To be complete and accurate this sanitary permit application must include:
I_ 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 8 112 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.
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.
ell
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rWisconSin Department of Industry, 0) AkD~ITE EVALUATION
Page Of
Labor and Human Relations a (
bRu
Division of Safety and Buildings in; accordance wii ..OLHR 83.09, Wis. Adm. Code
Anr ` r r 1
i' County
Attach complete site plan on paper not I than 8 1/2 ~m size f'la~t must /1/
include, but not limited to: vertical and h rirt*tal referees P (BM), diredtiOn and
percent slope, scale or dimensions, northr an lance tq`nearest road. Parcel I.D. #
~ APPLICANT INFORMATION - Please 11ii~totmafion. Reviewed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property ner Property Location
Govt. Lot 114 114,S T N,R(o
Property Owner's Mailing Address Lot # Bloc Sub Name or CSM#
T21-
city Statg Zip Code Phone Number ❑ Ci ❑ Village ~a Town Nearest Road
New Construction Use: Residential/ Number of bedrooms Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow gpd Recommended design loading rate bed, gpd/fF__A0__trench, gpd/ft2
Absorption area required bed, ft2th, ft2 Maximum design loading rate _,7bed, gpd/ft2trench, gpd/ft2
(as referred to site plan benchmark)
Recommended infiltration surface elevation(s) % ft
Additional design/site considerations
Parent material A ;Z I /A Flood plain elevation, if applicable ~4 ft
S = Suitable for system Conventional Mound T Ground Pressure AT-Grade System in Fill Holding Tank
U Unsuitable for system S0 U S ❑ U X S ❑ U S❑ U ❑ S JK U ❑ S JZ U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft2
g Texture Consistence Boundary Roots
in. Munsell Qu. Sz. C nt. Color Gr. Sz. Sh. Bed Trench
1 d
G~rroouLn~d 3 7
i1~-~-ft.
Depth to
limiting
fac or
Remarks:
Boring # (57 Z
o
Ground
ft. ;
Depth to
limiting
factor
~?~in. Rem ks:
CST Name ( e Print) / Signature -Telephone No.
Address Date CST Number
s -
SOIL DESCRIPTION REPORT
t ~ zlzw~ S
PROPERTY OWNER Page of
PARCEL I.D.# ~O f
Boring # Horizon Depth Dominant Color Mottles Structure 2
Texture " Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
~el
Ground
~eleev.
• - / fj
T'/f t
Depth to
limiting
factor
Remarks:
Boring #
A Y.
At bOv
r/_ Ile ~7 t• J hie"
Ground
elev.
Depth to
limiting
factor
,>1,PQ' in.
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 #
"a /Y
Ground
elev '
Depth to
limiting
factor
}'n. Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in.
Remarks:
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KATHLEEN H. WALSH
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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.
-------------------------------------------------------------------rR r, Owner of property r'__ 1C JA_' ) -I's LM 4
Location of property 114u A10 Section ,T_3_/ N-R_ZI_W
Township Sor►~e,~s~ Mailingaddress 7 d 5aA(_ At,
Address of site /A~
Subdivision name
no.
Other homes on property? Yes X No
Previous owner of property F/bM.:'r
✓
Total size of property 9,A c- e,.,-"
Total size of parcel
Date parcel was created .23 2 7
Are all corners and lot lines identifiable? X Yes No
Is this property being developed for (spec house)? Yes _,?~_No
Volume / and Page Number,J 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 n t_h e office of the County Register of
Deeds as Document No. ~ &1(=, , 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
4theoffice of the ounty Register of Deeds as Document No.
of Applicant Co-Applican
S-- 3e 7 0 --q 7
Date of Signature nat-P nf
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
/J St. Croix County
OWNER/BUYER 1 b l S ~,,yJ
r'c
MAILING ADDRESS 1-2 60 5 0
PROPERTY ADDRESS vZ (7 ~u ~t S~ ~l t f Y"'
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE S&AkU-~ ~IVOd
PROPERTY LOCATION 52~ 1/4, /Vzd1/4, Section T 3 N-R W
TOWN OF D~~ +t--~r 5 ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER 3
CERTIFIED SURVEY MAPS VOLUME PAGE LOT NUMBERS _
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 mus be com leted and turned to the St. Croix
County Zoning Officer within 30 days of the three-year ex trati ration d q.
SIGNED:
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
~v I
t YAL T2137PACE` 65
559006 WARRANTY DEED
ST. C _
t
Document Number MAY 7 391
,L 10:00 A l,q
Return Address KRISTINA OGLAND
Zilz, Estreen & Ogland
P.O. Box 359
Hudson, WI 54016
Parcel I.D. Number:
a/k/a Joseph F. Plourde
Joseph E Plourde /h single person. conveys and warrants to Bradley S Wishard a married-
the following described real estate in St. Croix
man
County, State of Wisconsin:
Part of the S W 1 /4 of N W 1 /4 and part of the SE 1 /4 of NW 1 4 of Section 11, Township 31 North, Range 19
West, St. Croix County, Wisconsin, described as follows: Lot 3 of Certified Survey Map filed April 23,
1997, in Vol. "I I", Page 3242, Doc. No. 558373.
This is not homestead property.
Exception to warranties: Easements, restrictions and rights-of-way of record, if any.
Dated this S day of May, 1997.
TRAM fC-k
~ (SEAL)
Joseh E. lourde, a/k/a Joseph F. Plourde
AUTHENTICATION
a/k/a Joseph F. Plourde
Signature(s) Joseph E. Plourde, / a single person,
authenticated this day of May, 1997.
Vl'~l , -
Kristin Ogland
TITLE: MEMBER STATE BAR OF WISCONSIN
THIS INSTRUMENT WAS DRAFTED BY:
Attorney Kristin Ogland
Hudson, WI 54016
9
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