HomeMy WebLinkAbout032-2090-50-000
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
ADDRESS 157
SUBDIVISION / CSM# /WT,6~a/eA 4424A-5 A~5'TAT2S LOT 0 16
SECTION_4 f T `3 / N-R_JI_W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
W l
N
/000 64. 5, 7"
Oc~SE
1 I
i I
1 ~
0A 8/1
/an°a
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
`BENCHMARK: Tp~ p 2 4 P= D/ Dc CL /Dog d
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: UZ gg~ 'S Liquid Capacity: JL1610
Setback from: Well House other
ufacturer Model#
Float seperation cle:
cation
SOIL ABSORPTION SYSTEM
Width:_ Length 6 7 Number of trenches _~L
Distance & Direction to nearest prop. line: %e` %v ~euT~y
Setback from: well: - House __7' t other
ELEVATIONS
Building Sewer_ 99.3 ST Inlet: ?S',52 ST outlet:
PC inlet ffA PC bottom Pump Off A(A
Header/Manifold 9S S_ Bottom of system ~y, 3 lv
Existing Grade Final grade
DATE OF INSTALLATION:
PLUMBER ON JOB: `
LICENSE NUMBER: 323'
INSPECTOR:
3/93:jt
• Wisconsin'bepartment of Commerce PRIVATE SEWAGE SYSTEM
Safety and Buildings Division CountY
INSPECTION REPORT ST. CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) SanitaruWgWtt.:
Personal information you provice may be used for secondary purposes [Privacy L , s.15.04 (1)(m)].
P@rWolde&me: [j8kL g*jpe Town of: State Plan ID No.:
CST BM Elev.: Insp. BM Elev.: BM Description`: L~Z ~ Parcel IiN~2090-50-000
TANK INFORMATION ELEVA ION DATA A9700281
TYPE MANUFACTURER CAPACITY STATION BS HI /IFS ELEV.
Septic ~Gv y S U' :::x Benchmark > a3• ! Z 99 (p+
Dosing Ll,
Aeration Bldg. Sewer 3
Holding St/ Ht Inlet y` Gf 'l,
TANK SETBACK INFORMATION St/ Ht Outlet 9'7 q~_l
Vent
TANK TO P/ L WELL BLDG. A
ir Ito ntake ROAD Dt Inlet
Air
Septic > /0 1 , 7/5' , NA Dt Bottom
9'05- ~Iy~3i
Dosing NA Header/ Man.
Aeration NA Dist. Pipe 5?"
Holding Bot. System
0.0_'5-
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand r~>
Model Number GPM
TDH Lift Fric ' System TDH Ft
S ad
Forcemain ngth Dia. Fi Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH width Length No. Of Tr nches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSIONS
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING manufacturer:
SETBACK
INFORMATION Typeof /X" CHAMBER Model Number:
System: , OR OMIT
r~ rSf 3~ y~U~ /
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 y a " Bed /Trench Edges zl.L Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: SOMERSET 15.31.19.892,SW,NW 512 217TH AVE LOT 15
Plan revision required? ❑ Yes E]-'No
Use other side for additional information. yn Z16
SBD-6710 (R.3/97) Date Inspe is Signature Cert No.
ADDITIONAL COMMENTS AND SKETCH '
SANITARY PERMIT NUMBER:
Safety and Buildings Division
Visconsin SANITARY PERMIT APPLICATION Po ~z7 nngtonAve.
Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 1/2 x 11 inches ih size. ,
• See reverse side for instructions for completing this application State Sanitary Permit Number
pp~T~S
The information you provide may be used by other government a79 ogr s ❑ Check if revision to previous application
[Privacy Law, s. 15.04 (1) (m)]. 5 I `1 , S . State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION
Prop e Owner Name Property Location
1/4 all /4, S T , N, R E (orl
Property Owner's M iling Address Lot Number Block Number
AV 2 .2 3
Cit
9 , State t Zip Code Phone Number Subdivision Name or CSM Number
( ~3) - A s
II. TYPE BUILDING: (check one) ❑ State Owned !t Nearest Road
p Village
Public 1 or 2 Family Dwelling -No. of bedrooms Town OF :2 12 III. BUILDING USE: (if building type is public, check all that apply) Parcel Tax Number(s)
1F1 Apartment/ Condo /5, 3 D r d
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. 'New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
System SystemTank 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
11E] Seepage Bed 21 ❑ Mound 30E] Specify Type 41 ❑ Holding Tank
12 'Seepage Trench 22 ❑ In-Ground Pressure 42E] Pit Privy
13E] Seepage Pit 43 ❑ Vault Privy
14E] 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
9~~40 5463 93 , Feet 77 Feet
VII. TANK Cap citTotal # of Prefab. Site Fiber- Exper.
INFORMATION New, Existin Gallons Tanks Manufacturer's Name Concrete st uCon- cted steel glass Plastic App
Tanks Tanks
Septic Tank or Holding Tank Ij ❑ ❑ ❑ ❑ ❑
lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sews e s stem shown on the attached plans.
Plumber's Name: (Print) Plu jes Signature: (No STLJ MP P R S W Business Phone Number:
a 7/
um er's Ac dress (Street, City, State, Zip Code):
f.-e s-
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved San! ry Permit Fee (includes Groundwater ate Issued Issuing Agent Si na ure (No Stamps)
Surcharge Fee)
XApproved E] Owner Given Initial
Adverse Determination /go
X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL:
SBD-6398 (R.11/96) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS r '
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, 608-266-3151.
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 a)~ sp- cifications 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.
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Wisconsin {department of Industry, SOIL AND SITE EVALUATION
Labor and Human Relations Page _L of
Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis.
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 5~' (f no
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
03?-. C"~ go -S-0
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
ba '7 f Govt. Lot 54) 1/4 lytJ114,S /s- T 3/ N,R /17 -Ift W
Property Owner's Mailing Address Lot # Block# Subd. Name or CSM#
City State Zip Code Phone Number Nearest Road
A4t / /I Sycg~ ( 7/S-) S--W / / 3 El City El Village Isa Town .2 / ?v4 /fee
X1 New Construction Use: R Residential / Number of bedrooms - Addition to existing building 104
❑ Replacement ❑ Public or commercial - Describe: c~
Code derived daily flow 4.; 0 gpd Recommended design loading rate bed, gpd/ft2 d trench, gpd/ft2
Absorption area required J~ 92' bed, ft2 _S';I.3 trench, ft2 Maximum design loading rate bed, gpd/ft2__._46_trench, gpd/ft2
Recommended infiltration surface elevation(s) B.f) it (as referred to site plan benchmark)
93 yv-
Additional design/site considerations
Parent material /2 Flood plain elevation, if applicable /yip ft
S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank
U = Unsuitable for system 29 S ❑ U 0S ❑ U 9S ❑ U INS ❑ U D? s ❑ u ❑ S R' 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
09 OL
Ground 3.3? 17SI r w . 7 00
ev.
P-2 Po 7r 151
Depth to
limiting
f~ctor
+ D in.
Remarks:
Boring # /
m -1 -fir G•J' ~i~
S~
d 2-30 7. rv,
- ,S' •
7,1 SA-el
Ground
s /
Depth to
limiting ' '
M fa or *
1 t
-Fin. Remarks:
CST Name (Please Print) I~ Signature I ~0.
Address / y Date , ' f C1'; ►uritr
( P /la / tg,-~eY-P fbZS~ 1~7 CJ
SOIL DESCRIPTION REPORT
PROPERTY OWNER Qa rr l % ae-4- 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
16
Ground S"9 rS .S
9zelev. - ' ' •
.~ft.
Depth to
limiting
factor
Remarks:
Boring #
r o-.~` d S (r Gw ~G
I o2 Z's- r 1 S rn r- ~J . Sr
6
Ground
elev.
9z~Zft. ;
Depth to
limiting
f c~or
rin.
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 # l 04 ,r3 2 S e? r C
Ar .S
S 1- /r.,s6 1'-'-7(' 0
3 -yo t/3 D 7
Ground
elev. ,
-fin.
Depth to
limiting
f or
-l-in. Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
SBDW-8330 (R. 08/95)
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER Damon ✓1 k/ D d- I~ e,,► D _ M c~ ✓4
MAILING ADDRESS -15- 19 23 `rc) Sf H yv-o n L .5-9016 2-
PROPERTY ADDRESS S) a I V'~ .
(location of septic system) Please obtain from the Planning Dept.
CTTY/STATE c3owe, ,5,4- 0 l
PROPERTY LOCATION _~J W 1/4, W 1/4, Section 16- , T 31_N-R [ W
TOWN OF ~s,nn 2X .S-e- ST. CROIX COUNTY, WI
SUBDIVISION ov 4 e r Q a s S T 0. LOT NUMBER 1
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 eSIGNED:
DATE: 7
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
8 T C - 100
. 7 M
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.
--------------------------f-----------------------------------------
Owner of property
Location of property AJVJ 1/4_1/4, Section N-R_j_I_W
Township DvvLe- r,& g Mailing address `
Address of site S) _21 A 0
subdivision name _ u r 44\4.rn na F -s I* Lot no. S
Other homes on property? Yes V-' No
Previous owner of property ~Ca~lC 1,41Sh
Total size of property o7. -7dD 0.cxeS
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)? Yes ~No
Volume ja yz 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. (e 0gf5- , 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.
i
1Sig7nat:ee of Ap icant Co-Applicant
-717 a /4 7
Dat o Signature Date of Signature
pp~or
Doeum• rd Number DoeuxDeat ndo
AEuIs~ENS G~F',.E
S? CROIX c; wl
WARRANTY DEED ,.rtivr.~•
! JUN 2 1997
5:30 A.
Keoed'iat Arm
flame amd Ram Addrm
Bivw Val[W Abstract & Mde, Z
P.10e Box 149 0 Zoo 2nd Si.
Hudson, Wi 54016
Paee d Ldp mmaw (Pon
i
!
~ j Ats'SFER
i
"THIS PAGE IS PART OF THIS LEGAL DOCM93T ' DO NOT UMVE"
TWW ithemation o m be enoPkd bs NdmmW r- 40ee.wau ads, none i rwmwrn dlress. od &M. 1 ,,gi9rd4 Odur iiAmui"""`A
- d- Snwiwt ch--. JcCd Aacp eae. wq be rimed an d~ir fdw rtt Af de Awwacw w M1 be rued we dt: vw Paz- df A
wire.nriw Smosm. JASI7 _WJ~AAS-.
Ieeerwene. use .f AA, ee.rr page o!!r Ms Jp~ r your 6re+.nov .r S2.m to At recorAwe lea .
4i
fi7k
Deed y1t .j ) par( fj 1
Warranty -
Ita"uAgs to Joint Tenants
(Reserved for recording data)
No dci*ucnt taxes and transfer entered; certificate
Rea! Estate Value filed not required
Certa6cate of Real Estate Value No.__
County Auditor
Deputy
State Deed Tax Due Hereon S
Date t 9
FOR VALUABLE CONSIDERATION, John E Walsh art unmarr►e~i man Grantor (s), hereby _
,
Grantee (s) as joint tenants, real property in
nm D MaR and Renee D_~rt,
coevey (s) and warrants to
cL roix County, Wisconsin, described as follows:
Lot Fifteen (15), Northern Oaks Estates in the Town of Somerset
together with all hereditaments and appurtenances belonging thereto, subject to the following exceptions:,
covenants, restrictions and easements of record.
a
ohn E. Walsh
,
7
STATE OF T-F-rT-1T"NES0+A-
~ Sx/ ) ss.
COUNTY O V /99
by
The foregoing instrument was acknowledged before me this 0;Aay of
John E Walsh an unmarried man._ Grantor(s).
t
PWTARIAL STAMP OR SEAL (OR OTHER TITLE OR RANK)
a e of person taking acknowledgment
A.
1
Tax Statements should be sent to: '
TfDS INSTRUMENT WAS DRAFTED BY
ai VNF D. ANDERSON ID#209624 i