HomeMy WebLinkAbout032-2090-90-000
A s' E I '1J•
STC 104
AS BUILT S
ANITARY SYSTEM REPORT
OWNER a;
~~~r ~eNSoN w ~ p ~ - : J UL ?3 1997
ADDRESS -11q gS cRO~X
i(VR~ ~1 rl\1, J ZONltr~t7 vIfrm
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SUBDIVISION / CSM
SECTION ~~~rwTCS LOT
T=s--N-R~~ W, Town of sp
ST. CROIX COUNTY,
WISCONSIN
SHOW EVERYTHING PLC VIEW
WITHIN 100 FEET OF SYSTEM
&AP,0C
q40 Js E
,
c~p,5
4o
INDICATE NORTH ARROW
Provide setback and elevation information
Provide on reverse of this form.
2 dimensions to center of septic tank manhole cover.
BENCHMARK: 're,p e- lpo5 i N"~T To Syj CORN&12 $TVr Y,6 , E-LE✓. Sa
ALTERNATE BM: 9MC-MCNT FLOOR 3191
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: WMK.S Liquid Capacity: 1000
Setback from: Well House Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: 12 Length 5'41 Number of trenches
Distance & Direction to nearest prop. line: lQ
Setback from: well: House Other
ELEVATIONS
Building Sewer ST Inlet: ST outlet: Jr.looZ
PC inlet PC bottom Pump Off
Header/Manifold--7,a Bottom of system
Existing Grade 101/ Final grade JOY
DATE OF INSTALLATION:
PLUMBER ON JOB: -Er/- X
LICENSE NUMBER: aPRS b503(D
INSPECTOR: M moi -TE to l ns
3/93:jt
Wisconsdn Department of Commerce PRIVATE SEWAGE SYSTEM Count
y
Safety and Buildings Division ST . CROIX
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) SanitarxPpur~jtNQ.:
Personal information you provice may be used for secondary purposes [Privacy L S.15.04 (1)(m)]. G tf y 3 J 4
4"
Poit H9ider's1VaKKY/OLSON , STEVE ~8AERe Town of: State Plan ID No.: 11 CST BM Elev.: TE Insp. BM Elev.: BM Description: Parcel 1S' L'-:2090-90-000
TANK INFORMATION ELEVATION DATA A9700209
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic ~i' ~rr~u~ .a rl~ i , . , Benchmark /J J
Dosing
Aeration Bldg. Sewer
Holding St/ Ht Inlet 3 U d~/
TANK SETBACK INFORMATION St/ Ht Outlet oho q
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic 7 S ;d ,a ' NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe 2~' ~0~ _ ~
Holding Bot. System 161-3
PUMP / SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
Loss i
Forcemain Len Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSION 4" DIMENSIONS
SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION TypeO CHAMBER Model Number:
System: OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length v`a 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 4 - Bed /Trench Edges ' Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: SOMERSET 15.31.19.896,SW,NW 523 217TH AVE LOT 19
~~,n ~ ,,ice} is ~:..^Y' ~ _ .1_ 1 "iY'.1-
Plan revision required? ❑ Yes E!T"No
Use other side for additional information.
SBD-6710 (R.3/97) Date I pe or's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
Safety and Buildings Division
~•pi.~R 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 Sanitar Permit Numb r
NY93g
The information you provide may be used by other government agency programs ❑ Check it revision to previou application
[Privacy Law, s. 15-04 (1) (m)]. 5A 3 ol 17 1` A vt ~ . State Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Property Owner Name Pr1 pert y Loc 1/4, $ ~S T , N, R E (or)
` 5 RY f3~ gC~N . E o~
Property Owner's Mailing Address Loth Number Block Number
19' Coy 9
City, State Zip Code Phone Number Sub ivision Name or CSM Number
b 1(7f!!r)zyx411Y1 N Z- ATC;S
IL TYPE F BUILDING: (check one) E] State Owned ❑ city Nearest Road
Public bedrooms C] Village S6 f#%gX64 M~wA■pQ~'Lt `
❑ 1 or 2 Family Dwelling - No. of Town OF 14501 _ P
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1!5.31. /9. 896 63.2-. ago _?z
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 on line B, if applicable)
A) 1. XNew 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. Repair of an
---System Tank Only______________ Existing System Existing System
-----System 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
Required (sq. ft.) Proposed (sq. ft.) (Gals/d.a lsq. ft.) (Min./inch) Elevation ,
-7 0 643 113 . / /Q/I *Z Feet 140// Feet
VII. TANK Capacity
in gallons Total # of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
New Existing strutted
Tanks Tanks
Septic Tank or Holding Tank O 7~a/r ❑ ❑ ❑ ❑ ❑
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.
Busi
Plumber's Name: (Print Plumber's Signature: (N amps) r P/I>14PR5+Af-Alo.: ness Phone Number:
L CS la 2-2 z 7/ - 75 =3 6
Plumbe Address (Street, City, State, Zip Co
00
IX. COUNTY / DEPARTMENT USE ONLY
❑Disapproved Sanitary Permit Fee (includes Groundwater Late ssue Issuin AgentSignature(NoStamps)
A roved p Surcharge Fee)
pp ❑ Owner Given Initial u~ Adverse Determination -77 CX
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SRD-6398 (R. 05/94) DISTRIBUTION: Original to Courtly. One copy To: Safety & Ruildings Division, Owner, Plumber
INSTRUCTIONS J
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit rriay 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 concerningyour onsite sewage system, contact your local code administrator or the State of
Wisconsin, Safety and Bbildin.gs 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.
IL 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 ofsystem. 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.
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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
intrude 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 REPORT Page of `S
Labor and Human Relations
Division of Safety & Buildings rnce with ILH 83.05, Wis. Adm. Code COUNTY
Attach complete site p lan on papeinch ize. Plan must include, but
not limited to vertical and horizonterect 2 d % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and locarest r
REVIEWED BY DATE
APPLICANT INFORMATION- OR ION
PROPERTY OWNER: PROPERTY LOCATION
ZON!NCiOE°FIC GOVT. LOT.iJ 114 / 1/4,S \ -T? N,R (or)f
PROPE _ OOWNER':S MAILI ADD LOT # BLQ K # SUBD AME OR CSM #
S 7 \ C• J
CITY TATE 11 ZIP COD ER ❑CITY VILLAGE MOWN NEAREST ROAD
New Construction Use Residential / Number of bedrooms [ ] Addition to existing building
Replacement ( ] Public or commercial describe
Code derived daily flow gpd Recomme ded design loading rate gybed, gpd/ft2-,,,
.~__trench, gpd/ft2
Absorption area required ! bed, ft2 trench, ft2 Maximum design loading rate ed, gpd/ft2_,,q_trench, gpd/ft2
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material - ? Flood plain elevation, if applicable 4/ 1e- ft
S = Suitable for system CONVENTIONAL MOUND IN GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable fors stem 7 S❑ U MS ❑ U IS ❑ U 2 ❑ U ❑ S ❑ S O U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Colo Gr. Sz. Sh. Bed Trench
Ground
elev.
Depth to
limiting
factor
LL
Remarks:
Boring #
Ground l
elev.
~ ft.
Depth to
limiting
factor
Remarks:
CST Name:-Please Print 1 Phone:
' - -
Address: ✓ !I
ell"
Signature: Date: CST Number:
PROPERTY OWNER SOIL DESCRIPTION REPORT Pag%~2 of
PARCEL I.D. #
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourg Roots GPD/ft '
in. Munsell Qu. Sz. nt. Color Gr. Sz. Sh. Bed Trench
Ground - S ~ln J, LJ ;7
elev.
Depth to
limiting
factor
Remarks:
Boring #
i r
12 ZL~~
Ground
elev.. ty Zz, -
-i;-12-~9q M Sef/W 41Z L- 1 //-q , ft.
Depth to
limiting
factor
Remarks:
Boring #
c
Ground
elev. -
Depth to
limiting
factor
}~l
Remarks:
Boring #
Ground
elev.
ft. F
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNEJ"UYIER
so J
MAILING A"JDRESS 0 Qk)R '
PROPERTY ADDRESS 5~ a j' ~U
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE z~-yy2 5
PROPERTY LOCATION _,v✓_ 1/4, /l//i✓ 1/4, Section T/ N-R W
TOWN OF SoajCp,5 (T ST. CROIX COUNTY, WI
SUBDIVISION A)n97- fEtFyIJ S -r qM S LOT NUMDER
CERTIFIED S URVEY MAP , VOLUME PAGE , LOT NUMBER M
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 prooerty owner agrees to submit to St. Croix Zoning a certification form, signed by the owner
and by a neater 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 staving that your septic has been maintained must be completed and returned to the St. Croix
County Zoning Officer within 30 days of the three ye iratio date.
SIGNED, JC5
DATE: C
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
Q3,,28i96 10:19 COUNTY CLERK l~JJ002/003
r
STC - lac
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.
Location of proP x~ ert-V.'S 1~ s a
1/4 1/4, Section
C p .
Township Mailing address #It
Address of site
Subdivision name kbeTtlOzrL)
_ dl9~S T- C- S Lot no.
Other homes on property? Yes No
Previous owner of property _ /yJ~ ~/I f1Eiy~?EY _
Total size of property
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 \
_Na
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 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 rug, 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.
Signat r of Applicant Co-Applicant
Eate of Signature. Date of Signature
50$21 STATE BAR OF WISCONSIN FORM 2 - 1982
WARRANTY DEED
DOCUMENT NO. I~ - _
- "heresa H fntchand stncl wcewPAwa
•+n nniicv a■r PnrVT_
_ JUN 10 1997
11:30 A M
conve and warrants to Te L. Benson and Steven t (llcen_ ~.a~,~
both single persons, as io nt tenan~s
1\!s SPACF RESERVED FOR RECORDOG DATA
ft"a no RETURN ADDRESS -
the following described real estate in Frei County.
State of Wisconsin: UJ
032-2090-90
i~11CF3 aENTIFICATIGN NUMBER
I
Lot 19, Northern Oaks Estates in the Town of Somerset, St_ Croix County, Wisconsin-
TRANSFM
I
I
This i n net homestead property
X)OM (is rod of record, if any-
Exception to warranties: Easemlents restrictions and rights-of-+iay o `
I
19 II
Dated this !I
day of June A.D 97
t ~
(SEAL)
011 I
(SEAL)
n Henry Theresa Hao~Y
~
(SEAL) (SEAL)
I
ACKNOWLEDGMENT
AUTHENTICATION
State of ~firuconsln,
signature(s) Marvin Henry, Theresa Henry ss.
County. II
n, 97 pew caac before me this day of
authenticated th ay of ,JUne , 19_ 19 the above named
I II
Kristin Ogl
i I
T1TLE: MEMBER STATE BAR OF WISCONSIN ~
I (If not, who executed the foregoing I;
authorized by §706.06. Wis. Stars.) to me know >mr Person
instrument aad i3-ledge the same. II
I
THIS INSTRUMENT WAS DRAFTED BY