HomeMy WebLinkAbout032-1048-70-100
STC - 104 PtCf1VED
AS BUILT SANITARY SYSTEM REPORT
~ JUN 05
1997
OWNER ST CF OX
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P-OWTY
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ADDRESS ~
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SUBDIVISION LOT #
SECTION T~N-R W, /T \wnofST. CROIX COUNTY, WISCO SIN LAk VIEW
SHOW EVERY I W HI 0 FE OF SYSTEM
1
ND ATE NORTH ARROW
Provide setback and elevation in rmatio on re a se of this form.
Provide 2 dimensions to center o septic an manhole cover.
BENCHMARK:
,o o'~~ l~~/U Seca✓E / •s sC'' /
ALTERNATE BM:
,a
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Liquid Capacity: /
Setback from: Well House -Ycl Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: Length Number of trenches
Distance & Direction to nearest prop. line:
Setback from: well House_ Other
ELEVATIONS
Building Sewer ST Inlet: //Q ST outlet:
PC inlet PC bottom Pump Off
Header/Manifold 17' Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION:
PLUMBER ON JOB:
LICENSE NUMBER: '2 s:i,2
INSPECTOR: _
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor andHuman Reis INSPECTION REPORT ST. CROIX
Safety and Buildings Div Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 289338
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
DOPP, KEVIN SOMERSET
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
032-1048-70-100
TANK INFORMATION ELEVATION DATA A9700154
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing
Aeration Bldg. Sewer
Holding St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Lriction System TDH Ft
Forcemain Length Dia. H Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSIONS
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type O 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 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 17.31.19.243B,SE,NE 2175 40TH STREET LOT 1
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
i
I
Safety and Buildings Division
~~■L117■1 SANITARY PERMIT APPLICATION Bureau of Building Water System!
201 E. Washington Ave.
In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
Madison, Wl 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. ° r
• See reverse side for instructions for completing this application State Sanitary Permit Number
R M'? S
The information you provide may be used by other government agency programs ❑ Check if revision to previous application
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Prope wrier ame Property Location
F /4 &IC 1/4, S T , N, R4
Propert Owner's Mailin A dres Lot Number Block Number
City, tate Zip Code Phone Number Subdivision Name or CS Number
II. TYPE BUILDING: (check one) ❑ State Owned It Nea st RoaAd
12 ❑ Village
Public 1 or 2 Family Dwelling - No. of bedrooms Town O ,
III. BUILDING USE: (if building type is public, check all that apply) Parcel Tax Number(s)
ck-?- -`oy~-yo
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. ~g New 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
11 M 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/da /sq. ft.) (Min./inch) Elevation
Feet Feet
Vi f TANK Capacity acltns Total # of Prefab. Site Fiber- Exper.
INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App-
New Existin structed
Tanks Tanks
Septic Tank or Holding Tank r ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for ins lation of a nsite sewage system shown on the attached plans-
Plum Name: Prin J Plumbe s S at mp MP/MPRSW No.: =Business Phone Number:
S~= l
Plumber's Ad res re City, St ip Code
~e <
IX. COUNTY / DEPARTMENT USE ONLY
Groundwater ate Issue Issuing Agent Signature (No Stamps)
❑ Disapproved Sanitary Permit Fee (includes Surcharge Fee)
Approved E] Owner Given Initial
Adverse Determi nation 7
X. CONDITIONS OF APPROVAL/ REASON FOR DISAPPROVAL:
SOD-6398 (R. 05194) DISTRIBUTION: Original to County, One ropy To: Safety & ituildings Division, Owner, Plumber
INSTRUC=TIONS
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.
Ill. 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 E3 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.
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DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
P.O. BOX 76
LABOR AND PERCOLATION TESTS (115) MADISO
N WI 3707
HUMAN RELATIONS
(H63.090) & Chapter 145.045)
LOCATION: SECTION: TOWNSHIP/MUNVN5a0= r OT NO.: BLK. NO.: SUBDIVISION NAME:
~ 1 /T 1 N/R 1 (or) w Somerset 1 _n La Tow
COUNTY: OWNER'S ME: MAILING ADDRESS:
St. Croix 12228 S. Main, Kalispell, Mont. 59901
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCR PTIONS: !PERCOLATION TESTS:
21Residence 3 n/a ®New ❑Replace ( 7_10_87 n/a
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN_ -GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional)
ES ❑ U ❑ S D U IS ❑ U ❑ S EAU ❑ S I U conventional step down trench
If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: class #1 Floodplain, indicate Floodplain elevation: n/a
decimal' PROFILE DESCRIPTIONS page 9 EME
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- 1 6.67 105.83 none >6.67 .42bl.s.l. 1.42bn.l.s. 4.83bn.c.s.
B- 2 6.92 105.34 none >6.92 .42bl.l.s. 6.50 bn.c.s.
B_ 3 6.25 103.15 none >6.25 .33bl.l.s. 5.92bn. c.s.
B- 4 7.00 101.65 none >7.00 .58bl.l.s 1.83bn.l.s. 3.92bn.c.s. .67bn.s.sil.*
B- 5 6.50 101.20 none >6.50 .50bl.l.s. .75bn.l.s. 5.25 bn.c.s.
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 P R PER INCH
P-
P- design rate
P-
P-_
P-
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori.
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope. upper trench=102.34
SYSTEM ELEVATION lower trench=100.15
V
40- 0-0
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INSIST IONS FOR COMPLETING FORM 115 - S BD - ua
To be a c; :curate soil test, your repo t include;
1. coinj")l to it 1,
2_ The use se arly it ! <>ther ths is a residence , -nerciai project,
3. MAXIMUM bedrooms r commercia use planned;
4. Is this a na.t _ nent syste1;
5. Co ete the rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL
SYST RULED JT LASED ON SOIL CONDITIONS;
6, Ise t:. ti') 1, here for vvriting profile descriptio ing the plot plan;
7. Iv f L locating y(.-- lest locations. g preferrc
f3. Ma ar, levation point are cle,Ay she i rn i ,
S. box-1 : :es, names, < flood plain data, ex, r1r~
s ilc .;riorts do ~r°~ N.A. in X.
t. your cur; !n yo ;,1ber;
I distribute ALL J L MUST TN THE
L,:; J At TIAIN 30 DAY: -OIL PLETION.
Rd VIATIONS i JIFIED SOIL TESTERS
at Textures oth'
BR
cob - SS
91 - LS - L
S HOVt - r
csP - ('etc:
lac'
~r - Bldg
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Bn -
3 : «11 BI B
y i oam plot
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H'W L. °
i) ureS
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VRP .11:e Point
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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 XW,%) 0AA)
Location of property_E_l/4 1/4, Section 1,T jj N-R_LT_W
Township 50r+r: Mailing address /J) ;Z6 FAM C7:
NS !h ~ 3
Address of site
Subdivision name Lot no.
Other homes on proper y? Yes No
Previous owner of property ICS( ~K I BC I ~4'q C o-H
Total size of property
Total size of parcel -3 (1'C,
Date parcel was created
Are all corners and lot lines identifiable? 4 Yes No
Is this property being developed for (spec house)? Yes J No
Volume IZ) and Page Number J/a 7 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. 31 Q ®Lf , 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.
XN
S gnatur of licant Co-App icant
0 -o1) S -Z5.5-
Date of Signature Date of Signature
v
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER ee t9~~ ~l~N 400
y J
MAILING ADDRESS 102-0 tC&7' 5-57
PROPERTY ADDRESS , 2 /75- ~
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE
PROPERTY LOCATION S_ 1/4, IV 4- 1/4, Section -7 T_3 JN-R 0 _W
TOWN OF ~Q 5C'7 ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
CERTIFIED SURVEY MAP , VOLUME , PAGE Imo, 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 year expiration date.
SIGNED: t v~~
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
J '
THIS SPACE RESERVED FOR REODRDW
WARRANTY DEED DATA
DOCUMENT NO.
531006
Yo! 1129PAGE 427 CFA. a
J U L 10 1996
9:45 A. M
This Deed, made between Patrick G. Cutler
a/k/a Patrick Cutler and Priscilla Dorn Rbata:er 1~3::3s
cutler, husband and wife, as survivorship o
marital property, Grantor, am Kevin J. Dopp RETURN erg Agency
and Kathleen A. Dopp, husband and wife, Carlson scaa Evergreen
Street
as survivorship marital property, Grantee, Osceola, WI 54020
Witnessetly That the said Grantor, for a valuable
consideration conveys to Grantee the following described coal
t estate in St. Croix County, State of Wisconsin:
1 a
Tax Parcel No: 032-1048-70-100
Part of the East One-half of the Southeast Quarter of the Northeast Quarter (E 1/2
of SE 1/4 of NE 1/4), Section Seventeen (17), Township Thirty-one (31) North of
= Range Nineteen (19) West, described as follows: Lot One (1) of Certified Survey
Map filed August 11, 1987 in Volume 7, page 1867, Document No. 429023;
Somerset Township, in St. Croix County, Wisconsin.
j 'ribs is not homestead property.
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And Grantor(s) warrants that the title is good, indefeasible in fee simple and free and dear of encumbrances
except Basements, Restrictions and Ordinances of Record and will warrant and defend the same.
Dated this day of 19!2q5•
EA.) (S)
6M
* • Mt k G. Cutler
(SEAL) ) 7L
# •Priscilla Dom Cutler
AUTHENTICATION ACKNOWLEDGMENT
Signature(s)
STATE OF WISCONSIN )
ASS.
authenticated this day of .19 Polk County )
Personally cane before me this o7 6 day
of 2rl,~.p . 19 9S` the
TnIR- MEMBI~R STATE BAR OF WISCONSIN above Aimed PaW& G. Ceder aed Prisc Me Don
(if not, .authorized by § 706.06, Wis. Stator.) Cellar to me known to be the persons who executed the
foregoiiinn,g, _instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY ~
~D
AN 1119x7
429023
c~I.h►,
CERTIFIED SURVEY MAP
Located in the E~ of the SEa of the NEa of Section 17, T31N,
R19W, Town of Somerset, St. Croix County, Wisconsin.
NE Corner Section 17 N
Z
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unplatted lands owned by others
_ _ bearings are
North line of the SEI of the NEI co o referenced to the east
S87034- 02"W 636.13' - line of the NEI of
1
3 331-0 section 17 assumed to
'
271.76' 297.62' bear N02057130"W.
681± 33.34' I 61I 33.41'
ence line I '
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3 rn SCALE: 1" = 200'
cn co
N~ 200 100 0 200
N centerline \ \ N
40th-Street 01 w I
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N ID
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a. 15.77'
SEE DETAIL 5 '
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m 624.98' 4 N a 34.27'
590.71' Ln i o 50.'04`'
Io S87o49'39"W 640.75 50.04'
n~ PRIVATE ROAD EASEMENT N i a 1
- - - S870491 39"W <n
661 Ln -j I Ln ; DETAIL
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38.15' I
604.94' OWNER
S87o49!3911WSr443.09' I
vl Janis Tow
I 228 So. Main
Kalispell, Montana 59901
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4 N
33.02' 16 6.1 APPROVED
612.41' I AU G 10 1987
N87o49'39"E 645.43'
E Corner Section 17 ST. C?O X CCU i'-'
South line of the NEB of Section 17 COMPREHENSIVE PARKS PLANNING
i ++Pd lands owned by others AND ZONING COMMITTOI