HomeMy WebLinkAbout032-2099-20-000
STC 104
AS BUILT SANITARY SYSTEM RE RECEK0
to
1997 d
OWNER ,E - Olt) -
ST ORM
ADDRESS zf)AlINBOFFICE
SUBDIVISION / CSM#LOT #
SECTION T_N-R 9 W, Town of
ST. CROIX COUNTY, WISCONSIN Sr
9Y-, 11
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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INDLCATE NORTH ARROW
Provide setback and elevat'on infor ation on reverse of this form. \~S'ntQrp Provide 2 dimensions to c ptic tank manhole cover.
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Wisconsin bepartmentof Industry, PRIVATE SEWAGE SYSTEM County:
,Labor and Buildings Relations INSPECTION REPORT ST. CROIX
Safety and Buildings s Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 284309
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
HARTMAN, MIKE/PINECLIFF PRTNRS PSOMERSET
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
032-2099-20-000
TANK INFORMATION ELEVATION DATA A9700079
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic ~o Benchmark loo.
Dosing ?
Aeration Bldg. Sewer
Holding St/Ht Inlet 2 5.Z 13
~
x
TANK SETBACK INFORMATION St/ Ht Outlet •1 .?~i - 1~
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic L25 95 / NA Dt Bottom
Dosing NA Header/Man. Q3,25
Aeration NA Dist. Pipe
98, ~5
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand L? 9, L515
Model Number GPM
TDH Lift Friction ystem TDH Ft
Forcemain Length Dia. Fi Dist. To Well Z::~l SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 9 75- DIMENSIONS
SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK CHAMBER
INFORMATION Type O e_, Model Number:
System: `~`C_CQ 95 ` ILO r tj//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 f ` Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: SOMERSET.26.31.19,SW,NW 62ND AVE LOT 2
r)
Plan revision required? ❑ Yes B"*N'o
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert No.
ADDITIONAL COMMENTS AND SKETCH '
SANITARY PERMIT NUMBER:
1
' oE:~ aMas _ F
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
than 8 112 x 11 inches in size.
• See reverse side for instructions for completing this application State anitary Permit umber
The information you provide may be used by other government agency programs 2 8 Z/sO 9
❑ 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 y caner m Property Location
- 114 1/4, S T , N, R (ore
ropert Owner's Mailing AcIcI~ess Lot Num er Block Number
Cit ate Zip Code Phone Number Subdivisi Name or umber
II. TYPE OF BUILDING: (check one) [I State Owned vlage Nearest Road
~p
Public 1 or 2 Family Dwelling - No. of bedrooms Town OF
Ill. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) ~a
1 ❑ Apartment/ Condo 0~ lE . 9 / , / ` , '7 77- 19-° ~®7
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. Dd 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 (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. Pert. ate 6. System Elev. 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./i ch) Elevation
Feet Feet
VII. TANK Capacity
INFORMATION in gallons Total # of Manufacturer's Name Prefab. Site Fiber- Plastic Exper.
New Existing Gallons Tanks Concrete Con- Steel glass App.
strutted
Tanks Tanks
Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATE-MENT
I, the undersignpd assume responsibility for ins II ti o onsite sewage system shown on the attached plans.
Plu b "s Na r Plumb s S ailN a s) MP/MPRSW No.: Business Phone Number:
Plumbe s Address( tr t u, Cit St te, Zip Cog&
b Vi c0
IX. COUNTY/ DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No Stamps)
1YI A roved Surcharge Fee)
r' Pp E] Owner Given Initial 410, Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: 6f V
SBD-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 maybe renewed before the expiration date, and at a time of renewal any nevv 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.
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.
iS i~am.~ srJ' iUw/-sev1 °l.~ir✓ no
Wisconsin Department of Industry, SOIL AND SITE EVALUATION
Labor and Human Relations Page of
Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis.
e /
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County
1.
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. par . # le
APPLICANT INFORMATION - Please print all information. R ' ed by` 4 t `t b i W w 0
ate
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). 1 ,.3QIX
Prope Owner / Property Location
GE
Govt. Loth 1/4 /4 GO 1:~ E (or)6
'-20) -.Le '12 / Aek're
Property Owner's Mailing Address Lot # Block# Subd. t~q
1
City Sta)e Zip Code Phone Number Nearest Road
c ~ ~ ) ❑ Cii~ Town
New Construction Use: ® Residential / Number of bedrooms Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow 6 gpd Recommended design loading rate bed, gpd/ft2-1--~trench, gpd/ft2
Absorption area required ~R _bed, ft2 ,trench, ft2 Maximum design loading rate 2 bed, gpd/ftz_,gtrench, gpd/ft2
Recommended infiltration surface elevation(s) !29 ft (as referred to site plan benchmark)
Additional design/site considerations
Parent material C Flood plain elevation, if applicable ft
S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank
U = Unsuitable for system S❑ u MS ❑ U E3 S❑ U ®S ❑ U ❑ s
U ❑ S U
9 2
i
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
^
LL
Ground
elev.
39, a rift. , D 5 ` _
WE, Ale
Depth to -xf
limiting ;
factor
min.
Remarks:
Boring #
1 1/15-'/3 ! s .z
3 /6 ~ as
,3 S L i ;
Ground
elev.
Depth to
limiting
factor
min. Remarks:
CST Name (Please Print Signature Telephone No.
t 9' /
Address
Date CST Number
a
Z", J L el,-_7J9 VV
SOIL DESCRIPTION REPORT
PROPERTY OWNER Page of
d6r'
PARCEL I.D.#
Horizon De th Dominant Color Mottles Structure 2
Boring # P Texture Consistence Boundary Roots Mft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed 'Trench
i
7 J
-1,o)e41-z Al 14.
Ground 1-
elev.
Depth to
limiting
factor ,
Remarks:
Boring #
`6 5
Ground _ S 'c -
-A4 41/1" elev.
Depth to
limiting
factor
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
V/
Ground S 14J
elev. k f ; P
Depth to
limiting
facto
in. Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
SBDW-8330 (R. 08/95)
A& yy
:
:
o
l
/
A-d i
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 (C e
~ ~ ~i ~..c,•-S
Location of property 1/4 _1/4, Section ,Tft_N-R_Z_2_W
Township S orney-sC-f Mailing address P-50x 33<v
Address of site `
Subdivision name Lot no. a
Other homes on property? Yes No
Previous owner of property ~~e6E ~'t,AWOA
Total size of property -9,~0a
Total size of parcel - AIL4
Date parcel was created JK 1N j Iq ql~
1 I
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house) ? Yes No
Volume and Page Number Ut~ 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 e office of the County Register of
Deeds as Document No. !51;2 D , 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.
Signature o pplicant Co-Applicant
/ 7 4
Date of Signature Date of Signature
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
/
OWNER/BUYER a r ~m~ r l"` C~L^
MAILING ADDRESS P y 3a (O ~j m GSE7 t,Jl - 5-
PROPERTY ADDRESS
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE /y J ) n 6e j
PROPERTY LOCATION _'Su1 1/4, h/ 1/4, Section T,4-
TOWN
OF c o-27?,~,C JE-( ST. CROIX COUNTY, WI
SUBDIVISION 40iA) E LOT NUMBER ~
CERTIFIED SURVEY MAP . VOLUME __J~,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 property 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 re ed to the St. Croix
County Zoning Officer within 30 days of the three year expiration date.
SIGNED:
DATE;
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016
11/93
4
_ J. t:v +lit.~i~ ; s' _f+ _ R'!'~~r Stale Bar of Wisconsin Form 2 - ISM
J C7 WARRANTY DEED XGWER'S 0 FF c
ST CROIX Ca.,
VAI DOCUMENT NO. _ RoedttXF-,-
MAY 9 1995
George T. Pennock, a/k/a George Pennock,_ 11:09 A..1
F~~~rrc.+n~, as
conveys and warrants to Pinecliff Partnership
THIS SPACE RESERVED FDA RECORDING DATA
v~NAME AND RETURN ADDRESS
the following described real estate in St. Croix
County, State of Wisconsin:
(Parcel Identification Number)
W1/2 of W1/4; SEl/4 of NWl/4; NE1/4 of SWl/4; all that part of NW1/4 of SWl/4
lying Ely of Apple River and that part of Sr7/4 of SW1/4 lying Ely of Apple River;
all in Section 26• and all that part of NE1/4 of SE1/4 lying Ely of the Apple
River of Section 127; All in Township 31 North, Range 19 West, St. Croix County,
Wisconsin.
SF00
This is not homestead property.
)W(is not)
Exception to warranties: Easements, restrictions and rights-of-way of record,
if any.
I
Dated this 64 day of May
(SEAL) _ (SEAL)
• George Pennock, a/k/a GAorQe Penna,k
(SEAL) (SEAL)
a •
AUTHENTICATION ACKNOWLEDGMENT
got!
T. Pennock, a/k/a STATE OF WISCONSIN
at
R ~Y 95 County.
3al-j Y , 19_- Personally came before we this day of
19_ the above named
. d land -
i TI B1CR STATE BAR OF WISCONSIN
(If n
authorized by §706.06, Wis. Stats.) Ito me known to be the
i person who executed the
foregoing instrument and acknowledge the same.
ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
n n x u M n r u ST. CROIX COUNTY GOVERNMENT CENTER
- - 1101 Carmichael Road
Hudson, WI 54016-7710
(715) 386-4680
July 15, 1997
Hartman Homes, Inc.
Attn: Becky
P.O. Box 326
Somerset, WI 54025
RE: SEPTIC INSPECTION FOR MIKE HARTMAN/PINECLIFF PARTNERSHIP
LOCATED AT 1976 62ND STREET, TOWN OF SOMERSET, ST. CROIX
COUNTY, WISCONSIN
Dear Becky:
An inspection of the septic system for the above referenced address
was conducted on July 2, 1997. This property is located in the
SW 1/4 of the NW 1/4 of Section 26, T31N-R19W, Lot 2 of Pinecliff,
Town of Somerset, St. Croix County, Wisconson. At the time of the
inspection, this septic system was found to be code compliant for
a four (4) bedroom home.
If you have any questions or concerns regarding this, please call
our office at (715) 386-4680.
Sincerely,
Mary J. Jenkins
Assistant Zoning Administrator
sm