Loading...
HomeMy WebLinkAbout032-2100-10-000 i r i STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER X~' - ADDRESS j 2=21 ~ '✓nS~ SUBDIVISION / CSM# LOT SECTION ~j _TN-RW, Town of _2 7 ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 'a 'e/../ A Q J'' Sh INDICATE NORTH ARROW P ovide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. i BENCHMARK: Efl ALTERNATE BM: ? SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: / Setback from: Well__,4,~_ House 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 /66.93 ST Inlet: ST outlet: 71 PC inlet PC bottom Pump Off Header/Manifold LV7 Bottom of system Y Existing Grade Final grade DATE OF INSTALLATION: _ PLUMBER ON JOB: LICENSE NUMBER: ~Qs~ INSPECTOR: 3/93 : j t ~^7 Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Hun)an Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitary PermitNo.: GENERAL INFORMATION 299041 HARTMAN,s NMIKE (PINECLIFF PTNRS ~O9 SEarjye Town of: State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: / 032-2100-10-000 TANK INFORMATION ELEVATION DATA A9700358 TYPE MANUFACTURER CAPACITY STATION VBS HI FS ELEV. Septic ~4-~XP'64 Benchmark to •/y, 2 Dosing Aeration Bldg. Sewer Z, X00,93 ` Holding StM Inlet 3 /o %a i TANK SETBACK INFORMATION St/Outlet 6. Y5-1 o o. G9 TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe 5/ ' Holding Bot. System 9 4 4' 9q, yg ' PUMP/ SIPHON INFORMATION Final Grade J-1VI 10,2, Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft I Loss 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 /d, / 551 1 DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE / STREAM LEACHING Manufacturer: SETBACK INFORMATION Type O CHAMBER Mode Number: System: -e6r,0 5~+7 Q ,l4 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 a$ Bed/ Trench Edges a a 6 Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: SOMERSET 26.31.19,SW,NW 1958 62ND STREET LOT 11 G°:' /~-!'1Jr..„a..,. •C2_af'c ? v U VU A-tj Plan revision required? ❑ Yes [31N o Use other side for additional information. 1y 1 1/7(l 6 ;J 6 SBD-6710 (R 05/91) Date ctor's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: bwo Safety and Buildings Division vp`'•'■; 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 Pef rmit Number ~ y`10I/ The information you provide may be used by other government agency programs ❑ Check it revision to previous application [Privacy Law, s. 15.04 (1) (m)]. s/Y inA n . State Plan I.D. Number 1. APPLI ATION FORMATION - PLEASE PRINT ALL INFOR A ION Propert ner Name P rty Location I 1/4, S T , N, Ror) W Property Owner s ailing Addres Lot Number Block Number Zip Cod " Phone Number Subdivisi Nam o M Number Cit tate > S"~ ( ) JP I Ill. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road ❑ vll age Public 1 or 2 Family Dwellin - No. of bedrooms Town OF so 111. BUILDING USE: - (if building type is public, check all that apply) Parcel Tax Number(s) ate - 3/.19.950 C_Z.~) -,-,-2ioo 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. %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 ;9 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/day/sq. ft.) (Min./i h) Elevation Feet Feet x Z Ai 99 Capacity VII. TANK in gallons Total # of Prefab. Site Fiber- Plastic Exper. INFORMATION Gallons Tanks Manufacturer's Name Concrete strutted con- steel glass App. New Existing Tanks Tanks Septic Tank or Holding Tank ' ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the dersigned, assume responsibility f ins I ion of onsite sewage system shown on the attached plans. Plum Nam P JPlumb s nat ( a s) MP/MPRSW No.: Business Phone Number: Plumber's Ad ress (Strptt -Ci ,State, ode): .~~1 19- bl'h_ IX. COUNTY / DEPART NT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issue Issuing Agent Signature (No Stamps) Approved ❑ Owner Given Initial -d ` Surcharge Fee) r,~ Adverse Determination ! o '7 X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: L SHD-6398 (R. 05/94). - DISTRIBUTION: Original to county, One cupy To: Safety & Buildings Divr ion, 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 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. 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. ~J r ~ S`~,rc~,~ L~~- ~ y~7~ ,taw, sm~ ~~~~~~,~s , J ~ ids ~3; .~1~,~ .S;z,~ - ,~z~~y q~~~~~~ h ///J ji ~ y ' ` r~ ~ / ~ 4 ' w°~ j ~~nG ~ ~ / ~ ~ Q~~~ ,~~-'mow-~ Wisconsin Department of Industry, SOIL AND SITE EVALUATION I abor any Human Relations Page of Division o. Safety and Buildings in accordance with s. ILHR 83.09, Wis. County Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must \ 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. Parcel I.D. # F-: " fe APPLICANT INFORMATION - Please print all information. Reviewed b ,f 14 Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).q Props Owner Property Location .y,.,t~,.i^E Govt Lot 1/4 1/4, T ,N,kt (or)~ MIA) Property Owner's Mailing Addres Lot # Block# Subd. Name or CS / f City Stag Zip Code Phone Number El Nearest Road City Village Town S` New Construction Use: © Residential / Number of bedrooms Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow j~&^- gpd Recommended design loading rate bed, gpd/ft2--L-Y-trench, gpd/tt2 Absorption area required Q9 bed, ft2 -<2? trench, ft2 Maximum design loading rate _ 7 bed, gpd/ft2_LL_trench, gpd/ft2 Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design/site considerations Parent material 22&C2.4;L-~ 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 0S ❑ U © S ❑ U 0 S ❑ U ® S ❑ U ❑ S ❑X U ❑ S 0 U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure GPD/ft2 Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Ground 3 elev. . /aft. .e Depth to I limiting - factor Remarks: Boring # B 3 Al m 7 ~ S / 1A "I-V Ground _ s i elev. _ 'VZ 17 .16 Depth to limiting factor _Z~Lin. Remarks: Signature Telephone No. CST Name (Please Prin) f. Y 1Z Address Date CST Number SOIL DESCRIPTION REPORT Page~of_, PROPERTY OWNER PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Structure 2 g in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench - , 7 U7,31 e4& lz~ Ground ~ elev. ©r~s Ztft. 15 8 - - 21 Depth to limiting factor in. Remarks: Boring # ~f a zfzh -All, 3 7 Ground AZf AZ/0 XA -7 elev. Depth to limiting factor ZQ_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 # " S bf, 79 XS-V 3~1 A/Z 7z -7 g Ground elev. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBDW-8330 (R. 08/95) 7MAIAq 4) /VIC tea . { S _ `b 1010 1 STC•105 SEPTIC TANK 1r7UlIlVTENAN AGREBNMNT St robs Cooaty OWNER/BUYER MAILING ADDRESS PROPERTY ADDRESS (location of septic stem) Please obtain from the Planning Dept. CITY/STATE , - PROPERTY LOCATION) 1/4 Section T_4~_N-R_Z2 _W TOWN OF ST. CROEK COUNTY, WI SUBDIVISION LOT NUMBER CERTIFIED SURVEY MAP_, VOLUME. PAGELOTNUMBER 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 o acre led this roAeration prior to July 1, 1978. St. Croix County p program in August of 1980, with the requirement that owmers 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 dater. SIGNS DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 8TC-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 oidner/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. r Owner of property Location of property _7!g-tj 114 1/4, Section ,T_4_N-R_j~_W Township Mailing address. Address of site -7 yZe- Subdivision name Lot no. Other homes on property? Yes No Previous owner of property ' ' 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)? I--,- Yes No 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 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 of Applicant Co-Applicant Date of Signature Date of Signature SZ8 /J9 I State Bar of U;'isconcin Form 2 - 1lt: 1I I • ~ C~ / J WARRANTY DEED G~.S DOCUMENT NO. ST CROIX C-3 I~ Roed fur R,,; George T. Pennock, a/k/a George Pennock MAY 9 1995 at 11:00 A. I I FI;? ~rrc.+t-E, I conveys and warrants to P, neck ff partnerhi - W l o' 7 NIS SPACE RESERVED F04 RECORDING DATA NAME AND RETURN ADDRESS the following described real estate in - St Cl OiX County, State of Wisconsin: i (Parcel Identification Number) 1 W1/2 of W1/4; SE1/4 of NW114; NE1/4 of SW1/4; all that pant of NW1/4 of SW114 lying Ely of Apple River and that part of SiU/4 of SW1/4 lying Ely of Apple River; all in Section 26• and all that part of NEI/4 of SE1/4 lying Ely of the Apple River of Section 17; All in Township 31 North, Range 19 West, St. Croix County, Wisconsin. M t J ptANSFED This 18 not homestead property. 1~~(is not) E:cepcioo to warnnciex Easements, restrictions and rights-of-way of record, if any. Dated this A 44A day of - Mrirr 19.. • (SEAL) _ (SEAL) • George Pe mKk.-Ak[L Pennock (SEAL) - (SEAL) AUTHENTICATION ACKNOWLEDGMENT ' Qbll T. Pennock, aA/a STATE OF WISCONSIN sa. r, RY 95 County. y of - , 19_- Personally came before me this day of • , 19_ the above named land - TI B'R STATE BAR OF WISCONSIN (if a authorized by §706.06, Wis. Ststs.) I* me known to be the persc u who executed the THIS INSTRUMENT WAS DRAFTED BY Foregoing instrument and acknowledge the saint. I Kristina Ogland _ • .s \ c>T. CROIX COUNTY WISCONSIN ` ZONING OFFICE M n n r n n r n n ■rrr6 ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016-7710 (715) 386-4680 January 5, 1998 Hartman Homes Attn: Becky P.O. Box 326 Somerset, WI 54025 RE: Septic Inspection for Mike Hartman located at 1958 62nd Street, Pinecliff Addition Lot 11, Town of Somerset, St. Croix County, Wisconsin Dear Becky: A septic inspection of the above referenced property was conducted on November 11, 1997 This property is located in the SW1/, of the NW1/, of Section 26, T31N-R19W, Lot 11 of Pinecliff Addition, Town of Somerset, St. Croix County, Wisconsin. At the time of the inspection, this septic system was found to be code compliant for a three (3) bedroom home. If you have any questions regarding this, please contact our office at (715) 386-4680. Sincerely, Mary en Pins 4~ Assistant Zoning Administrator /sm