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HomeMy WebLinkAbout032-2100-70-000 • STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER_l1___1~~~e.~ s ADDRESS SUBDIVISION / CSM# LOT SECTION _T N-R /L W, Town of_ ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM II J0,,-/7 si a JD' INDICATE N RTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. 417 - BENCHMARK: 101; , ALTERNATE BM:,~ SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer.;/)S Liquid Capacity: Setback from: Well-,Ze-2- House Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: /C5~ Length Sj , Number of trenches Distance & Direction to nearest prop. line: Setback from: well: House,,2 _ Other ELEVATIONS Building Sewer W ST Inlet: q ~Z ST outlet: PC inlet PC bottom Pump Off Header/Manifold Bottom of system Existing Grade/ Final grade DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: ZQ -9 INSPECTOR:- 3/93:jt 7` Wisconsin gepartmentof industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 299028 Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.: HARTMAN, MIKE SOMERSET CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 032-2100-70-000 00. TANK INFORMATION LEVATION DATA A9700347 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Q Septic Benchmark 0147 Dosing Aeration Bldg. Sewer „ Holding St/ Ht Inlet 6, ? S,` if TANK SETBACK INFORMATION St/ Ht Outlet X5.34' TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic yo15 a ° S! ` NA Dt Bottom Dosing NA Header / Man. q5-' gy, 71 Aeration NA Dist. Pipe 5-41 ' c( ~3 Holding Bot. System 8, 937`/ PUMP/ SIPHON INFORMATION Final Grade /qi 7, p Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft oss mead Forcemain Length Dist. To Well SOIL ABSORPTION SYSTEM BED /TRENCH Width x Len r 1 No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS l DIMEN I N LEACHING SETBACK Manufacturer: SYSTEM TO P / L BLDG WELL LAKE/STREAM INFORMATION Type O yd0, a r S ' 'd;/'A OR UN T CHAMBER Model Number: ToL" System: 7 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 tll Bed /Trench Edges: Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: SOMERSET 26.31.19,NW,SW 1946 62ND STREET LOT 17 0 64L "top Plan revision required? ❑ Yes E~No u / Use other side for additional information. SBD-6710 (R 05/91) Date Ins ctor's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: Safety and Buildings Division ~li~pry`~ li~+ Bureau of Building Water Systems v.■■„r■r, SANITARY PERMIT APPLICATION 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 i/2 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Number v?19oaf 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 Uylk_& State Plan I.D. Number L APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property er Name Property Location I~ 1/4 1/4, S T , N, R or Property Owner's Mailing A ress of Number Block Number lqwe os- /7 Cit tate Zip Code Phone Number Subdivision Name o M Num e II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ city Nearest Road l~ ❑ village 00 ❑ Public 1 or 2 Family Dwelling - No. of bedrooms _31 Town of III. BUILDING-USE: (If building type is public, check all that apply) Parcel Tax Number(s) 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. [0 New 2. ❑ Replacement 3_ ❑ Replacement of 4_ ❑ Reconnection of 5, ❑ Repair of an _____System________System_____________TankOnly - 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 1 1 0 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 ch) Elevation - Feet Feet VII. TANK Capacity gallonTotal # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existin strutted Tanks Tanks Septic Tank or Holding Tank -Q~ 01 ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for inst I ion 9f a nsite sewage system shown on the attached plans. Plum le r' ame: n Z Plumb 's Si at m MP/MPRSW No.: Business Phone Number: P u tier's A ress ( tre~et ity, State, Code): dR /0 , 1/1 /w IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps) Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination - X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05/94) DISTRIBUTION: Original to county, One copy To: Safety & Buildings Divi ion, Owner, Plumber INSTRUCTIONS 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. 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 8 112 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. r ys~1 W Wisconsin Department of Industry, SOIL AND SITE EVALUATION Page of Labor and Hbrhan Relations 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 S I percent slopek scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # APPLICANT INFORMATION - Please print all information. Reviewed by r ; to Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). ^ Prope Owner Property Location Govt. Lot 1/4 1/4,$- T ~ i f> or )A_ It V Property Owner's Mailing Address Lot # Block# Subd. N me orM h, ~4A``Cz Cry ft,~ 01 City Sta Zip Code Phone Number _ -Na&rAs 140 ❑ Cii. Village 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/f12_z_j/a_trench, gpd/ft2 Absorption area required,4j2~ bed, ft2_Z14(2_trench, ft2 Maximum design loading rate . bed, gpd/ft2_1_(~__trench, gpd/ft2 Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design/site cqnsiderations Parent material ~ a ,'!~Vfiy 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 IRS El U Es ❑ U El S ❑ 1 ❑ S U ❑ S au SOIL DESCRIPTION REPORT Horizon Depth Dominant Color Mottles Structure GPD/ft2 Boring # Texture Consistence Boundary Roots Bed Trench in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Pf 14 Ground eev.ft' - Depth to limiting factor in. Remarks: Boring # le i~r:~44 Al Ground elev. Depth to limiting factor _'~Lin. Remarks: ' CST Name (Please P ' t) Signature ' Telephone No. / - 11 Address Date CST Number jt -z ? elel PROPERTY OWNER SOIL DESCRIPTION REPORT dm~` 17 Page of PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots vp/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench 91 ;L 1 Ground elev. a 21(aft• _ Depth to limiting factor _in. ; Remarks: Boring # Z Al - f Ground elev. Depth to limiting facto ~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 # 10A. A, /V C'ZI Z S-yc°G ~ s - t P Ground elev. Depth to limiting ; factor 'n. Remarks: Boring # 6-/7 129 sy2~y Ground elev. ~ft• Depth to limiting factor _16 in. Remarks: SBDW-8330 (R. 08/95) aT ~y - . 3/5: :149J I- STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER G MAILING ADDRESS a ,r 3t~ ~ PROPERTY ADDRESS -~r~- r9i<a arc, (location of septic system) Please obtain from the Planning Dept. Y?~ CITY/STATE PROPERTY LOCATION 1/4, s- ,r 1/4, Section , T_W _N-R-_ / 2 W TOWN OF ST. CROIX COUNTY, WI SUBDIVISION Ali P LOT NUMBER CERTIFIEDSURVEY MAP VOLUME -L 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 on-site wastewater disposal system is in proper operating condition and (2) after in peontand 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 ow SI4eD AATE;: :'dr • gTC - 100 'phis applica is to be completed in full'and signed by the owner (s) of apsrty being developed. Any inadequacies will only resu delays of the permit issuance. Should this developme intended for resale by owner/contractor, (spec house), second form should be retained and completed when the pro is sold and submitted to this office with the. approp deed recording. 0 property - G 4------- ion of roperty//r1 1/4_,Sj 1/4, Section` N-R1<9 W ship _Mailing address 1- Address of site t4 Subdivision name P,"Z CITT Lot no. Other homes on property? Yes No Previous owner of property _ Total size of property Total size of parcel I> kc~ Date parcel was created Si SL Ly q Are all corners and lot lines identifiable? _Y, -Yes No Is this property being developed for (spec house)? X 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 i ice of the County Register of -O/P7 Deeds as Document No. ~a and that I (we) presently own the proposed site for he 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 o fice f the County Register of Deed-s~cument No. S atu of Applicant o-App cant .d;" to dv.''.lL: ~!'.:l►_:' srf ~.i~+[:1~AC. M r ~ S~pry~A I State Bar of Wisconsin Form 2 - NtI: E;A WARRANTY DEEDQFF~~ OOCU•MENT NO_6 t;t: 1995 a:,~ F George T. Pennock, a/k/a George Pennock, at o A.U conveys and warrants to Pined i f f ec ~a f I 1 - W to- THIS SPACE RESERVED "M RECORDING DATA NAME AND RETURN ADONESS the following described real estate in St. Croix r~0>~+~'ti` 1Q County, State of Wisconsin: IRW t i (Parcel Identification Number) W1/2 of Nil/4; SE1/4 of NWl/4; NE1/4 of SW1/4; all that part of NW1/4 of SW1/4 lying Ely of Apple River and that part of Sr7/4 of SW114 lying Ely of Apple River; all in Section 26• and all that part of NE1/4 of SE1/4 lying E1 of the Apple River of Section b; All in Townshi 31 North, Y Wisconsin. p Range 19 West, St. Croix Count y, i J I ~ . is not This homestead property. (is not) Y Exception to warranties; EBSeRlents, restrictions and rights-of-way of record, i if any. Dated this day of may . 19~... • (SEAL) (SEAL) ~ ennock • (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT T. Pennock, a/k/a STATE OF WISCONSIN SL !Ia y p -4 count. R day of May 95 Personally came before me this day • . 19_ the above named Ji Land - ~ TI B~•R STATE BAR OF WISCONSIN {If authorized by 1706.06, Wis. States) I e me known to be the person who executed the i TH13 INSTRUMENT WAS DRAFTEn wv foregoing instrument and acknowledge the same. ST. CROIX COUNTY WISCONSIN ZONING OFFICE p p N lop lip 11 p rMrN6 ST. CROIX COUNTY GOVERNMENT CENTER - 1101 Carmichael Road Hudson, WI 54016-7710 (715) 386-4680 November 26, 1997 Hartman Homes, Inc. Attn: Becky 1970 62nd Somerset, WI 54025 RE: Septic Inspection for Mike Hartman located at 1946 62nd Street, Pinecliff Lot 17, Town of Somerset, St. Croix County, Wisconsin Dear Becky: An septic inspection of the above referenced property was conducted on November 4, 1997. This property is located in the NW1/, of the SW1/ of Section 26, T31N-R19W, Pinecliff Lot 17, 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. S'ncerely, 0 P4'0-~ Mary J. Jenkins Assistant Zoning Administrator sm