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HomeMy WebLinkAbout036-1021-20-000 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER mli ADDRESS (.,13 T 5-y 06) SUBDIVISION / CSM## LOT # SECTION /0 T_31_N-R_Z_ZW, Town of ST. CROIX COUNTY, WISCONSIN PL IEW `SHOW EVERYTHING WITHI 100 FEET OF SYST M 7 P /aS D ~r aS INDICATE NORTH ARROW Q Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. c BENCHMARK: L ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: [,J Ie5•e Liquid Capacity: Setback from: Well House a5 Other Pump: Manufacturer Model# Size Float seperation Gallgns/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: /a Length /v?$ Number of trenches / Distance & Direction to nearest prop. line: /V - /Yd Setback from: well: N House- Other ELEVATIONS Building Sewer ST Inlet: ST outlet: q9•a (o PC inlet PC bottom Pump Off Header/Manifold Bottom of system ~7• Z Existing Grade / Final grade DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/93:jt i Wisconsin Department of 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 284280 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: MICKELSON, LARRY 0. & LAURA C. STANTON CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 036-1021-20-000 TANK INFORMATION ELEVATION DATA S115-191 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark 9c, ~,w~ Dosing Aeration Bldg. Sewer Holding St/0 Inlet TANK SETBACK INFORMATION St/b'outlet /0, 27 Vent 7 TANK TO P/ L WELL BLDG. A ir Ito ntake ROAD Dt Inlet Septic NA Dt Bottom - Dosing NA Headers Aeration NA Dist. Pipe ~/~3 /ASS ~~,GJ Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand mod' r Mo el Number GPM TDH Lift Fri Syst TD Ft ead Forcemain ength Dia. Fi Dist. To Well' SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PI No. Of Pits Inside Dia. Liquid Depth DIMENSIONS Z=2 S DIMENSION SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHI Man r: SETBACK INFORMATION SypeO CHA NIT Mo el Num DISTRIBUTION SYSTEM J Header /frFarrifeh~- „ Distribution Pipe(s) x x Hole Spacing Vent To Air Intake Length Dia. Length g ~ Dia. Spacing CO SOIL COVER x Pressure Systems Only xx Mound Or At-Grade stems On y i -,T Depth Over Depth Over xx Depth Of xx Seeded /Sodded lcheB ed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ No Tonues COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: STANT(ONn.10.31.1J7.134A,NW,NEf 1773 CTY RD H i i7,r ~ ~ c _ _ ! • r-~ ~ /f , t~. CL~'L2~ F.~ Wit, / ~,t„~' ~~,C~'CN-~`'a required? ' ❑ Yes to ; Plan revision Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. i ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: Safety and Buildings Division v~■~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. G y- e ?C • See reverse side for instructions for completing this application State Sanitary Permit Number The information you provide may be used by other government agency programs (Privacy Law, s- 15.04 (1) (m)]- ❑ Check if revision to previous application [State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Property Owner Name Property Location h G GY`. /Vol 1 /4 F, 1 /4, S /d T 31 r N, R /,;~Wr) W Property Own s Mailing Address Lot Number Block Numbe(n ,S- y City, State Zip Code Phone Number Subdivision ame or CSM Number hes,r- :CCXr-y, 3 00-7 C Wt-) a fg- 3V U,z A- II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ !ty Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms To wan OF Sfcc+r~► 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. `New 2. ❑ Replacement 3_ ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an _(--__System System Tank Only Existing System Existin System B) p A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11XSeepage 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 ®D Required (sq. ft.) Proposed (sq. ft.) (Gals/da sq. t.) (Min./inch) Elevation s Cla Irv l 7, 2 Feet X00, (o Feet VII. TANK Capacity INFORMATION in gallons Total # of Manufacturer's Name Prefab. Site Fiber- Ex per- New Existing Gallons Tanks Concrete Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holding Tank /as[~ ❑ ❑ ❑ ❑ ❑ --X+ I 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. Plumber's Name: ( rint) Plumber's Signa re: No Stamps) PRSW No.: Business Phone Number: /M uih ow-S S/3_S Plurpbbjer'sAddress (Streett,,Cit~y,~tate, Zip Cod): 6` `~a /X,S -5 f6/> IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issue Issuing A ent Signature (N a s) ApProved E:] 'yf Surcharge tee) Owner Given Initial Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SHD-6398 (R. 01/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Divrion, 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. i - I - 1 ' i ! I I i I i I I I 1 I-- -1 I , _ _ I L _1 _ ~ I I I - t I - 1 , i I ~ I I i I I I I I t ~ I I I I ' 1 I W ; S 1/6 i 43> LJ I I I I I 44 , I I A , I I ~,,y~~.~t ~ , 04ci fl/-o k A~ d ~ k X i ; --I L'ar, a 57t 47 I t ! ! ~ Al --i- i u i I } I i I i , i r- I I 1~ ~ I I I j ~ T I I i I ' 1 I , I I I ! I I I - r I ~ ~ I I r ' I I I I ~ I I ~ I i I f I , I I r a -r , r i I ~ ~ I I ~ i I I f i I , I I I T I ' I I ~ I I r ~ { r i I ~ t I : ff , I i t I 1 ~Q I t L. ' I i I ! I I I I , ~ I ~ I 1 i I I ' ! ! I I I t i I r f I I I i ~ I f I I I ~ I , i I 1 I f ~ I r + t I , r i_... 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DISTRIBUTIOM PIPE APPROVED SyVPETIC COVER 2" OF AGGREGATE OR 9" OF STRAW OR tjARSU NAy• tLEV. oF11.>fE~T-.. Ier.0F21/Z AGGREGATE ~~~1 DIS-rR15UTIOU PIPE TO BE AT LEAST AVp AT LEAST LO IIJCHES BUT MORE MORE TNq?J y2EAICNES 6ELOW FINAL GRADE E MAXIMUM DEPTH of EXCAV Ioti9 , AT FKoM .o~tGINqL f 9AoF. WILL BE ec) ----L-_ 1.1C H E 5 MIt'IMVM 95Pnt OF EACAVATION •F.FZOM 1 OcZr4lWqL CRAD€ WILL BE -S24 L- 6e~_ LICEMSE DUMBER: d DAT E : _ / / wisconsin`Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings B4reau 01 "Integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code Page of-3 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 -5-f C percent slope, scale or dimensions, north arrow, and location and distance to nearest road. r ` x Parcel I. D. # APPLICANT INFORMATION - Please print all information. Reviewed by v Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). - Property Owner Property Location e kS Oyu Govt. Lot NLA) 1/4 N f 1/4,S / 0 T31 N,R 7 for) w Property Owner' Mailing Addres$ Lot # Block# Subd. Name or CSM# a- 333 / ~S _ ti r~ a City State Zip Code Phone Number ❑ City Nearest Road ~212.1'~grk 1o,~' $-ilDD'~ IS ) dyg ~ '78f ❑Village Town S-fQ ErNew Construction Use; (Residential / Number of bedrooms _ --,q Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Coda derived daily flow -Afiw gpd Recommended design loading rate bed, gpd/ft2 r~ trench, gpd/ft2 Absorption area required_ _&_bed, ft2trench, ft2 Maximum design loading rate bed, gpd$ ~ trench, gpd/ft2 Recommended infiltration surface elevation(s) _ Z,2 ft (as referred to site plan benchmark) Additional design/site considerations Parent material Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System i Fill Holding Tank U Unsuitable for systerrr`' S❑ U (Z S❑ U EA S❑ U ❑ S (4 U El S [Y U ❑ S U SOIL DESCRIPTION REPORT A, MC, AwwL~ Boring # Horizon Depth Dominant Color Mottles Structure in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots GPD/ff2 Bed Trench / o-lo jovi, 3 s/ 3 W ari, ,S /d38 0 r / Ground .1~ 8 W a . ' • elev. 7 /o r S si -7 Lj TI ~S • A L2ft. 119 l S p r,, s - 1 K Depth to limiting factor in. Remarks: Boring # G-Il /p - s~ 13- bk ~Q ati. . S ; r 4A .9 16 /sue oms Ground e Depth to limiting IEEE] factor 5 _in. Remarks: CST Name (Please Print) Signature Telephone No. L _4" -27 213 f& Address ,p Date CST Number rr tG SOIL DESCRIPTION REPORT page o PROPERTY OWNER Y PARCEL I.D.if 2 D/ft Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots Bed ;Trench Boring # Horizon Gr. Sz. Sh. In. Munsell Du. Sz. Cont. Color ` ~l'1 5 r arr I A ; , 3- fa3 / r t A; . 5 Ground rn erlev. Depth to limiting factor Remarks:' Boring # r..~ S~ h4 r sW% •.'S • ~a r 2 , r w 3*- .5 • r ~Gjjroounnd~d le-l l Y. , I Depth to limiting factor Slum Remarks: Mottles Structure Consistence Boundary Roots P Horizon Depth Dominant Color Texture Gr. Sz. Sh. Bed , Trench in. Munsell ()u. Sz. Cont. Color Boring # - s/ 1 bk rr~ 1►i o . 5 o-/ o Ground Depth to limiting fac r in. Remarks: Boring # 13 Ground `elev it. Depth to limiting factor in. Remarks: SBD-8330 (R. 07/96) 7 i : ~ t i--_I F I I ~ j ~I d I I I01 J4 - ~I , , I I i 1 t ' I I I ' t t a i ~ I I I I I , i I t ! t I _ l • ' I I I ' I I ~ ~ ' I I 1 1 , i 1 f i I } 1 I i i l l I I , 1 ~ I I I ~ t 1 I I ij,-_~.~_i i I 1; i i ; I I I T't~ _ i I ~ I I I I i I ! l I I I f I 1_ I! I ~ I_- I I I I , ~ I I 1 1 I , 1 I I i I , I I ~'I - ~ r 1~a tl ~ I I , t ~ej q , . le-A i 1 , i I I i i ' ~ - _ I III i ' I I _ I I ' I t i M1 -_II I I i I I I r I i i a t I I I l - _I I I I I t I r I T I , I I j ~ I t ,I I t _I I I I i ~ I I I it I ~ __I i I i I I I I I I- II-- j I 1 I t ~ I t 1 j I r I I ~ I . - - t I 1 t I I I t ~ I I I I I I ~ ~ I I I I i ' t I . t I ~ I t t I i . L i _ I I I- I I - STC-105 SEPTIC TANK MAMENANCE AGREEMENT St. Croix County OWNER/BUYER. A-:!X 6z3 MA=G ADDRESS 33 S_ 7 f PROPERTY ADDRESS j c 72 (location of septic system ease obtain from the Planning Dept. C=/STATE L037, 55A PROPERTY LOCATION- &&J - 114,, 1/4,. Section T~N-R-L~W TOWN OF ST. CROIX COUNTY, WI SUBDIVISION A] /P1 LOT NUMBER CERTIFIED SURVEY MAP VOLUME 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 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: C&VV-rlq 7na~ DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road - Hudson, WI 54016 11/93 • 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 housej, 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 I' s Location of property_ &V 1/4_1/4, Section T_~LN-R / 7 W Township_ Mailing address :z-a.3 r r ~p Address of site vc7 Subdivision name" V ,rl1A Lot no. All* Other homes on property? Yes_!r No Previous owner of property =4 r►x .Ld rscry-,, Total size of property 00 Total size of parcel 30 Date parcel was created its Are all 'corners and lot lines identifiable? i( Yes No Is this property being. developed for' ('spec house)-? Yes __,.'V_No Volume 0-2- and Page Number .,,)/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, cif 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-1 (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 i Deeds as, Document No. 3 ; V7 , 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. Signa a of 9pp1i4cant Co-Applicant Date of Sig-nature Date of Signature E~OUK OIJ4 PAS'fel I I C3r_- 03-2/- 20 • DOCUMENT NO. S' E BAR OF WISCONSIN FORM 1-1988.0 THIS SPACE RESERVED FOR RECORDING DATA WARRANTY DEED .434143 REGISTER'S OFFICE Jovice r . Belisle, ST. CROIX CO., WI This Deed, made between Recd for Record William H. Larson and Lori S. Fischer, as tenants in common------------------------------------------------- Feb. 2 1988 Grantor, I at 10:30 AM and__--Larry- Q.__ Mickelson_and Laura C. Mickelson ar , husband and wife, as survivor- - - s hin m Register of Deeds ------------ita l pro ne r--- Grantee, Witnesseth, That the said Grantor, for a valuable consideration.---_- - - - RETURN conveys to Grantee the following described real estate in ---S-------------- t . CrolX County, State of Wisconsin: Tag Parcel No- The West one-half of the Northeast auarter (W 1/2 of NE 1/4) of Section Ten (10)..., Township Thirty-one (31) North, Range Seventeen (:17) West. X00 PEB This Js l s _ not homestead property. (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And:---grantor warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances e'dow and will warrant and defend the same. 30+1. January is.. 8.8.. Dated this day of < - - - SEAL) (SEAL) William H. Larson * Jo ce M. Be isle -------C,~,t (SEAL) - -------------(SEAL) * Lori S. Fischer AUTHENTICATION ACKNOWLEDGMENT of William H. Larson, Signature(s) STATE OF WISCONSIN Joyce M. Belisle and Lori S. ss. Wp% --------------County. r.,_ i RANCH UNIT RANCH UNIT 9-0 X 8-0 O.H. i xy~ o u ~ m o £ c RANCH UNIT RANCH UNIT m ,rte m A o m u x N f1 O o I ➢ y t j 1 m O ' I C 16.. E 2M 3-0 z aNe , ~ m ~zz x O A A e O m 3 x 0 B r~ a z 's g ~ _m o I? z x ci i °0 1 ° 0 ~m m t x A 0 4.1 I > ~ N 3-0 m 0 4-0 4-0 3 ~ D 7m qm ~ A m 'gym xA m I > A i 00 O o o~ O TW24310 1W24310 I `n m~ o go D Z C ! ~ X A D D m 0 mo ~o mZ oo z~ Yo _z 'o o$ ~ o \ C nA Z X v 1 I 1 1 c m 1 1^ 0 so •3 I i UN. O III III III III III III 9 1/2'1-JOISTS 1s' O.C. III III III III III ~ III w III 1N2032 V `