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HomeMy WebLinkAbout036-2003-30-000 STC - 104 RICE AS BUILT SANITARY SYSTEM REPORT JAM 19 98 OWNER ST CRTY tf f Ci0l1NTY ZONINGOFFICF. ADDRESS, dj L , SUBDIVISION / CSM~p^ LOT SECTION T N-R 7 W, Town of I-SY ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM i y~ sit, INDICATE NORTH ~RR W Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. i BENCHMARK: + ALTERNATE BM: C,, ~xa1 X95 SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: S Liquid Capacity:! Setback from: Well House Other ,ZZ Pump: Manufacturer Modell Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: Length ~7- Number of trenches Distance & Direction to nearest prop. line: Setback from: well:_ House Other ELEVATIONS Building Sewer ST Inlet: ST outlet: 2C F 7 PC inlet PC bottom Pump Off Header/Manifold - Bottom of system Existing Grade Final grade DATE OF INSTALLATION: 2 - t!~ PLUMBER ON JOB: i , LICENSE NUMBER: 91 INSPECTOR: 3/93:jt Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: Safety and Buildings Division INSPECTION REPORT :5t Croi A GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 3~-76 ©Z Permit Holder's Name: ❑ City ❑ Village ® Town of: State Plan ID No.: ae✓id I)a CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: too '066 0,3& TANK INFORMATION ELEVATION DATA 417oo 57cj TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Se tic O Bench rl ,,,a r.--K bs o p Dosing k- PA 8.3 S 3 3 Aeratio Bldg. Sewer AVAil5i, -.04 Holding e5?w inlet 2Z TANK SETBACK INFORMATION Outlet 9y:o7 TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake eptic ~5r t 3?~ NA Dt Bottom Dosing NA Header / Man. Aeration Dist. Pipe 95ev/ Holding Bot. System ?w ?.3 7/ PUMP/ SIPHON INFORMATION Final Grade f~.Ap 477 Manufacturer mand - 0i D►9ne'A Z g•~ Goo.B Model Number Z•SC2 1 ce•$3 TDH L' Friction ystem TDH Ft Forcemaln Length Dia. Fi Dist. To Well SOIL ABSORPTION SYSTEM BE TRENCH Width I Length 1 No. Of PIT No. Of Pits Inside Dia. Liquid Depth IMEN I N I DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE/ STREA CHING turer: SETBACK CHAMBER INFORMATION Type O 1 fOG i y- Mo el ber: System4"~1,e O DISTRIBUTION SYSTEM Header/Manifold ODistribution Pipe(s) rl x Hole Size x Hole Spacing Vent To Air Intake Length # Dia- 7 Length '71' Dia. Spacing 1?V4 -7A701, SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over FBed/ h Over xx Depth Of xx Seeded/ Soddedxx Mulched Bed /Trench Center Tren ch Edges Topsoil E] Yes E] No C] Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) 1, 'A14. Bm - & , j ?A lw"f X141 'P, ntJ 12,4 0-01 Plan revision required? ❑ Yes VQ No / Use other side for additional information. IZ ZZ a G! s SBD-6710 (R.3/97) Date Inspector's ignature ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: r Safety and Buildings Division `~SC011S%11 SANITARY PERMIT APPLICATION Po ~X~ Washington Ave. Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8112 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Number ' 3o-7 (a a2 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 INF RMATION Prope y Owner Name P operty Location 1/4 1/4, S T , N, R,/ ~7 fa✓(or Property Owner's Mailing A 40 ress Lot Number Block Number l2 13 City, ate Zip Code Phone Number Subdivision Name or CSM Number n~ C ( 11 T PE B ILDING: (check one) E] State Owned ❑ ity Nearest Road ❑ vIl age 1-1 Public 1 or 2 Family Dwelling - No. of bedrooms own OF 4 d III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 3J.3/. f 7. & 3A 3~- 003-36 1 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 [g 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. 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 gallons Total # of Prefab. Site Fiber- Exper. INFORMATION New Existing Gallons Tanks Manufacturers Name Concrete. struCon- tted Steel glass Plastic App Tanks Tanks eptic Tank 1200, ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber -L+ ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for instal tion of the onsjte sewage system shown on the attached plans. Plumbe ' Na iht) Plumber' Sign r St MP/MPRSW NO.: Business Phone Number: / - P umber' c dr ss ( eet, ity, tat ip Code): ~ 1 IX. COUNTY / DEPART ENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing Agent Signature (No Stamps) N Approved ❑ Owner Given Initial / Surcharge Fee) Adverse Determination 1GV 12.- 0 97 f X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: ~'~b fa'` Irl.Sp~ t fCis-h aukk ~o~'rv~ t/~% cowv*tglSe ri. IC L , vs~dp ~Do 0 SBD-63 (R:11196) 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 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, 608-266-3151. 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. r „dG Q ~~/~6be! .Vs' S w~l l u5 c' ,/ovd4l 7-2 vliisconsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page of Bureau of Integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 112 x 11 inches in size. Plan must County 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. S APPLICANT INFORMATION - Please print all information. Riewed by Data Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). 1 12• 11 "917 Pr Owner Property Location 7/,,/,, Govt Lot sCi 1/4s 1/4,S T ,,R )?f(or) Property Owne s Mailing Address Lot #k Block#f Subd. Name or ` City StaI Zip Code Phone Number El city tillage 10 Town Nearest Road r 1, ( s 7 l ni ❑ New Constriction Use: [Residential / Number of bedrooms Addition to existing building C9 Replacement ❑ Public or commercial - Describe: Code derived daily flow gpd Recommended design loading rate _ , I_bed, gpoltl2___?___trench, 9P? Absorption area required -bed, ft2 z5 ~tt1rench, ft2 Maximum design loading rate bed, 9P~~ . 9PW Recommended infiltration surface elevation(s) /S, 7 it (as referred to site plan benchmark) Additional design/site considerations l - , Parent material Flood plain elevation, it applicable ft Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in FII THolding Tank Unsuitable for system p S❑ U Ms 0u ®s ❑ u 10s ❑ u ❑ s ®u ❑ s® u LL_ SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/112 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench ' S 13 Ground 7?h elev. ft. Depth to _T 7: S limiting factor Remarks: ell Boring # 13 151?-1Q8 ex-l"I _T .9 Ground elev. Depth to limiting factor yin. Rem rks: CST Name PI e P ' t) ~ Signature Telephone No. Address Date CST Number SOIL DESCRIPTION REPORT PROPERTY OWNER Z&Z2 2~L' d.:4 Page of, -Z PARCEL I.D.# Boris # Horizon Depth Dominant Color Mottles Structure 2 9 Texture Consistence Boundary Roots G~Dtft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench X, Z' Ground elev. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/fl2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # Ground elev. ft. Depth to limiting factor in. Remarks: Boring # L Ground elev. ft. , Depth to limiting factor in. Remarks: SBD-8330 (R. 07/96) All. d0 XJi>~.~,~ ,✓~lCl~ M~•1.~ ~/lt ~ 889,E .E,~/Lb.O ~ /r .33o) y~ yy - STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER z4d,,"O ~~AWZ7 MAILING ADDRESS PROPERTY ADDRESS (lo ation of septic system) Please obtain from the Planning Dept. CITY/STATE II)t PROPERTY LOCATION, _1/4, 1/4, Section T__ZZ__N-R Z 7 W TOWN OF ST. CROIX COUNTY, WI SUBDIVISION _ 7C~~vcs LOT NUMBER_ CERTiFIEDSURVEY MAP , VOLUME_, PAGE , LOT NUMBER - 1 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 I, 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 a,id 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. UWe, 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 Bpi ation ate. SIGNED: DATE: E?J 1?7 St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 8 T C - 100 c ` 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 Location of property S(,4] 1/41/4 , Section 1 , T__fLN-R_2_7-W Township Mailing addr ss ZA"e Address of site Subdivision name Lot no. 1 / Other homes on property? Yes. No Previous owner of property 'Z2L Total size of property Total size of parcel Date parcel was created Are all corners and lot lines identifiable? Y Yes No Is this property being developed for (spec house) ? Yes _-Z _No Volume ~rS~S~ and Page Number,,2-~'~Q 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 pp icant Co-Applicant f FAJ hi 7 Date of Signature Date of Signature ` DOCIMMNT NO, *MOW I GJ STATE sAlt OF ttSCt Ai-! DUD ~ von 545 PA"E c. THIS SPACE ftt-!;IVEO Ort t:d10AG DATA 1 3365 BY TMS DEED, Harry W. Hop and Ruth B+HoP, REGISTERS OFHCE husband and wife, „ S1. CROIX 04., WIL Ra6'& for Record Ws_ , Arvid M. Flanum and day tai .1 X,_ -A a 191E Grantor conveys and warrants to Ramona J. Flanum, husband and wife, as i at 10-.Lc; -A.. AL !i _ tenants, Mldar of Sea& Grantee S I for a valuable consideration 11ETUIIN TO y - - the following described real estate in St . Croix- County, State of Wisconsin: J Tax Bey t fj This is homestead preprrly. Lot 13 of Oak Ridge Estates Addition to the Town of Stanton. This warranty deed is given in satisfaction of that certain land contract dated May 1, 1969, and recorded in the St. Croix County Register of Deeds office on May 6, 1969, in Volume 451 of Records on Pages 196 and 197, as Document No. 296173. I it F~ ! Exception to warranties: f U T/ Executed at New RiehmondT Wisconsin this a~ day of fi~~ lf~t. SIGNED AND SEALED IN PRESENCE OF ) rry W • H_ _ N/A .9 11 'SAL) , Ruth B. Ho _ s N/A ( - saEwL) .TEAL) Signatures of Harry W. Hot, and Ruth B. Hop J t _ . R authenticated this a276day of 1916 STATE OF WISCONSIN ST. CROIX CCUNTY _Cher_r i_1 t Hirst NOTARY PU3lIC Title: -A/eeabev-41wo 2w =wa~iror Otter Pa> CHERIU HIRS' a MY (TMMISSION EXPIRES Al T Authorized under Sec. 706.06 via. _Igottarv~yb,_ 'i ;i li STATE OF WISCONSIN q - NZA County. } ss. l it Personally came before me, this NSA day of the above named N/A to me known to be the person- who executed the foregoing instrument and acknowledged the same. N/A DOCUMENT NO. i WARRANTY DFXD Irr I STATE OF WISCONSIN-FORM I J A I' 7H 16 SPACE pEBEpV ED FOR RECOR.IHO DATA I G j i THIS INDENTURE, Made this` 41 day of--------- J3nuary-•., A. D. 19 67..., tt~ G1~_x I L; - C t between . Harry v7. Hop• eA4. Ruth 3. Hope..wife _ ST. CROIX Co.. W :'E'. i' Recd for Record this 17th • _ part_ .ies of the first art and l! day Of_JanuarY_.__.A.D.1`~67 Arvid T1. blanum na JFlahum' his wife as Opoint at_ i tenants wit!; rihltts of survivorship, New fiichmond,.__!fi IM j __--.-_..part _..i-M_ of the second part,; P•eq stA. N -1 Witnesseth, That the said art...ies of the first part, or and in consideration'' - of the sum of-.-.---.- Three Thousand and P1o1100 Dollars - - - Re7uR(J 70 -_--em to.___them in hand paid by the said part.;1! . of the second part, the receipt, _ whereof is hereby confessed and acknowledged, ha... e.. given, granted, bargained, sold, remised, released, aliened, conveyed and confirmed, and by these presents do dive grant, bargain, sell, remise, release, alien, convey, and confirm unto the said part. ies--. of the second part ..._.._.___er heirs and assigns forever, the following described real estate, situated in the County of......'t• Croix and State of Wisconsin, to-wit: Lot Twelve (12) of Oahe Midge F;-,tates, Town of Stanton J 1 (IF NECESSARY, CONTINUE DESCRIPTION ON REVERSE SIDE) - Together with all and singular the hereditaments and appurtenances thereunto belonging or in any wise appertaining; and all the estate, right, title, interest, claim or demand whatsoever, of the said part of the first part, either in law or equity, either in possession or expectancy of, in and to the above bargained premises, and their hereditaments and appurtenances. To Have and to Hold the said premises as above described with the hereditaments and appurtenances, unto the said part..1es... of the second part, and to-._t}?eTnselves) their _ heirs and assigns FOREVER. And the said Ifiarry 1. Hop and truth. J opL. him ~,nfe . for -_eir tt;emselves, th heirs, executors and administrators, do covenant, rant, bargain, and agree to and with the said part. :eu... of the second part, --...their heirs and assigns, that at the time of the ensealing and delivery of these presents ._....._a?'e...__...... well seized of the premises above described, as of a good, sure, perfect, absolute and indefeasible estate of inheritance in the law, in fee simple, and that the same are free and clear from all incumbrances whatever, nd...no P.xoer)ti_on: and that the above bargained premises in the quiet and peaceable possession of the said party (~5_-_. of the second part, ••-t}1er--------. heirs and assigns, against all and every person or persons lawfully claiming the whole or any part thereof, will forever WARRANT AND DEFEND. In Witness Whereof, the said parties_ of the first part ha... ye... hereunto set ..their S hand..-'__ and seal.S... this....... 1hiM----------- day of .---J3nii-l-y.............. 19. -Ar S NED AND SEATx IN PRr.sLNCJ: OF - . (SF-AL) Ha rr , Pa ul 0. Swonby _ huth 9 Eon y Joy SaFer