Loading...
HomeMy WebLinkAbout038-1181-20-000 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER _c ADDRESS L•~.`7`l~~cJ',~ SUBDIVISION / CSM#_t{a. ~ cy- Oevd LOT # SECTION 16- T-IfZ-N-R-,~ W, Town of fQQ,° r, ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM /r Q. TYrWdAes a ~ ~ s Q Z ~ t 1 INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. .p. r BENCHMARK: _1"a e ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: 10A50 ,U0 7',a','11,0 d Setback from: Well House Other Pump: Manufacturer Model#-` Size Float seperation~+ Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: -Jr Length 76- Number of trenches Distance & Direction to nearest prop. line: : -f Setback from: well.. AO`14ouse .3C"f 'o- Other ELEVATIONS Building Sewer ST Inlet: 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! INSPECTOR: A21f 3/93:jt Wisconsin Dbpartment of Commerce PRIVATE SEWAGE SYSTEM Count y 'Safety and Buildings Division ST . CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar~"WTL Personal information you provice may be used for secondary purposes [Privacy L , s.15.04 (1)(m)]. ra it PP . . H COL06VA BUILDERS ~'1'~ tiTwwn of: State Plan ID No.: CST BM Elev.: L Insp. BM Elev.: BM Description: Parcel T35%Q-;1181-20-000 TANK INFORMATION ELEVATION DATA A9700228 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark _j/ / Dosing Aeration Bldg. Sewer Holding St/Ht Inlet a0,3 TANK SETBACK INFORMATION St/ Ht Outlet / Vent TANK TO P / L WELL BLDG. Air Ito ntake ROAD Dt Inlet Septic NA Dt Bottom Dosing NA Header/ Man. s `6 7' .9 , Aeration NA Dist. Pipe 0' far 7` drl, / 7 9 Holding Bot. System 63 -7 PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Lricti System TDH Ft Forcemain Len Did. F( Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Widt Lengt No. Of Trenches PIT No. Of Pits Inside Liquid Depth DIMEN I N DIMENSIONS SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION TypeO zJ, CHAMBER Mode Number: System: z_4_ /S-, 3o, 3 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 Bed/ Trench Edges /0 - " Topsoil ❑ Yes C] No E] Yes E] No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: STAR PRAIRIE 15.31.18,NW,SW 1106 212TH AVE LOT 41 tom,' Plan revision requir ed? ❑ Yes ❑ No Use other side for additional information. t 7 S(R.3/97) Date n e is Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: 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 12 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Number Lt P1 The information you provide may be used by other government agency Ni ' y y y programs ❑ Check i evision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Property Owner Name Property Location C C-40 Cr- AC"4d °s/g!;, w 1/4 j 114, S T f, N, R l E (or) V Property Owner's Mailing Address Lot Number Block Number la 5-7S if'rIllev merle l City, State Zip Code Phone Number Subdivision Name or CSM Number A u) -Y-03 ,r ( l > sr-QsY G ~ ~ i'P.'6he&, G r~ GY ) (1k 11. TYPE F BUILDING: (check one) ❑ State Owned City Nearest Road Public 1 or 2 Family Dwelling - No_ of bedrooms ❑ village r Cc ❑ ~ SJ_Town OF ~QV III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 17 00, qo 1 ❑ Apartment/ Condo d 3~- 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 12E] 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. r a New 2_ ❑ Replacement 3_ ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an i `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 1-2 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./inch) qG, O E evation c1- Feet ~9 T Feet Capacity VII. TANK in gallonTotal # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App New Existing strutted Tanks Tanks Septic Tank or Holding Tank k f QQl j ,IYJ.'d •j.,J~s ~C//.,C~ ❑ ❑ 1:1 El 1:1 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: (Print) Plumber's Signature: o Stamps) MPRSW No.: Business Phone Number: - AI Plumber's Address (Street, City, State, Zip Code): / G IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Santry Permit Fee (includes Groundwater Date Issue Issuing A ent Si m pproved ❑ Owner Given Initial Surcharge fee) 7 Adverse Determination / X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Divi ton, 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. 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. G G~ ~a dw . ors ors ~Ga T l f~/"~~C e /s v er ~ 0 p I^~ v i r~ 5 ~ b /Od dp c elo r G: / TYD iJk s G s:` 7 e d tz O L U Ail Wsoonsln Department of Industry, SOIL AND SITE EVALUATION REPORT Page / of 3 Labor and Human Relations DMalon of Safety R Buildings in accord with ILHR 83.05, Wis. Adm. '1¢ sT, c R o r K Attach complete site plan on paper not less than 8 1/2 x 111 inches in size. Plan must but not limited to vertical and horizontal reference point (BM), direction and % of slope, or / CEL a).:#. 't dimensioned, north arrow, and location and distance to nearest road. ~U APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION t`._1NED BY GATE PROPERTY OWNER: PROPE AJOfiIr ;Vi'G /I RD 5 7-o v T GOVT. L 4,S / oT Y/ N,R E P E T OWN 1:8 MAILING ADDRESS JOT / B K Ili SU , ~f V 4 7-0 A-,E~jE TiP. /~i!/~i J3E~v CITY, STATE ZIP CODE PHONE NUMBER ITY []VILLAGE AES T TZAD~ it so..~ "/S. 5yofco (/15)5141-(v731 snip, PRhtRtF: ,ywy cc Fi,, IVew Construction Use [ -}~iesidenlial % Numt~er of t>6drooms 3 0 q { 1-Addition.lo existing building Replacem ent ,:Public or commercial dmoxie derived daily Now ' ?o oy gpd Recommended design loading rate bed, gpd/ft2 • trench, gpd/ft2 Absorption area required A9 bed, 112 12-6b trench, 112 Maximum design loading rate bed, gpd/0G trench, gpdnt2 Recommended infiltration surface elevation(s) SEA X0..3 ft (as referred to site plan benchmark) Additional d~slgn I site cons rations V SF La.~ G- .vi4-/lWO cJ S' o v y . Parent material 5'CS (11) e lte Rood plain elevation, It applicable ft S =Suitable for System MJ;NTIONAL MOQ"U~18 Q U IN RfaUNO U PRESSURE ATuGgABE❑ U O SYSTEM SIN O HMDING TMIK U =Unsuitable for system us p'S CJ U $ [ [a.$ SOIL DESCRIPTION REPORT N~~ = ,vor ,P~o~►,~~,~fl~D Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence eourxlary Roots GPD/ft In. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Tionch o-/o /0 yle 3 /aL S . 4,n c s Z . S_ . G L -/G /d Vie 31s/ 2.w, ~16c f2 w .2 . s Ground 3 f/o " 2f S S//Z 11~C¢ ~S ~S e et.,~ - • 7 . $ elev. /V/.0 it. 00g 7.5-YR l//9 Depth to limiting factor 1> L Remarks: Boring # yR 31.1- /o,¢,,~ zf sb,~ ~+^~i2 s 3 S ^ . G zo,✓ 3 y 37 o YW 3111 1, fie es 16~f_ . s G Ground elev. /oo •d tt. G Depth to W I9 /D K - /S 1 ~ 5' limiting factor Remarks: ST Name:-Please Print R d g e R T- V LQ R IBC 7- Phone. 71s Address: Z N- f4 0 CSTA 1 V 04I.;_ Signature: Ulbricht Date: CST Number: private Qpwaea consultants A PROPERTYOWNER Rri~iPD S'f~~T SOIL DESCRIPTION REPORT pap Z o< PARCEL I.D. If /E /11E~ 8&A.),P Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounfty Roots GPD/ft In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed y 9- z~ /0 Vie 3/3 - /s /f rP 4u~ s h1 f . 5- Ground 3 2'y 7 5 Y X 31V - ~S /,,,,•r 5`✓e ,rF~Z C &J l U~ .57 • ~ elev. io~rt. W yo 75, v s d,5-,,,,, _ Depth to Orniting factor Remarks: Boring # / O- f /ON 34-- S %Xs6,~ 11-wvyl~e S 2- f . Y -S L 3 fshe h4 CS .s •G E 3 If- 3o 7S Ground Depth to limiting factor n Remarks: Boring # / 0 _ 6 Y,? 31,~- U,e,'4W 'I" v 13 2- ~S v , y y_ ,5 0 YR z~L S~ , f ,w- =i Gs A~O I Ground 3 lo 3/ 741 GS , s" elev. 3 - y /0 W S 1f5he 41A vfP- 4FW s •Cp 70 It. Depth to t"511 -6? GGcI - • 5- . ~o f citorg (P {2 r -5- Remarks: Boring # Ground elev. It. Depth to t limiting factor No L o T - 2 2.9 R, L"D 7- ya ~ ~ 133 3~-' ScA~~ . I 3o Pt-7--s 1 a J /3M ' Tyr o~ ~ ~ /1-T ilJ6 Ld T ~G M ~IEv~t'T(-OA3 M 1 93 • y I RR ~ I B Z /Ob. p 3 6, E 1 ~J h-7-10v S 70 \ WEST LINE OF THE SWI/4 Ivvv ro 41 c 143.95 172.20 N J~ fA o n .1-0 00 i z O R") I` 00 z F/ m Ir- 1 N M Icy 1(-) 1 rJ ( N N - N s t to . N 1) I S 1 ~1 ZD I o O g I ~ n IC) Id*I I~ W 1 I~ O SOO°16'21"W 418.36' 1,0, if- I N a~ I 33' 133' T N O t11~ \ 00 ly No \ ND ND• I ~i cA , ~ N n Lr IfIl 0 ri I'= ~ I Zi f- I N04 ° 2 3' 21 "E Z 1-1 ~ I 375.01' I I) 1 1 I y co I I I I I iv ~ ~ I C> _ I CD Irk 1 w rn 6I6, o w N m I 1 1 -I m p D O N 1 CD A I ` D to W 111 o cb °D LAI 11`J N : SOO° 58' 52" W 398.30` a. 1-) v © 6' IV IGJ 0 0 WA ICS 1 Oo Ank ~N r I ~ D ~ N I f ~►n ~_o = O n in s N y O, O N $ m IC,7 ENO - ~ \IE N00° 15'4371.41' z jr- m 1 J 33' 33' I (Py a . s' I ' i o ~ 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 lor d-. (L / A o VA Location of property Al VI) 1/4 SW 1/4, Section IS , T 3 1 -R If W Township fqa~ 1,01?ma-i Mailing address Address of site ~'1G1 e an/Z / lj / ~I <}<< yt C Subdivision name _/q~'D R < UF✓L 8f Lot no. Other homes on property? Yes No Previous owner of property R cE,~ ~,2fl IA-#'4 Total size of property =40 A Total size of parcel A C o E~ Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house) ? Yes Ix No Volume 490 and Page Number 0/67 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. Ire `1 + , 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. Sig a re of Applican Co-Applicant '?-0l-9`7 Date of Signature Date of Signature STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County P.C. COLLOVA BUILDERS, INC. OWNERBUYER ,A,I T12~575 Keller Ave. J / IVIN 55938 ATD/'l1A PH. 439-9547 ID. #1073 MAILING ADDRESS / PROPERTY ADDRESS -,'212 f t' e-- IL /Z f f (location of septic system) Please obtain from the Planning Dept. CITY/STATE '5~ tQ_ t A r i2 (`c. PROPERTY LOCATION 1/4, S1L~ 1/4, Section l S T_3- W TOWN OF A~ P7 A I rL I e' ST. CROIX COUNTY, WI SUBDIVISION k I c1 Eet 6"D LOT NUMBER 4 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 n date. SIGNED: DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 %1744 STATE BAR OF WISCONSIN FORM 1 - 1982 WARRANTY DEED DOCUMENT NO. 3.~2T49Pa~E01.5 r REGISTER'S OFFICE This Deed, made between Richard, n Sinn i- ST CROIX CTY., W) Grantor, juv 1! 199t and P_ O_ cn 1 l nua R,l i 1 d er.5 f Tnc`.' d' 11:49 AM 'Hegleterof Deeds Grantee, E Witnesseth, That the said Grantor, for p valuable consideration i conveys to Grantee the following described real estate in S - . roix THIS SPACE RESERVED FOR RECORDING DATA County, State of Wisconsin: NAME AND RETURN ADDRESS Lot 41, Plat of Apple River Bend First Addition, Town of Star Prairie, St. Croix County, Wisconsin. ii PARCEL IDENTIFICATION NUMBER i TRANSR"' o ~=Z This i a not homestead property. (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And Ri nharA n Sprit warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except L IIj easements, restrictions, rights-of-way and covenants of record, if any, li and will warrant and defend the same. II I~ Dated this 1 gi' day of .71 11 y i (SEAL) (SEAL) • Richard O_ Stout • (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) State of Wisconsin, ss. St. Croix County. ....~t.e..~:..~m.1 Iei,- A." -r 1D Pomnnaflv ramp hofnro mn thin 1 Rt day of