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Home My WebLink About038-1105-60-000 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER 11;2 , A1-f ! ADDRESS Z- Z'2 SUBDIVISION / CSM# LOT # SECTION TN-RCW, Town of ~~~.1/l^ar~,~2 ST. CROIX COUNTY, WISCONSIN PLAN VIEW HOW EVERYTHING WITHIN 100 FEET OF SYSTEM f r\ ~o ~ a ~ " J - - - INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: 4%/u- ~j p c/ e " c~ ALTERNATE BM• SEPTIC TANK (MP CHAMBER OLDING TANK INFORMATION Manufacturer: Liquid Capacity: Setback from: Well House 3 Other Pump: Manufacturer Model#_---~'T Size l Float seperation Ltd Gallons/cycle: Gb Alarm Location- 2 SOIL ABSORPTION SYSTEM r ` Width: z Length ,-j`~ Number of trenches Distance & Direction to nearest prop. line: Setback from: well: 1014 House LAn / Other ELEVATIONS Building Sewer ST Inlet: ST outlet: PC inlet PC bottom Pump Off Header/Manifold Bottom of system Gj' . Existing Grade Final grade a- DATE OF INSTALLATION: ex PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/93:jt 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 284319 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: HEXUM, KEITH & LUCILLE STAR PRAIRIE CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 038-1105-60-000 l TANK INFORMATION ELEVATION DATA < - P11r TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Cb " Dosing Aeration Bldg. Sewer Holding St/Inlet j TANK SETBACK INFORMATION St 00 Outlet d, 08 Vto TANK TO P/ L WELL BLDG. A ier Intake ROAD Dt Inlet /i, !G r Septic NA Dt Bottom /3.5,6Dosing NA Headed 7,51 -1 Aeration F NA Dist. Pipe Holding Bot. System 8 7s/' PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand ?S Model Number GPM TDH Lift Friction System TDH Ft Forcemai n Length Dia. Dist. To Well Head SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type O CHAMBER Model Number: System: 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 Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: STAR PRARIE 26.31.18.440C NEW RICHMOND Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No ADDITIONAL COMMENTS AND SKETCH ' SANITARY PERMIT NUMBER: ! Safety and Buildings Division r~~■I`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. /7c_ • See reverse side for instructions for completing this application State Sanitary Permit Number 20 ~f-~19' 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)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Property Own Nam Property Location -e lc/??/4 Ag~1/4, 5,,4K T, , N, 1,1f 'E Property Owners ailing Address Lot Number Block Number City S Zip Code Phone Number Subdivision Name or CSM Number . TYPE OF BUILDING: (check one) ❑ State Owned ❑ city Nearest Road E] Public 1 or 2 Family Dwelling - No. of bedrooms -5 r] Vown of i'ce'- r g 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 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 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 r1 O Required (sq. ft.) Proposed (s . ft.) (Gals/day/sq. ft.) (Min./inch) Elevation 7 `1 l Feet 197 Feet VII. TANK Capacity in gallons Total # of Prefab. Site Fiber- Ex er. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel Plastic p New Existing strutted glass App. Tanks Tanks Septic Tank or Holding Tank 0 ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ VI11. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. e: (Print) Plumb 's Signature: (No Stamps) MP/MPRSW NO.: Business Phone Number: Plumb:Awl' " Plumber' ress (Street, City,- tat Zip C 160 IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issue Is uing Agent Signature (No Stamps)` ~A roved Surcharge fee) PP ❑ Owner Given Initial t Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05194) DISTRIBUTION: Original to County, One copy To: Safety & Ruildi figs Di-_i on, 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 isto 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. ' y PROJECT„~1 ADDRESS INS /T,,$/ N/RAW WN COUNTY, PRS Byron Bird Jr. 3318 DATE BEDROOM. CLASS PERC_ i CO . TIONAC,,> -G U D PRESSURE CONVENTIONAL LIFT_ MOUND- HOLDING TANK SEPTIC TANK SIZE LIFT TANK SIZE b z, DOSE TANK SIZE ' HOLDING TANK-SIZE , ABSORPTION AREA _,,oO PERC RATE BED SIZE Benchmark V.R.P. 'Assume Elevation 100' Location of Benchmark * H.R.P. M Borehole Q Well Scale _ Feet 0 Perc Hole System Elevation Uent - v' 12■ Grnrlp TYPAR COVERING 2M 12' 3 6 Sewer Rock it t 2l j G bz Div ►y 0 Wiscorisin Department of Industry, `"A Labor and Human Relations S v/§IV - TS,~VALUATION Page of Division of Safety and Buildings edd~a~ne with 1 83.09, Wis. Attach complete site plan on paper not less than 8 1/ inchestiAti?Ytr3.' Plan must County include, but not limited to: vertical and horizontal ref point (BM), direct' d r G!"O 1 percent slope, scale or dimensions, north arrow, and c on atactowst r Parcel I.D. # "il~ _105-4e C APPLICANT INFORMATION - Please pfin fore Reviewed by Date Personal information you provide may be used for secondary pu r es Law, s. 15. (im Property Owner C ti erty Location' ❑ Govt. Lot LI 1/4 LT 1/4,S ❑ T ❑ N,R E (or( Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# City tate Zip Code Phone Number Nearest Road 3q 01 -7 (715 /_Z104- E] City E] Vill g r Town , l Ate, ❑ New Construction Use: r""esidential / Number of bedrooms Addition to existing building Replacement ❑ Public or commercial - Describe: Q' Code derived daily flow 450 gpd Recommended design loading rate = bed, gpd/ft2 v trench, gpd/ft2 Absorption area required 6 a :3_bed, ft2_5trench, ft2 / Maximum design loading rate bed, gpd/ft2=trench, gpd/ft2 Recommended infiltration surface elevation(s) / ft (as referred to site plan benchmark) Additional design/site considerations Parent material ~ G 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 S ❑ U 59-S ❑ U Pi -s ❑ U ❑ S [U ❑ s Lieu SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Ground elev. ` ~ft. Depth to limiting ; factor Ax Remarks: Boring # G /3 .Z 0~ 42 tee Ground e ev 7 ft. Dept~t to limiting factor ,714 Remarks: Please Print) I Signature Telephone No. Addre Date CST Number CST A-11115A SOIL DESCRIPTION REPORT PROPERTY OWNER Page of PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 ~j in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Ground elev,~ Depth to limiting factor , /,2!~( in. -~r Remarks: Boring # Ground elev. ft. Depth to limiting factor 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 # ; Ground elev. ft. Depth to limiting factor in. Remarks: Boring # Ground elev. ft. ' Depth to limiting factor in. Remarks: SBDW-8330 (R. 03/95) A Soil Test Plot Plan Project Name ,-~,ex x ~ By n Bird Jr. Address 1.2- 15;~ /y5-7~lz A TM #3479 Lot Subdivision Date _fIf1 /4A:--1 /4SA T N/R /-!~'W, Township ❑ Boring O Well PL Property Line County BM or VRP Assume Elevation 100 ft. s System Elevation *HRP_ r -34 40 Scale 1/4" = 10 Ft. When Dimensions aren't stated • PUMP CHAMBER CROSS. SECTION. AND SPECIFICATIONS vent cap ~4" Vent Pipe approved locking 10', from door, weather proof junction box manhole cover & window or fresh i warnina_ label air intake 12" min grad 4" min conduit - 1811 min 18" min % inlet provide ~t a irtight 'seal _ T roved joint A pp i eep I 11hole xtending 3' approved )nto solid soil . . B ALA joints C i ON extending 3' onto solid pump oil OFF D concrete bloc 3" Approved Bedding Under Tank . SPECIFICATIONS Septic and Dose Tan'ks Manufacturer': -eel ;,Number of Doses:'' per day Tank Size':' a,~,W ;Gallons Min Dose Volume;5;,2&o gallons Alarm Manufacture'r':' L4 Capacities:A_ inches~jallons Model Number:' - Bze i inches' i 0 gallons Switch .Type:' 57; X C- O inches2!o gallons Pump Manufacturer: D'=inch es'/Eg ggallons Model Number: S3 /jam NOTE: PUMP AND ALARM ARE TO BE Switbh Type: h-- Pump Discharge Ra e .c GPM INSTALLED ON SEPARATE CIRCUITS Vertical Difference Between Pump Off and Distribution Pipe* ~v2....feet capacity + Minimum Network•Su$ply Pressure,, 0 0 0 4 0 + .F.ee.t, Of. For.cd Main X ,f A/10.0. It Fr.i.c.tion pac.tor: feet -,Total Dynamic Head = /v2 feet Internal Dimensions of Tank: Length __Z Width Liquid Depth Signed / No. l~. Date HEAD/CAPACITY CURVE EFFLUENT and DEWATERING WARNING: Model 18514185 should not be subjected to less than 30 feet TDH, TOTAL DYNAMIC HEAD/CAPACITY PER MINUTE sus W SERIES 43 74_ 13T-119 1 1 16114161 163416 - 16SM1 1859111 1 tt IW4188 1 1t 1 P7. i'•. y tS.L 12U > I;M 'Go.. G,1. I" GA 'US GAL Ltri: ca. un G.I. usW1. Ltn': 0.1 ,Lb, COL' s~ CA 111iA /a Lh. G.t Las: GK ilo. 14 i 13Y 1t 5'12 21 ':;104 43 113 72 273' 12 :.112: $4 054 IDS 401 41 27111 61 ;23f: k Q 125, in ,;Yfl its 537 U )ISE 42 10 ZAS tli SI 27 17 34 121 61 is 20C i~i >0 >34I 100 371 N 131 N 72 ' ;f' i N <"!M tN >s6F 1s1 i/2 41 171.:. 1.9 11 1s 4S 2i 2 214? 1 10 i w i?`.~t<3 x W. t 41 U S 2 i25 W x n r'2n'i a 3,0as 223 w .,,Y11:.'• a . tx >i1t: 140 u 11<I::: IS 40 IS !{2 t 1P . N :234 74 210 S7 211 SS 227 z N E?32t tx 114 172 i01 49 <Srl _ 12 : 701:. 65 240 SS 701 r. St 226; to i41. N ?27f 121 {I 127 !1911. 43 13 x ...11;.: N 30 ,1X~ i N 174.'': 46 tl2 t li :Mfa 75 4A : It 3~17C. 109 s 1:. 114 sAf1 i 4s 77 12S ! 31 x,1i1, x ?1 IS 'Zt{t s/ 100 !1l:; 41 38-125- SO f #17iE N ;32CEi 71 ?".110 10 41 111.; tS U N x11 S.. o:<o>:: p:;: 36 12 x 10 `°.?34 E is ts :0 » t$ 45 36 14 UI is^2<>i u E:v ► 28 14 tot u I7-777 -7T r 191 22 :.1..21.: 2 ;,;:is,>>•; 21 u 101x:: AUI; ii;~:i ..~"v..k'.%•':E: it s: 21 :.?A: N 111,;: 34 1.F 7 #<?•`:s< 1 'i4::.. x ?111: 111 Ix 105 s1t1: 1/r 13r 32 LodVww. 214 2r 19=5' v it 4r ss 11' it 7r llr if 100 30 95-- 28 90 186, 26 %kk 4186 85 80 165, 24 4165 75- 2 22 70 x V 20--- 65 18 60 163, 4163 189, 55 4189 0 16-- 50--- 4 45 12 40 _4~ 140, 188, 35 '4140 4188 10 30- 137. 1 B5, 8 25 139 4185 ti 6 20 t 15 4 10 . 2 5-- 43 57,59 98 161 0 U.S. GALLONS 10 20 30 40 50 60 70 80 90 100 110120. 0 140 150 160 LITERS 80 160 240 320 400 480 560 640 0 FLOW PER MINUTE 009922 Note: For Head Capacity on Model 112, industrial column-explosion prooof pump, see FM0219. a STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER MARJNG ADDRESS PROPERTY ADDRESS 1Ue~ 104~ ~ ~syr l 5 ~y~ (location of septic system) Please obtain from the Planning Dept. CITY/STATE PROPERTY LOCATION 1/4, 1/4, Section, T~3TN-R W TOWN OF ST. CROIX COUNTY, WI SUBDIVISION R LOT NUMBER CERTIkUDSURVEY 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 expiratiqn date. SIGNED: DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, W1 54016 11/93 ~ `a C: _ 1 v u This application, form is to be completed in full and pgned 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 ~1/4 1/4, Section o2~ , T IN-R-/,~5W Township Mail ' g address 2, 5Ss / y s-! z5 Address of site, Subdivision name Lot no. Other homes on property? YesNo Previous owner of property 4 Total size of property k ado Total size of parcel "P7 GIG S Date parcel was created 2 7j Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house) ? Yes Z No Volume a.5*and Page Number~~ 2 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 t e sewage disposal system or L (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. Si nature of Appl cant Co-Applicant Date of Signature Date of Signature I DO(uMt-NT NO. WARRANTY DEED STATE OF WISCONSIN-FORM 9 THIS SPACE RESERYF.D FOR RECORDING DATA I 1 IIa.lla, lll5 dN!?!iN'I'UR[i, At,ulc by Rubye I . I ?7tt1 i I ~ A I us t f;9 aat<,r ,I (aunty, WiKonsin, hereby conve s and warrants ~ - ~ to I `.h II 1 iO D,,,c lt~ IIexum, hu:~and and grantee I RETURN TO ('aunty, Wisconsin, for the sum of 1)()), In YS - i h:• (cl'.,~,ii;.:' ,ail r,I I,:al in tom. C~IX (;ounty, State of Wisconsin; ll;; ~`tIl.tlZn;l t cornCr• of tI'e 'oil!,h~ iSt I.~I1 i, P,F C:f sertien TF,.,n!-.,i I II fl{ ~ .f L~ ~.c .l :~1 ~-~ht. r~pr~ ~ 1_f~ ,i~~',-i i. i(_ii~~_ iii I : h(,_~ nnin7 t:herice Borth 5G' f('0 t, ~`t1i'' Ili) 'f thE'ncC' C)l.2t}: iG f ect; thr2nc- Fast ( I I i Y• J hand and s(.,I t1:i- d 1% ~ I ic,til,l) i,`.I) 1N PI:P:SCtiCE OF (SEAL) 'c SEAL r - t~F, , I I , 91~P,L) J County