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HomeMy WebLinkAbout038-1166-40-000 I a o o ~ ♦ o~~ I o° I h J c g , y I 3 I N O. ~ I h ~ ~ I v` I o I m 0 a m v, ~ I m`o Itm.x a`~i m w D c in I t' o c z °rn c z .2) M v,r LL C LL C C cc M L p m E ww I ¢ E o I I I v Cl) ~I u3i't I z y z yj E E 00 'o I co z a m a to , o I c t! ~ I O z - C C 0 z' o c o o rn H r rn z c c E -o m m M I m N 9 N m m I vi n y ca C (D 0 •i O ° Q Z co z r. Z F= Z O 6 z N ° c N N w m f~ m E E e6 ~3 j w r a c o FL HQIL c EaOd` a E pNI a _ N rn j U to v) to L w c°n 3 rrrr nlO a FL Z o 3 3 3 3 3 ° 3 000 •N o as Zaaa v, a I in I c N t 0 0) CD 0 U) J V rn z 0 rn rn Z I N C N N N O fA p ~O 00 N E 7 N ¢ OI C -6 m N 0 m m y d Q z In 'O Q co ~r O N 7 r N 7 0 U) O _ C ~ O O) N C 7 H C CD 0 C U O m m ° (D C O O O O co L U) C_ f0 N C N a p l l O V co co C -1 m E€ I O f0 co Cl) C O O c ` d o d O N N ° € E o° W m r a 0) w VJ m 1- v U 0m v H c moo 0 o m m co m (D p in E o ;I V co o (n o f v I • O N (A O 2 ~ z a N 0 z N Z O w 0. I Y • a y ! d m c m m c rr`i~v E c 0 3 u v,t~ ~1 A c0 a2 'l0cl cu 0 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ADDRESS_ j> c~ 7 RUC OPC A10-141,4 liv'd SUBDIVISION / CSMf_ d gz,i,U e^s LOT f SECTION .2 7 T 3l N-R_W, Town of ST. CROIX COUNTY,. WISCONSIN _ PLAN. VIEW . SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Pr v e ul h 2 -5X 7 $ TYevc-fie 3 o .seat c INDICATE NORTH A OW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. . _ . Lei." : •'~ENCHMARK: S at ~ G Q S / ~S ALTERNATE BM ;SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: V , W we Liquid Capacity: 1;20d Setback from: Well r~ House /,d other Pump: Manufacturer ;Model# Size Float seperation` Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: Length Number of trenches :Z Distance & Direction to nearest prop. line: s'~~ 7~!r 1t/p Setback from: well: House ~oother 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: J 3/93:jt ` Wiscorisin Department of Commerce PRIVATE SEWAGE SYSTEM Count Safety and Buildings Division §T. CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanita2§9jVh1P.: Personal information you provice may be used for secondary purposes [Privacy L *W, s.15.04 (1)(m)]. PPermit HCOLUNK BUILDERS f1,,EYR09)f Rgyv` o : State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description: Parcel &39°-1166-40-000 TANK INFORMATION ELEVATION DATA A9700260 2 / 2 7 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark , d 0-0 s n C, C- r Dosing !Q IVL , /S Aeration Bldg. Sewer 4, Zj, Holding St~W lnlet L a7~ TA-ICK SETBACK INFORMATION St/,W Outlet 5/Q r Ventt TANKTO P/L WELL BLDG. Aiirlntake ROAD Dt Inlet Septic ~p / NA Dt Bottom yf' Dosing NA Header/Man. ASS Aeratio NA Dist. Pipe ' Holding Bot. System 9,~ 3 z 37 PUMP/ SIPHON INFORMATION Final Grade cturer Demand Model Number GPM TDH Li Friction System TDH Ft loss Head F cemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width , Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS S 7S a2_ DI N I N SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACH anu acturer: SETBACK INFORMATION Type O /j~•_v / C BER Mo a Num er: System: to d R UNIT DISTRIBUTION SYSTEM Header Distribution Pipe(s) f, x Hole Size x Hole S e it Intake Length 7 Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-G a Sys 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 28.31.18.796,NE,SW 1926 104TH STREET LOT 4 01 0 ~ ~h f~ /t. II /~'1 f1 ~ ^ {~,('l~, ( Fly-:/ ,•~q .i ~ / Plan revision required? ❑ Yes [g-IVo Use other side for additional information. TI I SBD-6710 (R.3/97) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: Safety and Buildings Division SANITARY PERMIT APPLICATION Bureau of Building Water Systems tom'■L■'■■'1 201 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. fi_- • C,,-©l • See reverse side for instructions for completing this application State Sanitary Permit Number Zgq it~4 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 Owner Name Property Location G, CC k e,_ Z-, /-,K; 1/4,5 1/4,S J' T2% ,N,RIF- E(or(-W-.,) Property Owner's Mailing Address Lot Number Block Number 5- e- I/ e r cz-e-, -e V City. State Zip Code Phone Number Subdivision Name or CSM Number ll. PE OF BUILDING: (check one) ❑ State Owned ❑ it Nearest Road ❑ vll (age i ❑ Public 1 or 2 Family Dwelling - No. of bedrooms Town OF l« r -Y • 5, III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) ~e, J~ G - BYO 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. aNew 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 Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation t1) Feet /dG- '0 Feet _ TANK Capacity VII in allo Total # of Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturers Name Concrete con- steel glass Plastic App New Existing strutted Tanks Tanks Septic Tank or Holding Tank ,;2 rC~ 1 L; %t f~ I~ 1/'cam Fd] El ❑ El E] Lift Pump Tank /Siphon Chamber ❑ Ij ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite se ge system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature) (No Stamps) P PRSW No.: Business Phone Number: K1 r C u h /j L4 T N Lt ~r Y Gc~ G Gl ~7 cr~✓~ T- G 3 l 21 Plumber's Address (Street, City, State, Zip Code): z S cJ ~J , ' 1",~P -7,~59 C e- 717'_ IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issue Issuing A ent Signature (No Sta ,k/Approved cludergefee) Surcha ❑ Owner Given initial 7/Z ~J7 Adverse Determination v X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SHD-6398 (R. 05/94) DISTRIBUTION: Original to county. One copy To: Safety & Buildings nn pion, 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 tai: 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. f e 1 + ` Y ~I LI) 1Y, i 3 j r lid G~y~eY j ~a GJ Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page L of 3 Labor <$d Human Relations Division of Safety & Buildings in accord with ILHR 83.05. Wis. Adm. Code COUNTY J~~~ Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but , e x not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY 0 NER: PROPERTY LOCATION GOVT. LOT 1/41/4,S 7-8 T N,R )(5 X(or) W PROPERTY OWNER':S MA!I.ING ADDRESS / LOT # BLOCK # SUED. NAME R CSM # 3 e c = CITY, ST TE IP CODE PHONE NUMBER CITY VILLAG OWN NE REST ROAD jl~ Y' L i m rr/t~~, 5 `117( N^ l,b Ed (Y'rr4 r 1 = jVf- S74 New Construction Use [ Residential / Number of bedrooms -3 [ ] Addition to existing building j j Replacement Public or commercial describe Code derived daily flow S_0 gpd Recommended design loading rate bed, gpd/ft2 trench, gpd/ft2 Absorption area required e:~3 bed, ft2.5-(3 trench, ft2 Maximum design loading rate .Z_bed, gpd/ft2 trench, gpd/ft2 Recommended infiltration surface elevation(s) 9 '00 _ft (as referred to site plan benchmark) Additional design / site considerations / Aq Parent material /_-6 -ta9 ,4 C Flood plain elevation, if applicable ,N 14 ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable fors stem I S ❑ U al; ❑ U I 0S ❑ U ❑ U ❑ S (U_ ❑ S 01 SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft Boring # Horizon in. Munsell Gu. Sz. Cont Color Gr. Sz. Sh. Bed Tivirctl 67 5 r,,7 Ground O .5 2 c_ /S D elev5.o Depth to limiting factor Remarks: Boring # A) ~1'17Z L37_ 76'ytz,','14 Ground . ?Z 4/ elev.go _S Depth to limiting ti.r aL factor 7gZ~i ym " 1:i Remarks: G GFtC'X CST Name:-Please Print Phone: GCr ~'C4" Address: ✓r . -17 Signature: Date: mbar: PROPERTY OWNER SOIL DESCRIPTION REPORT Page of PARCEL I.D. # Boring # Horizon I Depth Dominant Color Mottles ITexture I Structure Consistence Bourxjary Roots GPD/ft in. Munsell Du. Sz. Cont Color Gr. Sz. Sh. Bed (Trench Ground 1 . elevo i 10/ -ft. 5-y/0- Depth to 1/0 --5s IVZ ltl limiting factor Remarks: Boring # A0 Y/ f- '511 2msa,~, M a3 cl) -;5 M IVA 0,114 Ground elev. ~ ft. Depth to limiting factor r " Remarks: Boring # Ground nnelev. Depth to limiting factor Remarks: Boring # n4 Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(R.05/92) STEEL'S SOIL SERVICE Gary L. Steel e C.S.T. 2298 New Richmond, WI 54017 MPRSW-3254 ~E Sub S (715) 246-6200 ,Brn fan g d w'f' k-d Z- /~-"f- 0,4 "0 ~ A / 30l ~ I sotse A LO rA STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER P. C. Collova Builders, Inc. MAILING ADDRESS 12575 Keller Avenue North, Hugo, MN 55038 PROPERTY ADDRESS xxxx 104th Street, New Richmond, WI 54017 (location of septic system) Please obtain from the Planning Dept. CITY/STATE New Richmond WI 54017 PROPERTY LOCATION NE 1/4, SW 1/4, Section 28 T 31 N-R 18 W TOWN OF Star P r a r i e ST. CROIX COUNTY, WI SUBDIVISION Red Pine Estates LOT NUMBER 4 CERTIFIED SURVEY MAP VOLUME 12 S PAGE 5(a 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 d e. SIGNED:' 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 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 ofproperty P. C. Collova Builders, Inc. Location of property NE 1/4 SW 1/4, Section 28 T 31 N-R 18 W Township Star Prairie Mailing address 12575 Keller Avenue N Hugo, MN 55038 Address of site c, A 104th Street Subdivision name Red Pine Estates Lot no. 4 Other homes on property? Yes X No Previous owner of property Hemmer Total size of property 2 acres Total size of parcel Date parcel was created Are all corners and lot lines identifiable? X Yes No Is this property being developed for (spec house)? Yes X No Volume as and Page Number -5&3 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. Si ature f Applicant Co-Applicant Date of Signature Date of Signature 562465 YOl ~.~rJ1 PAGE lcrurr: # STATE BAR OF WISCONSIN FORM 2 - 1982 WARRANTY DEED _~w.. DOCUMENT NO. REGISTERSOi FIPE ST CROMCTY-,VII Ja C. Hemmer and Gail J. Hemmer 'JUL 16 199T, husband and wife 12:05 P P C Collova Builders, Inc. conveys and warrants to NegiSter of Deeds THIS SPACE RESERVED FOR RECORDING DATA NAME AND RETURN ADDRESS the following described real estate in C a i v County, River galley Abstract & Title, Inc. State of Wisconsin: P.O. Box 149.206 tad St. Hudson, WI 64016 C q 3 - 35 7'L/ 038-1166-40 PARCEL IDENTIFICATION NUMBER Lot 4, Red Pine Estates in the Town of Star Prairie, St. Croix County, Wisconsin. TRAo SF FA .51This is not homestead property. XsXX (is not) Exception to warranties: Easements, restrictions and rights-of-way of record, if any. July , A.D., 19 97 Dated this ' l0 day of (SEAL) (SEAL) v-- Jay C Hemmer Gail J. Hemmer (SEAL) (SEAL) i AUTHENTICATION ACKNOWLEDGMENT Jay C Hemmer State of Wisconsin, Signature(s) ss. Gail J. Hemmer County. niL .t,;day of