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HomeMy WebLinkAbout038-1172-60-000 0. o aa) N O K3 ° d j O tl O 0 H 5 N O. q N L ~a cc m y x c 01 N ~ r N O N Z O L N c ?'3 chi f6 - LL c f0 .O 0 f0 a 3 N 00 O O Q N t~ C r v Q r z pj CO Z z m C', IL Go 0 O z :i c uvi z y o O V1 H r N z C E 'O Cl) N C,) C (0 N CL Of N N Q) c: CO (L) Q ° w z co z o N z N m o ~ E E i J O d ~ Y a _ H d N C O c c a c m (j v h w o O U) U) U) FL Z • ~ aaaa IL 3 O O O O N fA J V > O) O) O GO I~ r- N Y O r y ° L O O E L m y c a z~ d Quin ~ ~v o 0) 0 ~l O ° 3 0 ~ c ~ o O > = o `O Y CD 0 V o H c c a O Y C a N N IyOy r C (D C 7 r d co d n r a Z. C N M-4 n O M w0 N V' C N (0 f6 U irF • O Y~i O N (A `1 N 0 z C (n ` a • ed O. y ,V m rr`1~~1 E 2 c c u IL U) 0 ✓,K- STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ADDRESS SUBDIVISION / CSM# la-z a LOT # SECTION,.29 T N-R W, Town of ST. CROIX COUNTY, WISCONSIN ~3g I 2 X06 -DOD r PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET TEM G I i p,P,J.~'i✓~ INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: i Setback from: Well ~5- House Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: Length Number of trenches Distance & Direction to nearest prop. line: I"~ //Z Setback from: well: House Other ELEVATIONS / Building Sewer ST Inlet: l'7 5 y ST outlet: ,97, 37 PC inlet PC bottom Pump Off Header/Manifold Bottom of system T; ~a Existing Grade Final grade DATE OF INSTALLATION: ~Zi `-99''7 :::;e PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/93:jt Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: af and + Relations Safety INSPECTION REPORT ST. CROIX and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-: 284287 Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.: KRAFT, ANTHONY R. STAR PRAIRIE CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: v( oor 10 v 038-1172-60-000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/Ht Inlet 9r TANK SETBACK INFORMATION St/ Ht Outlet 47, 317. TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom Dosing NA Header/ Man. 7. zl;?, Aeration NA Dist. Pipe 17,5 (,14 Holding Bot. System (p I S a PUMP/ SIPHON INFORMATION Final Grade 03 Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft Forcemain Length Dia. Fi Dist. To Well SOIL ABSORPTION SYSTEM BED /TRENCH Width LengtJ~ I No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 1A DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type O CHAMBER Model Number: System: LjLt-,Z mo, 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 E] No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: STAR PRAIRIE.29.31.19,NW,NE NIGHTHAWK DR LOT 10 & Plan revision required? Yes ❑ No r Use other side for additional information. SBD-6710(R 05191) Date Ins a or'sSignature Cert No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: SANITARY PERMIT APPLICATION Bureaux BB l u,ildis ding WaterlSystems In accord with ILHR 83.05, Wis. Adm. Code 201 E. Washington Ave. 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 81/2 x 11 inches in size. • 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 98 / 2-S / (Privacy Law, s. you (o de E] Check if revision to previous application State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Prop y Owner Na2]~~ Property Location 1 /4 1/4, S T , N, R jq~(or) Propert y Owner' d of Number r Block Numb Cit S to Zip Code Phone Number Subdivision N e or M Num er II. TYPE F BUILDING: (check one) ❑ State Owned o !ty Neare R a Public 1 or 2 Family Dwelling - No. of bedrooms village - Town OF 4L 9 me III. BUILDING USE: (If building type is public, check all thatapply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo ©3~ -11.77? 60 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 0 SyNew stem 2. E] Replacement 3. ❑ Replacement of 4. F] Reconnection of 5. E] Repair of an yTankOnlyExistingSystem 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 f4 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 31 ST Al Feet Feet VII. TANK Capacity in gallons Total # of site INFORMATION Gallons Tanks Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Aper. New ExiStin Concrete strutted glass App. Tanks Tanks Septic Tank or Holding Tank R ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ 0 VIII. RESPONSIBILITY STATEMENT I, th undersigned, assume responsibility for in allatiop of onsite sewage system shown on the attached plans. Plumb s N e: irlt Plum rs S' o a s) MP/MPRSW No.: Business Phone Number: P uIn b 's dress tree City, Sta Zip Code). IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved sarlltary permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps) Approved ❑ Owner Given Initial Surcharge Fee) t Adverse Determination g CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SOD-6398 (R. 05/94) 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 maybe renewed before the expiration date, and at a time of renewal ary 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 thlssanitary 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 fo- 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 b2 j m,~Er Ole I } t i i { 1 { ! n } j I ~ ~ ! j i i I F } 1 ; ~ 1 ~ I i ~ ~ i 1 I~ f r j ~ ~ ~ ~ ; i i } + i f i ~ i - t I ~ t I ~ ~ ~ - } ; } t ! ~ ~ i I ~ ~ r ! I } ' _ i { ~ i 1 f ' I ' _ ~ r - - t i , , I ~ i _ i I ; i - - r ' + i i i } a ~ f ~ - , ~ a j } ~ ~ - t- ~ ~ l { I ! i i i r _ t I ~ j j . ~ . i 4 i i+ ~ f i l i l f i i i~ f i j r i~ 1 E i j ~ j I} ~ i ~ f ~ I~ 1 i ~ ~ ~ t i j i~ I ~ j~ ~ i t i 4 r~ j i i j i I f f , I j;, ~ I ! ~ f ~ { _ ~ ~ t_ ~ _ I f ~ -1 F i ~ ~ I l i ; I ~ ~ 1 1 j ~ ~ ~ ~ ~ ~ ~ I I i ~ i i i } i ~ } i } I } i i j i ~ i ~ I f i ~ i i { I r ~ I - - - } j j ~ t+ } ! I I~.. i I I 1 I } ~ i I i ~ I I 1 j I ~ i ~ ~ ~ t i ~ 1 i j ~ ~ i i I ~ ' j - ~ I i { ~ t ~ ~ i I ~ ~ 1 i ~ 1 {j ~ ; ~ I I 1 ~ ~ } j } i t i ~ } - - a i ~ - i ~ ~ } - ~ - ~ i ~ j t ~ ~ ~ ~ ~ I ~ ~ I I I I ~ i ~ t j ~ i } f t- j i ~ i i j ~ ~ i I_..._ i ' i i 1 ~ ~ ~ 1 - _ I _ I ! ~ 1 j I I i ~ ~ ~ i ~ j - i j ~ j f ~ ~ ~ i I I 1 ~ I + ~ 4 ~ I ~ ~ ~ II - - - - . ; f ' ~ I ~ f ' j + , ~ j ~ i I. , I t t . ~ , i j ~ ` _ - ~ tt j t'' I 1 } i ( ~ t t L I ~ 1 ~ ~ _ - - 1 -i ' ~ ~ f- ~ ~ j t - - ~ ~ ~ ~ ~ - - i Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of Labor and Human Relations Division of Safety & Buildings in accord-vu}#h,1l HR 83.05, Wis. Adm. Code 46. t y` COUNTY Attach complete site plan on paper not less thx 11 inchesrr`►ea~t~e Ian must include, but -X not limited to vertical and horizontal referen t (BM)4irection and?/o lope, scale or PARCEL I.D. # dimensioned, north arrow, and location an dig Ance V) tt&rast road. APPLICANT INFORMATION-PLEAS INT ALL INEOgJ1 0 REVIEWED BY DATE -TI PROPERTY OWNER: 4 r OPERTY LOCAuuON VT. LOT~(~(J 1/4~/=1/4, T ,,R / C E (or -31 PROPERTY 01 MAILIN ADDRES err y `b L T # BLOCK # S BD. NAME OR CSM # CITIPTATE ZIP CODE PHI~Ntj UM c7 ❑CITY ❑VILLAGE OWN NEAREST ROA New Construction Use J)(f Residential / Number of bedrooms Addition to existing building ILReplacement [ ] Public or commercial describe Code derived daily flow gpd Recommended design loading rate - 7 bed, gpd/ft2 - trench, gpd/ft2 Absorption area required 6Y 3 bed, ft2 ? trench, ft2 ximum design loading rate bed, gpd/ft2 - 6y trench, gpd/ft2 Recommended infiltration surface elevation(s) r' ft (as referred to site plan benchmark) Additional design / site considerations /_Q10 '14 Parent material ~Z_~,@-, Flood plain elevation, if applicable Z; ft S = Suitable for system CCOVENTIONAL 0 ND IN-GROUND PRESSURE AT. GRADE SYSTEM IN FILL HOLDING T NK U=Unsuitable for system J!4 S❑ U S❑ U S❑ U S ❑ U ❑ S U ❑ S U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trendh 3 -61 Ground _ e y 0 l, 7 - ~I Depth to limiting ~a factor Remarks: Boring # L 7 1, Ground 5 Depth to limiting f~t~ Remarks: CST Name:-Please Print , Phone: Address: Signature: Da _ 9CST Number: If' LZZ PROPERTY OWNER SOIL DESCRIPTION REPORT Page of PARCEL I.D. # Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft Boring # Horizon in Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench lie s A~4 ~Jel Ground q~ v / ft. Depth to limiting factor v Remarks: ring # D IWIP 2 sL Ground elev. G~~-t ft. Depth to limiting Remarks: Boring # d Ole xwl i 4 Ground ele . aft. Depth to limiting factor w 0 Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) Soil Test Plot Plan Project Name Charles Borgstrom Byron Bird Jr. Address 2033 Co. Rd. C~ Somerset Wi 54025 TM #3479 Lot 10 Subdivision Country Livin Date 8/31/94 NW 1/4 NE 1/4S29 T 31 N/R19 W Township Star Prairie R Boring ()Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft.Base of Wood Stake Red Ribbon System Elevation 95.8 * H R P Same as Benchmark 5% B-4 lope Rep A 0' B-5 30B- 30' -2 30' Pri A ow ° B-1 CD 30' * Pro 3 r B.M. Bedroom House 180' 240' 175' to Property Line Night Hawk Drive STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER t~oyV MAILING ADDRESS Ke d Sd, 7 PROPERTY ADDRESS , (location of septic syst m) Please obtain from the Planning Dept. CITY/STATE PROPERTY LOCATION l~ 1/4,_ 1/4, Section T_N-R_y Z_W 'S'OWN OF Sp &L: pn!:~j ST. CROIX COUNTY, WI SUBDIVISION xl ~vr~~ s f' LOT NUMBER 16 CERTIFIED SURVEY MAP VOLUME 113~.JPAGE ~l 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 I, 1978. St. Croix County accepted this program in August of 1980, with (lie requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning n 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 piration date. SIGNED: - ~ DATE: z- 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 of property Y `C Location of property_lVu) 1/4 t(f 1/4, Section ? T3 ( N-R~W Township ~Mailing address /(-~0 ~,L,~tr. ~fS S Address of site Subdivision name 6k - ,v of no. /b other homes on property? Yes No Previous owner of property _44-1111-5 Aap-ps&oen { Total size of property ~qrc, C Total size of parcel tV0 Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes No Volume //3 Z and Page Number 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 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. Signatur f A icant Co-Applicant 2- 7 y --C)- Date of. Signature Date of Signature x.18'76 z Bar of Wisconsin Form 2 - 1982 WARRANTY DEED DOCUMENT NO. .1132PAU'614 r}g'S Ot 8-T.C~yROX Cj.y VIA ;i PAd for Charles H. Bor strom and Dolores Borgstrom, aka Dolores S Borgstrom, husband and wife. JUL -31 1995 8:00 A.] conve s and warrants to Anthony R Kraft and Victnr; a M. yKraf t, husband and wife, y Cyterbf i1'sd3 THIS SPACE RESERVED FOR RECORDING DATA NAME AND RETURN ADDRESS the following described real estate in St. Croix County, State of Wisconsin: 60 (Parcel Identification Number) Lot 10, Plat of Country Living in the Town of Star Prairie, St. Croix County, Wisconsin. This is not homestead property. (is not) Exception to warranties: Easements, restrictions and rights-of-way of record, if any. Dated this LA day of . Ttt1 V ' 19-95-. (SEAL) (SEAL) t w Charles H. Bor trom (SEAL) (SEAL) * Dolores Borgstrom, /k/a Dolores S. Borgstrom AUTHENTICATION ACKNOWLEDGMENT Signature(s) Charles H. Borgstrom, Dolores STATE OF WISCONSIN ss Borgstrom, a/k/a Dolores S. Borgstrom County. 4.2." ~ I - - f% r, L c M4 day of