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HomeMy WebLinkAbout040-1233-60-000 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ~f~lP 1-Z 16 ADDRESS A'Osa'Q 4-~I. syoi~ SUBDIVISION / CSM# LOT # SECTION 3 T ~,F N-RAW, Town of--7,f o y ST. CROIX COUNTY, WISCONSIN Oto- )2-3~3- PLAN VIEW W EVERYTHING WITHIN 100 FEET OF SYSTEM Tw f~ yflJt Al J"~ °F Sv ,8E.t1cHM~PK~ ~O,,F't7 f/rcN J/RI,UcM T,o S.W. CORNER ov PE< CEO. T' fCE~. = Ipv.oo L~.rt7P.F~ ~lcrtdex 4,-7N C,poss qo" i ik~ ~~Sr TR~ucN 1.?60 bAc. G,!lES,fQ St0 tC Tir /~0 7 p Sch' 9/O p/G SE-Lf 41Aj e- 1 &AlqAj aQ ~Ex/57An~ t Jt4d O 51,40 0 INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: ~Q W • L0PA16e Or AWt f ~Ed !'.'4e✓ = /00, e0' ALTERNATE BM: /op of e-nyp aNr IS4ocK &s~-~ avr ~.4tt ZC4v - /0~-°`~ SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: G~ics11P Liquid Capacity: 1950 4. L Setback from: Well House Other Pump: Manufacturer Model# Size Float seperation - Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: 15;-' Length 90' Number of trenches a Distance & Direction to nearest prop. line: o?S/' S, Setback from: well: • House 3~1Other ELEVATIONS Building Sewer O. ST Inlet: 0. y3 ST outlet: 90. PC inlet - PC bottom Pump Off Header/Manifold `$°F. i`~v Bottom of system 'Tg-80 Existing Grade I's 1~3 ` Final grade f3--?S DATE OF INSTALLATION: f G/ 7r'< PLUMBER ON JOB: .4f~Qs( ~/10St_ LICENSE NUMBER: 1K~/r'S Y325 INSPECTOR: 3/93:jt Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labo~arldHumariRelations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No-: GENERAL INFORMATION 284271 Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.: HINTZE PETER TROY CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: r , 040-1233-60-000 / 1,06" TANK INFORMATION EVATION DATA A9700041 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic 0 Benchmark b Dosing Aeration Bldg. Sewer s 96 Holding St/Ht Inlet 90-93~ TANK SETBACK INFORMATION St/ Ht Outlet Vent TANK TO P / L WELL BLDG. Air Ito ntake ROAD Dt Inlet Septic 5 - 69 51 NA Dt Bottom Dosing NA Header/Man. y a 8q, y~ Aeration NA Dist. Pipe 18'?, ? ca ! ,7 2 Id. Bot. System y, g~ ' PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft Loss mead Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS b 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 _ S!a -*1 1 Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: TROY.3.28.19,NW,SE 651 TOWER ROAD LOT 26 Plan revision required? ❑ Yes ❑ No Use other side for additional information. a 0 = 4r'r ? ( -4k] SBD-6710 (R 05191) Date Ins c or's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH e L SANITARY PERMIT NUMBER: E IL.HR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code couNTY~ a~..wt s,unn.~ws~ STATE SANITARY PERMIT -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ 42,11 8% x 11 inches in size. Check if revision to pre sous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROOWNER PROPERTY LOCATION :UTY .,,^/TXE Ud '/a SF Y4, S 3 T N, R /q E (o W PROPERTY OWNER'S MAILING ADDRESS LOT # n / BLOCK # 6S~ TowErt /(o.oo ~f Y CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISISN NAME OR CSM NUMBER o.,• ~S"y°~~ 6/2 %~6-~53~ c'aNrlPy Gr~cr~4 11. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD D ❑ State Owned ❑ VILLAGE =N OF: ❑ Public 1~1 or 2 Fam. Dwelling-# of bedrooms PAR LTAX NUMB RO , " III. BUILDING USE: (If building type is public, check all that apply) 05'0 - - 40 1 ❑ Apt/Condo 2 ❑ Assembly Hall 60 Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 70 Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 80 Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1.New 2.E] Replacement 3.E1 Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) Ib) A Sanitary Permit was previously issued. Permit # 01 6~1 d1:~' 99 Date Issued 0--/V) ` 96 V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 300 Specify Type 41 ❑ Holding Tank 12 ~ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 12. 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 LO 00 " 900 X. 0'0 Feet 92- J D Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App. Tanks Tanks structed Septic Tank or Holdin Tank Lift Pump Tank/Si hon Chamber + 1017 R I El I F-1 1:1 E] VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Sign ure: No S ) MP/MPRSW No.: Business Phone Number: Plumber's Nam//e~~)(jPrint)t)1: 17- /¢pP.~ /✓C_ 9/5 lunAddress (Street, City, State,, Zip Code): 'l /-!E;- 4- 7T AJ. ~4SO~ IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater E e Issued Issuing Agent Signature (No Stamps) j Surcharge Fee) ® Approved ❑ Owner Given Initial 11 _ Adverse Determination - , X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) 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 the time of rerewal 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:: 33D 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 & 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 in 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 in ##1-7. VII. Tank information. Fill in the capacity of every new and/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% x 11 inches must be submitted to tie 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 sewe, fells; water mai i,;iwater 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 veitico! elevation refererce points; C) complete specifications for pumps and controls; close volume; elevation differences; `riction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil abso ption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1982. hv'isconsin Act 410 included the creation of surcharges (fees) fora QUr. ;;:=r of regtdated practices which can effect groundwater. The monies collected through these sumharges are used for rr, nitoring groiar,d1wE-iter, grounr'- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) T f ~c4,~.~y ey PLB 67 ARrA T I \ yS , 6eAk r4tn, ,ex T °P PLOT & CROSS SECTION PLANS S.w. COQN~`J~ 90 8 or ZAPPA BROS. EXCAVATING INC a ~ J£>,1•rs g~ 46 3 A8 J~ P~Q PLUMBING UNIT 4 S ~V t, _ wv.oo' y" 50R 3o3y Nc PROJECT EG~iw / LJUT 4,,-Jf 3° o • r i~sa G Fs. G ',ESp ,c ? fff TAE K wee A10 ~r 4" ~O a , Iy y.. S~~~a S c+P - u o SuIeJ~. ~ ~ ga g8 ~ / ow oG J o~ec 45,o wine ~ 13.trQn1 a Q Q s,~o ~ourr~- S~cv NoT~t f~BsnQ'Pr,w.J ~Er} ~ ~6 W cs r Cur 06900 6O4+4A6 o /✓ldtz T •~,.vE &14K. OeprN ~~qu,~6rrrdavTS w E NO S SCALE FRESH AIR INLET AND OBSERVATION PIPE APPROVED VENT CAP MAXIMUM 12' ABOVE FINAL 'GRADE 4' CAST IRON VENT PIPE MAXIMUM OF 42' ABOVE PIPE TO FINAL GRADE SIGNED: c. MARSH HAY OR SYNTHETIC COVERING LICENSE: /~'f/~!/'S 33 SS MINIMUM 2' AGGREGATE DATE: OVER PIPE DISTRIBUTION PIPE I---1 TEE SOIL TESTING BY: ELEVATION BED 6' AGGREGATE • BOTTOM PER SOIL BENEATH PIPE • PERFORATED PIPE BELOW T ST18 ' 4rO FT COUPLING TERMINATING AT BOTTOM OF SYSTEM Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of Labor and Human Relations Division gfSafdty 8 Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but C'a0 tk 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 PROP~r-rt_P_ OWNER,:I PROPERTY LOCATION `I' m. ~ GOVT. LOT 1/4 1/4,S T ,N,R E (or) W PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SABD. NAME OR CSM # j ae h, 26 L"Oc~a ~~eX WtneNhk CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑V~ GE (TOWN NEARREES t ROA,eD I New Construction Use ~,Yf Residential / Number of bedrooms [ J Addition to existing building j J Replacement [ J Public or commercial describe Code derived daily flow 5D gpd Recommended design loading rate 06 bed, gpd/ft20,7 trench, gpd/ft2 Absorption area required 00 bed, ft2 7so trench, ft2 Maximum design loading rate 6 bed, gpd/ft2 trench, gpd/ft2 Recommended infiltration surface elevation(s) ric► ;Vy - ft (as referred to site plan benchmark) Additional design / site considerations Parent material Flood plain elevation, if applicable It S = Suitable for system NVENTIONAL OUND IN-GROUND PRESSURE_ I T-GRADE SYSTEM ~y, FILL HOLDIN T K U= Unsuitable fors stem S❑ U S❑ U 0S ❑ U S ❑ U ❑ S 131 U ❑ S U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence lBoui-day Roots GPD/ft in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed Trends 10 Y l L rh ro rn r A -r3 Z 3 Ground $ 1-63 16V414 S /r► r ri► GW - 017 a8 elev. pp ~ . ft. I7 ^ i2 ~dy 5 C~ r rl, - 6, 7 01 Depth to limiting factor ? Remarks: Boring # D-I `.23 / - I rYt solo I~~r 0.4 -Z-? vk 3 3 s, c 1 s>ox a k) 6.'2 0.3:? 0 Y _ 5 rvr ) w_ 67 3 Ground ,pp r o3 - `Z 16Y 4 6 S a elev. ft. W, 4 Depth to limiting factor $ 1 ___7 T__L Remarks: CST Name:-Please Print a J N~~ Phone: O Address: ~~dw t-J) Signatur 0 Date: CST Number: a© L PROPERTY OWNER P&-q 91 Z SOIL DESCRIPTION REPORT Page ~ of 3 PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bouncby Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. -e-d- ff n3nch - S - L / n Sbx nlYr- 6.4 O.S 2-7 4/3 56K n7 ~r .6.2 6.3. 07 Ground 7~6g Y ,4/3 S /h r L"11 c.J O.6 elev p _ eft ~-171 10YR s r nt .6 `6 Depth to limiting f to -l Remarks: Boring # A -z3 /a 'O I L n~sbk n,~rr 5 ?o.s 23-44 bvo - 511- / th sbK i .z 10.3 _67 / Y 3 - S A 9r' 1 5 0.~ Ground elev. vie 9 - S r nI 3.2 ft. , Depth to limiting factor > Remarks: Boring # A -~o / 3 I - t- l rn s~ r~ir 5 .S 5 ~ -zz 3 - S. ~ 1 SICK n1~r S . z 3 Ground elev. 3 z6 - l- ft R, 4 - 5 N► r O, 7 6, Depth to limiting factor 7~Z Remarks: Boring # wf iVaT ,~,v15 , ,►1 rJEL,o ,L tc~~4T16rv L1tc1JL P,?VJl6Q L\-/ L\MLc1r4T Q 6)T-E- T/l 9o6St 1Z A1TL` Ground $v !LT r1 S rTC wrJ ~v fl T'D elev. ft f ~LN1 aU LY L JA L LJ T & A S) T-6-. . Depth to limiting factor Remarks: SBD-8330(R.05/92) R , d v AaA W C Exisr,NG ~u3is 3L r M ~ D D .p Z ' N Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor acid Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary PermitNo.: 268588 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: HINTZE, PETER A & BONNIE L TROY CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA A9600292 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet Vent TANKTO P/L WELL BLDG. A irIto ntake ROAD Dt Inlet Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft Head Forcemain Length Dia. Dist. To Well 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: TROY.3.28.19W, NW, SE, TOWER ROAD 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 4 e SANITARY PERMIT NUMBER: Safety and Buildings Division c~~■~r■rt 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 ` n C~! % than 8112 x 11 inches in size. • See reverse side for instructions for completing this application state Sanitary Permit pa; The information you provide may be used by other government agency programs ❑ Check if C2 revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Prope )0 c- rty Owner Name Property Location ,R E(Or)W 7'C In&AJ iC -e - t 14T g~ 1/4, S Tai N - Property Owner's Mailing Address Lot Number Block Number 7 02 City, State Zip Code Phone Number Subdivision Name or CSM Number II. TYPE F BUILDING: (check one) ❑ State Owned ❑ it Nearest Road ❑ Village /J Public 1 or 2 Family Dwelling - No. of bedrooms Town OF d y 10 10, III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment /Condo d YO _ 4 O 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 KLNew 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System SystemTank OnlyExisting 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 G at) 1 -046*0 od /WOW 1.94!~' 401~ c Q-- Feet 9Sr3~ Feet VII. TANK Ca in galloacits Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existin structed Tanks Tanks Septic Tank or Holding Tank (a d~,' WC ~Te~~ ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite s age system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature- (No Stamps) MP PRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): l © 76j .Sc o d IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved tary Permit ee (Includes Groundwater ate Issued Issuing Ag nt Zna r e (N " mRs~ Surcharge fee) 2 1 Approved ❑ Owner Given Initial Adverse Determination l v W X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05194) DISTRI811TION: Original to County, One copy To: Safety & Buildings. Division, Owner, Plumber INSTRUCTIONS y 4 y 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. 11. 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 of-with complete d1-miLansions, location o`°f"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. ~v G !Z- ~~a~ 4, %J y X I STEEL'S SOIL SERVICE Gary L. Steel Richard Stout 1554 200th Ave. CSTM2298 NW4SE4 S3-T28N-R19W New Richmond, WI 54017 MPRSW 3254 town of Troy (715) 246-6200 t lot #26-Country Wood N Alt. BW top of cement base of corn crib @ el. 4111M' Bm.= top of cement slaB OF BARN DOOR C el. 100' bJ~ 200 0 _ r n t 4-1 0\ .a Gary L. Steel 8-6-96 Wisconsin Department of lndusUy, SOIL A I4 D SITE EVALUATION REPORT , r 1 of 3 •,Labor'nd Human Relations Division of'Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code t', C Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or EL I.D. dimensioned, north arrow, and location and distance to nearest road. ; € Win .Pf APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION WED BY DA' Ed PROPERTY OWNER: PROPERTY LOCATION Richard Stout GOVT. LOT 1/4 1/4,x°` AE (or) W PROPERTY OWNER':S MA!I.ING ADDRESS LOT # [BLOCK # SUED. NAME OR ` - " 1353 Awatukee Trl. S -3-5-24-, na u d CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE OWN NEAREST ROAD Hudson Wi. 54016 115) 549-6731 Troy Tower Rd. J )q New Construction Use [x) Residential / Number of bedrooms 3 [ ] Addition to existing building ] Replacement [ ] Public or commercial describe Code derived daily flow 450 gpd Recommended design loading rate • 5 bed, gpd/ft2 •6 trench, gpd/ft2 Absorption area required 900 bed, 112 750 trench, ft2 Maximum design loading rate • 5 bed, gpd/ft2 •6 trench, gpolft2 Recommended infiltration surface elevation(s) 91.88 ft (as referred to site plan benchmark) Additional design / site considerations na Parent material stream terrace Flood plain elevation, if applicable na ft I CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK S =Suitable for system I U = Unsuitable fors stem [R S El U IIR S ❑ U ®S ❑ U ®S ❑ U E] S ®U ❑ S mu SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure GPD/ft In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Consistence Botrtdary Roots Bed (Ttertdl 1.,.. 1 0-8 1U r3/2 none 1 2msbk mfr gw if .5 .6 2 8-44 7.5yr4/4 none scl 2mgr mfr gw if .4 .5 Ground 3 44-84 7.5yr4/6 none lfs osg mfr na na .5 .6 A!e ft. Depth to limiting factor +84" Remarks: Boring # 1 0-16 10 r3/3 none 1 2msbk mfr 9w if .5::.6 ii2 16-36 7.5yr4/4 none scl lfsbk mvfr gw if .2.3 Ground 3 36-90 7.5 r4/6 none " is osg mfr na na .7::.8 elev. 96.1 ft, Depth to limiting factor +90" Remarks: CST Name.=Please Print Phone: Gary L. Steel 715-246-6200 Address: 1554 200th Ave., New Richmond, Wi. 54017 10-24-95 cstM02298 Signature: Date: CST Number: PROPERTY OWNER Richard Si n„t. SOM DESCRIPTION REPORT Page 2 of 3 PARCEL I.D. # pending Depth Dominant Color Mottles I Structure I GPD/ft Boring # Horizon Texture Consistence Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed iTrerxh 3 1 0-13 10 r3 2 none 1 2msbk mfr gw if .5'..6 2 113-40 7.5yr4/4 none scl 2mgr mvfr 9w if . 4 j . 5 i; Ground 3 40-88 7.5 r4/6 none Ifs osg mvfr na na .5'1 .6 elev. 95.3 ft. Depth to limiting factor +88" Remarks: Boring # 1 0-10 10yr3/2 none 1 2msbk mfr gw if .5 .6 4 2 10-24 10yr4/4 none sil 2msbk mfr gw if .5 .6 3 24-61 7.5yr4/6 none lfs osg mfr gw na .5.6 Ground elev. 4 61-73 7.5yr4/4 none scl osg mfr 9w na .4 .5 94.1 ft. 5 73-84 7.5yr4/6 none lfs osg mvfr na na .5'.6 Depth to limiting factor Remarks: Boring # 1 0-20 10yr3/3 none 1 2msbk mfr 9w if .5 ~.6 5 2 20-44 7.5yr4/4 none scl 2mgr mfr gw if .4 .5 Ground 3 44-90 7.5 r4/6 none fs osg mvfr na na .5 .6 91e1 ft. Depth to limiting factor +90 Remarks: Boring # Ground elev. 1 ft. Depth to limiting I factor i Remarks: SBD-8330(R.05/92) STEEL'S SOIL SERVICE Gary L. Steel Richard Stout 1554 200th Ave. CSTM2298 NW4SE a S3-T28N-R19W New Richmond, WI 54017 MPRSW 3254 town of Troy (715) 246-6200 r lot #35-Country Wood N 1"=40' BM.= top of cement slab by barn door C el. 100' Alt. BM.= top of cement base of corn crib C el. 101.8' Dc /10 'K v w ci" '19 .%K ~a IL/ cam`' Gary L. Steel 40-24-95 I C F C vL l r i n/ I L. C- \ j ArAoh oornplete vile plan on paper not lees: than 61/2 x 11 inches in size. Plan nwst include. but St _ CMJ RM Ill *010 vertical and ha tsantai reWence pant (8", dkecbon and 'ys of slope, scale or rPAACE t.D. e dimensioned. raft arrow, and location and dWance b nearest road. pending APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION :0 BY DATE PROPERTY OWNER: CE OCATION Richard Stout 1N 1N,S T NR E W PROPERTY OWNER':S MAPJN13 ADDRESS OCK uk SUBO. NAME O CSM s 1353-Awatukee Tri. 4 na d STA ZIP CODE PHONE NUMBER ILNEAREST ROAD Hudsm, 54016 $15) 549-6731 Tower Rd. []I Flew Conshdiort use [x l Res idvdW ! Number of bedrooms 3 -.-.•W [ I Rsp<aoonten< [ PuM or =.v, rdat dnce _ [ 1 Addition Code derived daily fbw 450 gpd Aeoanwax'so design boding rap . 5 bed, gpdm • 6 _W o% "V am fired 900 bed. S2 750 1t2 Maximum design loading rate . 5 bed, gpdm , ' 6 Vwch, gpd* Recommended infOs ion surface "vak rt(s) 91.88 ._ft (as referred to dm plant bench,, park) Adtfiportel design I sip =*dwvfi m na Parent meterJW stream terrace Flood PWn elevation, d ap na ft Suigibie for system cNv~ ZONAL hfOtNrD MWIRD PRESSURE AT•GiRADE Y5rEM N FILL HOLOM TAN( V= Unsuitable for t tIS E3 u ®s CI U ® S 0 U ®s o u :3s ®u o s ov SOIL DESCRIPTION REPORT Boring # Horizon Depth 0eminant Color Mon Texture structure ~ Roots G ~ tz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed 1 h" 1 0-0 10 r3 2 none 1 2msbk mfr 1f .5 .6 2 -44 7.5 r4/4 none acl 2w mfr 9w if .4 .5 Grand 3 44-84 7.5 r4/6 none ifs osg mfr na na .5 .6 95.7 it D" b smiting factor +84" Remarks: Boring # 1 0-16 1 r3 3 none 1 2msbk mfr 9w it .5'.6 M21 2 16-36 7,5 r4/4 none sci Ifsbk mvfr if .2 .3 9w Qnxund 3 36-90 7.5 r4 6 none is osg mfr na na star. i 96.1 WOO 4 +9011 Remarks: FN=7.-4%us Print Gar L. Steel 715-2- -6200 1554 200th Ave. , New Ra . mi . 5?-017 10-24 95 cst1+A2298 : Dow CST NUFAW. MPERTYOMR Richard ste„ot SOIL DESCRIPTION REPORT Pegg 2 3 f PAW A I.D. s Pendincr Boring # FHonzon Depth 0omiriant Color Motlles Texture 3trucotre Gar>siSwm ' GPO/ft In. Munsell c" Sz. Com Color Gr. Sz. Sh. ~s Y Roots Bed fTi6rM C~3 r 013 1 r3 2 none 1 2msbk mfr if .5 .6 13-40 7.5 r4/4 none sci 2rngr mvfr 9v if .4j .5 Gmund 3 40-88 7.5 r4 6 none Ifs mvfr na na .5 fr.6 r 95.3 it NOW NAM factor +88.' Remarks: Boring # 1 0-10 10yr3/2 none 1 2msbk mfr gw if .5 .6 4 2 10-24 1 r4/4 none Gil 2msbk mfr gw If .5 .6 GWW 3 24-61 7.5 r4/6 none US cog mfr 9w na .5 .6 94 1ft 4 61-73 7.5 r4/4 none scl oe mfr 9w na .4 .5 Do* to 5 73-84 7.5yr4/6 rx)ne ifs osg mvfr na na . 5' .6 Remarks: Boring # 1 0-20 10yr3/3 none 1 2asbk mfr gw 1 .5 }.6 } 2 20-44 7.5 4/4 none sci Zmgr mfr gw if .4 1.5 E GuM 3 44-90 7.5 6 none fs mvfr na .5 .6 95.1' f t D" 10 x+90" Remarks: Boring # 1 0-12 10yr2/2 none i 2msbk mfr gw If .5 .6 6 2 12-29 10yr4/4 none sci 2msbk mfr gw If .4 i.5 3 29-45 7.5yr4/4 none sci zw mfr gw na .4 .5 08 tL 4 45-10 7.5yr4/6 none fs Osg mvfr na na .5 1 .6 ~ ~ D90 a bar +100" ` i Remarks: •wwlp~ µr.i+ ilia ""I WrAi1, PPdW Mp e ~ ~ Ay BBiQO. .w ~ 2.~ ~ yy V IC ~v / AAA, ID g L6y 09 1-I 2 6T / ti im c,i q J ~ IL J S $ a / jIR a W o w ~ ~p N p w y (b C 7~i 1 ~ . gu I a ® o m II' ,00'ilf? 3.6G,Gf.tON I ICJ 1 1~1 00'99 00'►Gf 1 Its M.6G,Gc.ZOS ~1 1 I I la. I- w • ly $ I_I 1• ire A I Icy Ir' Icy ~o r w I g o ~ I A 1 ~1 ~ 2o24da 8~ • ~ I ~ Ire 0 I I M.6GG,,G`C.zOS iU Ir- Ir- Icy ICj \ Iw I. ISn I'I I IV I la 1f .fi IT1 Ib I I~ 11' Icy Ir- ~ I£~ 1 I'0 I ILA 1.4 I (A M. je.iON Fin. 9 \ \ s a 'Q O WN ~ " C O s CO- 14- 00 l 7 & H6to sox) f-~r,, ~ ~ ' s T c - ioo Nw/J se-3 r ~ 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 ,Jc:y 1/4,5,45 1/4, Section, T.ZL_N-R_Zy_W Township rY~ Mailing address y~ /!L a A 1, d in e", r1 ~L_~ Il Address of site_ C4,•j:'1 r10AJ It W Rj IVAA,-d 5'rA) Subdivision name Lot no. W j2 Other homes on property? Yes t< No Previous owner of property /?,"I/. Total size of property 1 Glj Total size of parcel y'9:,e'c Date parcel was created -r u,.) e- IX~ pG Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house) ? Yes Z No Volume IiTa and Page Number 4~reZ 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 Applicap&I Co-Applicant 6~ / 77 Date of Signature Date of Siqnature STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER 7- ,v o r' 2 MAILING ADDRESS Z; 2r _4~~sa,.4-) 1.7.t- D' A Td 1Yi g 611 PROPERTY ADDRESS (location of septic system) Please obtain from the Planning Dept. CITY/STATE PROPERTY LOCATION 1/4, 1/4, Section T N-R_4,Z W TOWN OFa ST. CROIX COUNTY, WI SUBDIVISION is Ltyt-~ G,~7~ LOT NUMBER s CERTIFIED SURVEY MAP , VOLUME/1 7. PAGE (jam, 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 y expi ation date Cam(." SIGNED: i2& DATE: 17L(I St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 WARRANTY DEED Richard O. Stoat This Deed, J Fj UN 2 - Hintzet 0~ A. ntze and 3onn_ie - - - - Peter A.. H i t- - husband and wi - - Wltnes.-eth, Tint the saki Gr,wf. Croix St . .,•ari<<„nt, t, Ilr.v,,.t,fescrbp, a - ~ _ ~ ,,,,,t; Sate of ~V!scons~n- p f T= Cy Lot 26, Plat of Country e.ood, Town N, St. Croix County, Wisconsin. r I:1 I ii -home to 11, tv is not_ T n ; _ nst fis nOtl A3 bt o`G I q ~ ~<-.,,t, nen;s and ap['urt nan '~i Together •v,th all and singular the ,un-bnns2sexcept - StCut c,e.• And -_Richard O_ if any. wa•rants that the title is •lood. (ndeteas(hl in t e s;mp'e and free an f-w'ay of record, easements, restrictions and rights-0 a 9~ and will warrant and detend the same une J 18th - - fav t>t Dated this- 8th f - I-- (SEAL) - - RicharO. ---:SEALI (BEAU ACKNOWLEDGMENT AUTHENTICATION - `"SCONS'N I g(gnaturelsl.____ 1$ th ~I St._ _Croix_ ~mQt,Ft an.1.] 96 day of - LilllQ - - authenticated ih(s _ i BiCriar~ _Q_. Stout - AhJ ,..-,t t a ~i e n , II TITLE MEMBER STATE BAR OF WISCONSIN to r•~% u t the tl( not. - - - authorized by § 706.06. VV,s. Slats iNSTn(IMFNT VJAS DRAFTED 5` ~ L.~;'~~~~ ~ i~ Janet P Stout - x - - - nda Poulin r ~uinli_-~r~(•5 ii