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HomeMy WebLinkAbout040-1235-60-000 r 4 S rv RECEIVED STC - 104 101 2 AS BUILT SANITARY SYSTEM REPORT 1998 ~ - ' ST CROIX COUNTY OWNER I ' 11 .Q T) \ 14j o ZONINGOFFIOE~~/ r r- l uu ADDRESS 945W y 1/ ~`1 419 SUBDIVISION / CSM#_ CU'„ itV AJ)0 1) P LOT # S SECTION 3 T) N-R 19 W, Town o f 1 TKO ST. CROIX COUNTY, WISCONSIN l I 3S ~OU~' 3. Z8 . L `11 PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM d i ~ U 0 KJ z ~~pNU4,~ BM (00' 6~(Ie~ (3p~'c g 3 Sk~V N~ 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:- W C.2 k S Liquid Capacity: ~a0U Setback from: WellO"?, ~ House 51 Other Pump: Manufacturer Model# - Size Float seperation Gallons/cycle: Alarm Location -:SOIL ABSORPTION SYSTEM Width: 5 Length S d' Q5' Number of trenches 3 Distance & Direction to nearest prop, line: Setback from: . well •GV~2 House 51_ Other p N - 9;~, I Q, q~g (I 1.33 g~. to 3. L - 104 3 31 9.) ELEVATIONS Building Sewer - ~ ~ caueR g9,ag ST Inlet ; S -00 ST outlet 4y, ~8 PC inlet PC bottom ~ Pump Off Header/Manifold Bottom of system N too Existing Grade SDI _ 4 ( 4V dS Final grade 0 4 M -9y ss L~ ~9.Ut~ DATE OF INSTALLATION: 30 PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR : ~~57 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 299131 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: DEJNO, MIKE TROY CST BM Elev.: Insp. BM Elev.: BM Description: S4-"f u,0 Parcel Tax No.: JZ1'j' / 00 040-1235-60-000 TANK INFORMATION ELEVATION DATA KQ7nnAAQ TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic P Z p d Benchmark / 2.S- 100.25 Dosing /D.S ~M -"fanK►, ~j. J ')3 Aeration Bldg. Sewer Holding St/Ht Inlet 5 9S TANK SETBACK INFORMATION St/ Ht Outlet g,g'Z' 9y.l~g~ TANK TO P/ L WELL BLDG. AirI to ntake ROAD Dt Inlet Air I Septic yZ' -r3s to"3" -flo'3" NA Dt Bottom Dosing NA Header / Man. L h 01 c. Aeration NA Dist. Pipe 9 ~S sa o•n- i 4Y 33 s 3` g i 5 ai 9/ 4' Holding Bot. System q Z-S 1 t> 11.2S 9,1 cle,z r] 71,91 PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand q-22, 19 2 F( Model Number GPM TDH Lift Friction System TDH Ft Forcemain Length ia. Fi Dist. To Well SOIL ABSORPTION SY TEM BED / EN Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMEN I NS S DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufactur SETBACK INFORMATION TypeO CHAMBER _ Mode Nu e : System n ~-2p -t 35~ f(oo OR UNIT DISTRIBUTION SYSTEM l R~ 2 -7 2 ell Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length - Dia - Length L,7' Dia. Spacing G - I SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth 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 3.28.19,SE,SW 535 GILBERT ROAD LOT 45 1 4 3 -t rcn " S. v4 c, lrf-- vSe~ i ~Sk e Ecl ar 4w e 5_`i(-75' -h;re vv. "es - 3 6dv'wt + ~ ]octe-r o . 3) IJc l ( i5 i A row J 44Ae *us-e Na,~e n a'! !t ~l 1a Plan revision required. Yes ❑ No Use other side for additional information. l 11 ~7 SBD-6710 (R 05/91) 100< Date Inspector's Si ature Cert. No. ADDITIONAL COMMENTS AND SKETCH ' r SANITARY PERMIT NUMBER: Safety and Buildings Division SANITARY PERMIT APPLICATION Bureau of Building Water Systems 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County, than 8 112 x 11 inches in size. ~ C-) • See reverse side for instructions for completing this application State Sanitary Permit Number ❑ Check if revision o previous application The information you provide may be used by other government agency programs [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Prope O ner Na r Property Location e e q . © 114 1/4,S T 10 ,N,R~ E(or)W Property Owner's iling Addres Lot Number Block Number City, St to Zi d/ Phone Number Subdivision1Yam CS/M Number ~ 1 ( > G? I gL --Z II. TYPE BUILDING: (check one) ❑ State Owned '0' ❑i C Vitllyage Nearest Road Q ❑ Public 1 or 2 Family Dwelling - No. of bedrooms Town of / CT' h- III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment /Condo 0"~ 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 OnlyExisting System _________Existing System B) 'j''A Sanitary Permit was previously issued. Permit Number a y jam 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 12XSeepage 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 / Requi ed (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft_) (Min /inch) L. $9.0 Elevation o Q / da0 1605 ~Q A . 4 ).00 Fee# l' 93 a G Feet VII. TANK Capacity gallonTotal # of r Prefab. Site Fiber- Exper INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existing strutted Tanks Tanks Septic Tank or Holding Tank pp /e $ ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Nam Print) Plumber's Sig ture: (No Stam s) MP/MPRSW No.: Business Phone Number: U-me g Plumber's Address (St eet, City, State, Zip ode): rd r IX. COUNTY / DEP RTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issue A2." ssuing Agent Signature (No Stamps) [Approved ❑ Owner Given Initial Surcharge Fee) /Q a~ X Approved Adverse Determination 1319 X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05194) DISTRIBUTION: Original to County. One copy To: Safety 8 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 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- V11. 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. V111_ 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. Wisconsin Department of Industry, SOIL AND SITE EVALUATION - l 3 Labor and Human Relations Page of Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I. D. # 7 C-' APPLICANT INFORMATION - Please print all information. Reviewed by Date Petsonal information you provide may be usectfor'secondary purposes (Privacy Law, s. 15.04 (1) (m)). fltoperty Owner / Property Location /f r !6 ~E :D[ _X PC) Govt. Lot . SE 1 /4 SW 1/4,S 3 T. N,R I Q E (o We Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# 5S 5 G i L QE1R ~C' ~ !'0llf1r14?Y zobo,49 LIE- Ciry State Zip Code Phone Number Nearest Road "tu fJSo~ W l - Sr/Ol to ( ) ❑ City 1:1 P o L~ Town 19 ew Construction Use: esidential / Number of bedrooms 3 Addition to existing building ❑ Replacementu ❑ Public or commercial - Describe: IVJA= 4-10 7- ELQ E•vl~E Code derived daily flow <gpd Recommended design loading rate R bed, gpd/ft2 6 trench, gpd/112 Absorption area required bed, ft2 7`50 trench, ft 2 Maximum design loading rate IV/4 bed, gpd/f12 _-6 trench, gpd/ft2 Recommended Infiltration surface elevation(s).5 • 3 ft (as referred to site plan benchmark) Additional design/site considerations usE X .0"S Parent material ~O~SS Cr('~ OLXt- fi}NfPy 0 uTcy fP4- Flood plain elevation, if applicable N~~ ft S = Suitable for system ~Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank U = Unsuitable for system Ers ❑ U 9-T-b U L~ ❑ U E4-s- U ❑ S C3-u- ❑ S SOIL DESCRIPTION REPORT Boren # Horizon Depth Dominant Color Mottles Structure GPD/ft2 9 Texture Consistence Boundary Roots in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench l i o- iOYA 2-13 - TZ_ Zfs e 4„ ft ~s 2f . s; . Z iaY 3/3 s~~ /fs s f • Z • 3 444T GPS .s; .~o Ground 3 ioY 2~t At elev q(. eft. ~o .SL a 1 She. /,A4 cw . s . 74 40 //5 VIA 41111, Depth to limiting factor ~~-in". Remarks: zabuo '83TT wagsds T Tetu.aou JOJ paouequa gsow aq uoTgd.aosge ? quatugea.zq ueo Aem sTgq uT ATuO •gaxonq aqq 40 sapTs aqq uo paqunow aq SaDlAap buTd3Tieos gegq spu9tut103pJ uaAa •uuTys •azngonals Teangeu sTTOS aqq 90 TTe asodxa-a.z o Slu644pq STjeMapTS aq-4 axe z pueq dT zado zd oq Tn jaaeo AjaA eq, ZSf1~I' .zaZ~'e SbT age ) £1•£8 HHU Jad sV •gTnsaj TTTA ajnTTeJ aingPwaid sinooo sTgq uagM •uoTjonagsuoo 14ouaJ4 buTinp gaxonq aogxoeq a Aq uana pagoedwoo JO pajeaws ATTSea aq TTTM 'g ueo (•oqa 's4TTS'SweoT) STTos paznqxaq zauTj aql TTY' :HHggV1SNI '3 SHHNMO 01 PROPERTY OWNER /q ' !7 E.T tJ i) SOIL DESCRIPTION REPORT Page of d7 6' d G Z PARCEL ID# 12-3 S• G 67 - 415 4u 0 Boring # Horizon Depth •Dominint Color Mottles Texture Structure Consistence Boundary Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench 3 D•I3 'royie -4/3 SQL 2 -fSdlve IM 7' fe e5- .2 -T- .S . Co 4074 8-16 /10 313 s-le. lie 5;41e e ~4 Ground 3 G • 1 y SiL 2 -"XT4" ~'TiQ C S • S ; • to elev. S (o Depth to ` ' 1 GTs f ^o~e limiting factor ; J Remarks: Boring # 4 'Z3 /0 YX ~/j CY /7f- .sly Z&m Me ,w 7X es _ . s . ~ Ground ~Y J Z f 's ~iJ 7/C CG(~ ..S . ~O elev. /,Q YA S ; Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Structure GPD/ft2 Texture Consistence Boundary Roots in. MurSsell Qu. Sz: Cont. Color Gr. Sz. Sh. Bed . Trench Boring # / D /D /O 3 ,SIL 24S S /7c • S . 4~- S Z D•. / 3 SIL / c ' />c . z ' • 3 X 3 •3 %DY S L 2 rs .S Ground ' /tja S L Z -~S / k 7~e a.c' • S Y -zle 141 T2, o elev. n. Gds 'N 44e Depth to J /0 S / limiting factor y rl~/ in. Remarks: Boring,# Ground elev. n. Depth to limiting factor in. Remarks:" SBDW-8330„(8. 08/95) To of P~ S3S- ~r AT- A.)4..,) 407- 49)f1(JL=1< No, 1-o 7- 33 ~ti' ✓ sVsT 10 , o 0 II .I ~ v I, I , I W .I T6P Ar Pei, m I 2q' i L ~ I 3 - 1-1 /?v-,f T/CLVS i0 B ~ 5.30 , ztM~ ~ g 132 f6, 32, eousr%&cT. A !3 P. Q. t_. ~ 7 LOT 11 I-) 0 S 5 SEC-1-1(*.)I\l ~ I-? P O J EC r I' lam. l~_~ . i', - _ N AM E ..N.A•M E ITR PL OCA 10 N-,s3~--~~ IC E NS E 3y~ y S~I'cti'1 V$ got k s' j4 i ~ i ~ r I I I~ 90' 5g Top of ca"cot* r^ s t ~~v = IUD. b Z 6 ; ot~ l►)Q~~ is IAik Wisconsin *Department of Industry, PRIVATE SEWAGE SYSTEM County: labor and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) sanitary99035 GENERAL INFORMATION Z 49 - llage Town o : State Plan ID No.: Permit Holder's Name: ICIR8 CiT Vi DEJNO, MICHAELAUHMAN, JANE CST BM Elev.: Insp. BM Elev.: BM Description: 1 /Q4 Parcel Ta o.: 0-1235-60-000 TANK INF MATION ELEVATION DATA A,9700352 TYPE MANUFACTURER CAPACITY STATION HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/ Ht 1 134 TANK SETBACK INFORMATION St/ H 'Outlet TANK TO P/ L WELL BLDG. Air ttoke ROAD D Net Septic NA t Bottom Dosing NA Header/Man. Aeration Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number / GPM TDH Lift Friction System TDH Ft Loss- j Forcemai n Length Dia. ,.ad Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width L gth No. Of Trenches PIT N f Pits Inside Dia. Liquid Depth DIMENSIONS DIMEN I N Manufacturer: SETBACK SYSTEM T P/ L BLDG WELL LAKE / STREAM LEA \UNI INFORMATION Type Of CHModel Number: System: OR DISTR IBUTION SYS M Header /Manifold Distribution Pipe(s) x Hole Size x Hole acing 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 x ulched Bed /Trench Cent Bed /Trench Edges Topsoil ❑ Yes ❑ No E ]-e s ❑ No COMMENT : (Include code discrepancies, persons present, etc.) LOCATION: TROY 3.28.19,SE,SW 535 GILBERT ROAD LOT 45 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: ` IIlr~pE~ Safety and Buildings Division ~~■~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. Sfi, CF,0,1X • See reverse side for instructions for completing this application State Sanitary Permit Number g,4?r/03__ The information you provide may be used by other government agency programs ❑ Check if on to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Property Owner Na 7e , r- Property Location 0 "0 4 3ANe L~,~ NAtj SE 1/45 1/4,S 3 T ;t$ N,R 9 E(or)W - Propert Owner's I~IIa di A~ ss Lot Number Block Number City, ate v , Zip Cude Phone umber Subdivision Name or CSM Numb r T`1 II. TYPE F BUILDING: (check one) ❑ State Owned ❑ ity Nearest Road ❑ Village ❑ Public 1 or 2 Family Dwelling - No. of bedrooms own OF G1 ~erd j III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment / Condo 0~ - / p~ 3 5- ^ CL0 c) 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. RNew 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an -_____SystemSystem 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 C&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. S stem Elev- 7. Final Grade Re uired (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) EleXption 00 0 100 tQ • l0 Feet 9S,1~ Feet VII. TANK Capacity gallons Total # of site Fiber- Manufacturer's Name Prefab. Con- Steel Plastic App- New Existin Gallons Tanks concrete strutted glass Appp. Tanks Tanks Septic Tank or Holding Tank I SOU Ill ~Lt ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (No Stamps) MP/MPRSW NO.: Business Phone Number: To-rk 301AM-f-e fi pa IQ, 3`IOv 715- L- 9Q0 Plumber's Addr s (Street, ity, State, Zip Cod b~0 U, 43S n -4 0 L IX. COUNTY / EPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee .(Includes Groundwater Date Issue Issuing ent S at re (N to ps) roved Surcharge Fee) pp r-1 Owner Given Initial/,(~v Adverse Determination /U X. CONDITIONS OF APPRO AL / RE ONS FOR DISAPPROVAL: SBD-6398 (R. 05/94) DISTRIBUTION: Original to county. One copy To: Sufety & Ruilaings Dive ion, Owner, Plumber INSTRUCTIONS 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. 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 8 112 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 establishmrvof standards. h -r. N A M E N-6 C)k\tj 6 4.iakc AM E Y) m O L 0 C A I O N-...--- u `D - I C E N S_ 1... A_____ • I" .S1~e~l P'~~ ~I~e~~ luo,o , 80' Naee b~~p~~ lofiJ NUS brz-9 foal ~AA o 1ZvU 90. I vU• N die : ~~I~ 'is o~ pnfil-~K ~~„a~ Sp l-7 3p(D gy wt.b 3a3 . ' ~ U i v o p r• FRESH AII: IREF.FiS-AND OBSERVA'PIdN PIPE CliOSS SECTION Approved Vent Cap Minimum 12" Above "P Final Gra~j~___~ 4" Cast Iron Vent Pipe Above Pipe Final Grada To F Wiscort_,in Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3 abor arfd Human Relations 'Division of Safety & 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 St. Croix not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or . ARGEL(.D. # .ofe ~ d 4 "7 a ~ dimensioned, north arrow, and location and distance to nearest road.. n APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEW QF:; DATE PROPERTY OWNER: PROPERTY L ATt6N Richard STout GOVT. LOT IiSj 1/4 SW, 114,S 3 T 28 ~ A,R 19 fc (or) W PROPERTY OWNER':S MAILING ADDRESS LOT # BL,.CK# SUED" NA EbR CS4# 1353 Awatukee Trl. 45 na Count Wood CITYa;STATE ZIPCODE PHONE NUMBER ❑CITY ❑VILIAGE 91TOWN• NEA, ROAD Hudson WI. 54016 (715) 549-6731 Troy r Rd. New Construction Use [ Residential / Number of bedrooms 3 Addition tq axis ' wilding j J 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, ft2 750 trench, ft2 Maximum design loading rate • 5 bed, gpd/ft2 - 6 trench, gpd/ft2 Recommended infiltration surface elevation(s) 91.18 ft (as referred to site plan benchmark) Additional design/ site considerations alt. Site= 90.0' system el. Parent material outwash Flood plain elevation, if applicablena ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable fors stem :K1 S ❑ U [3S ❑ U :E] S ❑ U ® S ❑ U ❑ S ®U ❑ S ® U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence BoLx>day Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench F<: 1 0-14 10 r2/2 none 1 2msbk mfr gw lf..5 .6 1 << 2 14-30 10 r4/4 none sicl lfsbk mfr 9w if .2 .3 Ground 3 30-84 10 r4 4 none sl 2csbk mvfr na na .5 .6 elev. 94.7 ft. Depth to limiting factor +84" Remarks: Boring # 1 0-12 10 r2 2 none 1 2msbk mfr if .5.6 2 12-27 10 r4/4 none sicl lfsbk mfr if .2 .3 Ground 3 27-82 10 r4 4 none sl 2csbk mvfr na na .5.6 elev. 95. Depth to limiting factor +82" Remarks: CST Name: Please Print Phone: Gary L. Steel 715-246-6200 Address: 1554 2 h Ave. New Richmond WI. 54017 m02298 Signat&: Date: CST Number: 4-24-96 PROPERTY OWNER Richard Stout SOIL DESCRIPTION REPORT Page Z .oj 3 PARCEL I.D. # pending Lot #45 Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 1 0-14 10 r2/2 none 1 2msbk mfr c1w if .5 .6 3 '2 14-29 10 r4/4 none sicl lfsbk mfr If .2 .3 Ground 3 129-84 10 r4 6 none sl 2m elev. 93.68ft. Depth to limiting factor +84" Remarks: Boring # 1 0-18 10 r2 2 none 1 2msbk mfr aw if -5: .6 2 18-32 10 r4 4 none C;i ri Ifsbk mfr 9w if M Ground 3 32-80 10 r4 6 none US os elev. 92.95 ft. Depth to limiting factor +80" Remarks: Boring # x<::'::1 -15 10yr2/2 none 1 2msbk mfr if .5: 2 15-34 10 r4 4 none sicl lfsbk mfr >aw .2i.3 Ground 3 4-80 10 r4 6 none sl 2csbk rMav fr elev. 92.9ft. Depth to limiting factor +80" Remarks: Boring # :`••'tk i Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) s STEEL'S SOIL SERVICE Gary L. Steel Richard STout 1554 200th Ave. CSTM2298 SEgSW4 S3-T28N-R19W New Richmond, WI 54017 MPRSW 3254 town of Troy (715) 246-6200 lot #45-Country Wood t N 1".+40 BM.= top of 1" steel pipe @ el. 100' 604 1 lU l la Gary L. Steel 4-24-96 8 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 pr~operty~"C,L ~a / T)e Tne Ikl~rnctYl_ Local ion u;f property SF 1/4 5PJ 1/4, Section 3 IT Z e N-R W Township //WI/ Mailing address LdT 4/S" 611hu1 PV Vi Address of site X35 i~ y0~6 Subd i vision name 6vn /r4 (Ndd Lot no. yS Other- homes on property? Yes X No Previous owner of property 0i4x S~Uf Total size of property 2,22 Total size of parcel 2,2-2 Date parcel was created 29, 410 Are all corners and lot lines identifiable? _ Yes No Is this property being developed for (spec house) ? X_Yes No Volume/Z,5-Z- and Page Number _5TZI as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRA11TY 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 Gate) the owner(si) 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. 56 26 F5 and•that I (we) presently own the proposed site for the sewage disposal system or (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 o.E Deeds as Document No. S62 4, 2S `Y x 4&1i Si nature of Applicant Co-Applican." , t~.~ ~s, rrrnt urr. Dat o of Signature STC - 1115 till TIC TANK MAINTISNANC , A(:I EE.MFINT St. Croix Cou110. \r o\~~N1~.IVlsuvr•It . A_ / a ---a,2~2~,~_.,~ahe... MAIII.ING ADDRESS I ROPI~,RTI ADDRESS .5'35" ~~/beef Pd. ~vdon_ ak 5-;(1v1& (location of septic system) Plcase obtain from the Planning Dept. CITY/STATr, PROPIE.RTY LOCATION 5, 1/4, Sk) 1/4, Section 3 T Zg 1q-1t /9 TOWN 01. ~2pt/ ST. CROIX COUNTY, WI SUBDIVISION 66ill- y KJdO~/ _ LOT NUNIBEIR _y5- CERTIFIEDSURVEY MAI' , VOLUME/ZS_Z, PAC E, 3"5el , LOT NUMBER /YS 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 lank 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 life 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 the requirement that owners of all new systems agree to keep their system properly maintained. 111c properly owner agrees to submil 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) lite on-site wastewater disposal system is in proper operating comfitimm mid (2) after inspec(;oll alld punlpinf; (if necessary), the septic lank is less than 1/3 full of sludge and scum /We, life undersigned have read the above requirements and agree to mainlain the private scwagc disposal system in accordance with the standards set forth, herein, as set by file wis Ceriilicalitm stating that your septic has been maintained must he completed and returned to the 4"1 Croix County Zoning Officer within 10 days of the three year expiration date J,~'yZ~~ZGP/Vt~~ MIT- 7 `I 1'Irnx 1'c►nnly 7.1116111; ( ►Itir.r (;ovl..lllllit-Ill ( *villel 1101 Ca1mN•1►a1.1 (toad 1111ilmin. \VI '1I016 11/'► •..562695 WARR MN I r F N^ ~J 1252;•:=554 This Deed:~. Richard_ U M 9:00 A. . e o-_ and .Jane-- Mi chael C. Dln-+: - and rsons._- - - two-__sing _e p_- Witnesseth, Iha ,he ;aw i rant!K. !.x - St. Cr C. ranee the !,)!iJU ing dts;;1[XC rea". estati IR %AYE ~N.- RE-. ' County, Mate of Wlsconsm. _ Lot 45, plat of Country Wood Fizst Addition, Town of Troy, St. :roix C:unty, Wisconsin. PPRC[~ '-.`+ENi,F ~P:'Ch NUMPER k TRANSFEP This S not_ hoinestead properl} ;is) s not' Together with ,il and singular the hereduaments and ap-, _1_.k And _21C ha lx)d :^de;er;b!e to fee simple and Tree e warrants that :he title is g easements, restrictions, rights-o-~ Am;3y and covenants of record, if any, and will warrant and defend the same l9 QZ_ Dated this __17 [SEAL) - (SEAL' L \ Richard U. Stout isEat) (SEAL - - - - v ACKNOWLEDGMENT AUTHENTICATION State of Wisconsin, ss Signature(s) St. CLOLx County ~t h _ d-'-;; of i9--- Personilly game before rie this __Aauthenticated this day of July 199 the above named Richard. O. Stout _ 1ITLE MEMBER STATE BAR OF `1ISCONSIN