HomeMy WebLinkAbout040-1236-30-000
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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
ADDRESS
SUBDIVISION / CSM# 1-5-4)dOT # S-2.
SECTION 3 T Zf N-R_',~? _W, Town of
ST. CROIX COUNTY, WISCONSIN 7d
?0-ON` p
72.
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
/07
a -7
0
w~u-
INDICA E NORTH ARROW
Provide setback and elevation information on reverse of this form.
0"i81*q11mensions to center of septic tank manhole cover.
BENCHMARK: ® 1
ALTERNATE BM: Zie 0" sfz ~90y { .
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: L~J Liquid Capacity: Zlve
Setback from: Well 7S3 House Other
Pump: Manufacturer Model# Size
Float seperation :Gallo c_
Alarm Location
SOIL ABSORPTION SYSTEM /
%
Width: /L Length Number of t-r r hes Z
Distance & Direction to nearest prop. line: S'O !
Setback from: well: ~;P_rO House Y2 other -01101r~/D7
ELEVATIONS
Building Sewer ST Inlet: Q0• p'l ST outlet: J7, ~7
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system .7w"
Existing Grade O. Final grade ~DD.a
DATE OF INSTALLATION: J
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR: / -27
3/ 9 3: j t FR'1Y PLUMBING
DATE:
/Q 7
JOB PT:
JUB SP:
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 284267
Permit Holders Name: 11 City El Village Town o : State Plan ID No.:
KE 4YR4)1 J TROY
CST BM Elev.: Insp. BM Elev.• BM Description: Parcel Tax No.:
' lo 3- &2-' /a 3. 62 0 ~`Gtm~ Gis L~ 040-1236-30-000
TANK INFORMATION ELEVATION DATA `1/.79 ¢Y
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic 60 G Benchmark K /a 3, 62~
Dosing /(6 , e_.W, ,2 2l0~ _5_1 q3 f
Aeration Bldg. Sewer 7d f ,-Y 3 -
Holding St/ iW Inlet 7 Sp' / 7'
TANK SE. CK INFORMATION St/ bK Outlet 27,
Vent 7!01
TANK TO P / L WELL BLDG. Air Ito ntake ROAD Dt Inlet
Septic s' a' NA Dt Bottom
Dosing NA Header 4td= _ 7#' 17
Aeration NA Dist. Pipe 176 27,
Holding Bot. System 6,6' (09'
PUMP/ SIPHON INFORMATION Flrirade 4,70'
Ma cturer Demand 7-
Model Num GPM
TDH Lift Loss ctlo ` TDH Ft
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width r Length N0. Of Trenches PI No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMEN I
anufacturer:
SYSTEM TO P/L BLDG WELL LAKE/STREAM 4HAMB~ER
SETBACK INFORMATION Type O na_J+ CcU: , Mode Numer.-°---
~r ~Qh c/6 9~ OR UNIT
System:
DISTRIBUTION SYSTEM
Header / MrrrI1T1td- " Distribution Pipe(s) Hole Size x Hole Spacing Vent To Air Intake
Length Dia. ~L Length ~5_z 1 Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At- e s Only
Depth Over Depth Over xx Depth Of,, xx Seeded/ Sodded Lied
Bed /_T ~ Center JS _ Bed/ Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: TROY.3.28.19~,SgE(,,SW 532 GILBERT ROAD L 52
64r .
Plan revision required? E] Yes No n / "
Use other side for additional information.
SBD-6710 (R 05191) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
I
Safety and Buildings Division
SANITARY PERMIT APPLICATION Bureau of Building Water System:
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. s
• See reverse side for instructions for completing this application State Sanitary Permit Number
7
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
ft"22 Z. p 1/4 w 1/4, S ,,,3 T N, R E (ork!%P
Propert Owner's Ma Ing Address Lot Number Block Number
1911X3 A* ktW-A , 4f S-2- 1
City, State Zip Code Phone Number Subdivision Name or CSM Number
ywa!A)l yo (1V)fN
II. TYPE F BUILDING: (check one) ❑ State Owned ❑ ~t~r Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms 3 5T gwOF W 1124-4
111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo DyD ^ /23 4- .7 a
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. [r New 2. ❑ Replacement 3, ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
System System Tank Only Existing System Existing System
-
B) ❑ A Sanitary Permit was previously issued- Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 ® Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation
Z/" 1 19 3 Z vs -7 .7 fr.? Feet 959.,ol Feet
VII. TANK Capacity
in gallons Total # of Prefab. Site Fiber- Exper-
INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
New Existing structed
Tanks Tanks
Septic Tank or Holding Tank C ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of T-Kel onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: N T S) PRSW No.: Business Phone Number:
/
'r f 11 7qf
,A* 13. 1
Plumber's Address (Street, City, State, Zip ode):
S ~
IX. COUNT / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater ate ssue .11IssuingA ent Sig ture (N a )
D r
AA/pproved E] Owner Given Initial Surcharge Fee)
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05/94) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
t. 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. Onsibe sewage systems must be properly maintained.. The septic tank(s) must be pumped by a,licensed pumper vvbenevpr
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:
I.- 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 online 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 scal6,or with complete,dimgnsions, location Qf 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 x;15 form; and F),. all sizing information.
GROUNDWATER SURCHARGE
1983 Wisconsin Act.410 included the creation of surcharges (fees) fora nui'nber of.reglilated practices whicKcan
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
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Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3
Labor an6 Human Relations
,Division oESafety Buildings in accord with ILHR 83.05, Wis. Adm. Code
OUNTY
Attach complete site plan on paper not less than 81/2 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 QI PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road. endi $
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY OC`ATION
Richard Stout GOVT. LOT 1/4 9w' 1AS 3 T 2s N,R 19 { (or) W
PROPERTY OWNERS MAILING ADDRESS LOT # BLO K.#` •SUBD: NAME'OR CSM #
1353 Awatukee Trl. 52 naR' 9221
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGEc [OWN: NEAREST ROAD
Hudson, WI. 54016 (715)549-6731 Troy Tower Rd.
( New Construction Use [x] Residential/ Number of bedrooms 3 [ ] Addition to existing building
(J Replacement [ ] Public or commercial describe
Code derived daily flow 450 gpd Recommended design loading rate • 7 bed, gpd/ft2 -8 trench, gpd/ft2
Absorption area required 643 bed, ft2 563 trench, ft2 Maximum design loading rate • 7 bed, gpd/ft2 .8 trench, gpd/ft2
Recommended infiltration surface elevation(s) 97.7 ft (as referred to site plan benchmark)
Additional design / site considerations alt site= 96.701 el.
Parent material pitted outwash plain Flood plain elevation, if applicable na ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable fors stem S ❑ U ® S ❑ U IRS ❑ U :R] S ❑ U iaS ❑ U ❑ S 91U
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 Tmrtdt
1 0-10 10 r2 2 none 1 2m . cs if .5 .6
2 10-26 10 r4 6 none sl 2mcir mvfr 9W 1f -9 -6
Ground 3 26-80 7.5 r4 6 none R ORry ml nn na .7 .8
elev.
99.73 ft.
Depth to
limiting
factor
+80"
Remarks:
Boring #
1 10-12 10yr2/2 none 1 2msbk mfr cs if .5 .6
2:'''; 2 12-26 10yr4/6 none sl 2mgr mfr gw if .5 .6
Ground 3 26-80 7.5 r4/6 none s os ml na na .7 .8
elev.
99.29 ft.
Depth to
limiting
factor
+80"
Remarks:
CST Name:-Please Print Gary L. Steel Phone: 715-246-6200
Address: 554 200th Av . , New Richmond, WI. 54017 m02298
Signature: Date: CST Number:
4-23-96
PROPERTY OWNER Richard Stout SOIL DESCRIPTION REPORT Page 2 of 3
PARCEL I.D. # pending Lot# 52
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
{ in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
gm-
1 0-9 10 r2 2 none 1 2msbk mfr CS if .5 .6
su~ 2 9-18 10 r4 6 none sl 2csbk mvfr C1w 1
Ground 3 18-84 7.5 r4 6 none s os ml na na .7 .8
elev.
100.7 ft
Depth to
limiting
factor
+84
Remarks:
Boring #
1 0-11 10 r2 2 none 1 2msbk mfr cs if .5 .6
M 4
2 11-20 10 r4/4 none sicl lfsbk mfr Cfw if .2 .3
3 20-33 10 r4/6 none is os mvfr Cfw na .7 .8
Ground
elev.
101.8 ft 4 33-90 7.5 r4 6 none s os ml na na .7 .8
.
Depth to
limiting
factor
+9011
Remarks:
Boring #
4 1 0-10 10 r2 2 none 1 2msbk mfr cs if .5 .6
5
2 10=24 :10 r4 4 none sicl 1 bk mfr
Ground 3 24-36 10 r4/6 none sl 2msbk mvfr Cfw na .5 .6
elev. 4 36-88 7.5 r4/6 none s os ml na na .7 .8
101.05ft.
Depth to
limiting
factor
+88"
Remarks:
Boring #
Svc;
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(R.05/92)
STEELS SOIL SERVICE
Gary L. Steel 1554 200th Ave.
CSTM2298 1 Richard stout New Richmond, WI 54017
MPRSW 3254 town of s3- Troy o28N-R19w (715) 246-6200
town o
lot #52-Country Wood
N
111=401
BM.= top of 111 steel pipe @ el. 100' top of marker stake @103.621
~a
i 33' _39' a '
tvl g't t
~l
~I q
0 8 tY
i
Gary L. Steel
4-23-96
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER /AW ,2.o hJ r % 4-
MAILING ADDRESS
PROPERTY ADDRESS ~30~ n ,"CT Kam(
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE
PROPERTY LOCATION _ 1/4, X kJ 1/4, Section T__=:R~N-R_j _W
TOWN OF 7,-0& 1Z ST. CROIX COUNTY, WI
SUBDIVISION CmuvTi~~s kvvj_) LOT NUMBER
CERTIFIED SURVEY MAP , VOLUME ---PAGE LOT NUMBER
Improper use and maintenance of your septic system could result in its premature failure to handle
wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed
by licensed septic tank pumper. What you put into the system can affect the function of the septic tank
as a treatment stage in the waste disposal system.
St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost
of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that owners of all new systems agree to
keep their system properly maintained.
The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner
and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1)
the on-site wastewater disposal system is in proper operating condition and (2) after inspection and
pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum.
I/We, the undersigned have read the above requirements and agree to maintain the private sewage
disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR.
Certification stating that your septic has been maintained must be completed and returned to the St. Croix
County Zoning Officer within 30 days of the three year expiration date.
SIGNED: '
DATE: 7 /
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 Aoloa
Location of property 1/4S4,t-) 1/4, Section T.-2j N-R_4f _W
Township D Mailing address
2 1`^
Address of site 6`32
Subdivision name cif 1~~f~ Lot no. ~Z
Other homes on property? Yes No
Previous owner of property s~'vu j
Total size of property -
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? ___/Yes No
Is this property being developed for (spec house)? Yes _I.,- No
Volume 2 and Page Number 3cV 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. Ea y-fS , 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.
,~'s6 y3S`
y
Sign ure 6-r--Applicant Co-Applicant
Date of Signature Date of Signature
VOL ~6 PACE 349
556435 STATE BAR OF WISCONSIN FORM 1 - 1982
WARRANTY DEED
DOCUMENT NO. REGISTERS OTr;^,E
ST. CROIX CTY., WI
Richard O. Stout Wdlo Mud
This Deed, made between
MAR 6 1997
Grantor, 3:00 "t P. M
and Myron J Kempen i -A w,4,k
Register of Deeds
Grantee,
Witnesseth, That the said Grantor, for a valuable consideration
conveys to Grantee the following described real estate in St. Croix THIS SPACE RESERVED FOR RECORDING DATA
County State of Wisconsin: NAME AND RETURN ADDRESS
Lot 52, Plat of Country Wood First Addition,
My"ate S kj-AEj Town of Troy, St. Croix County, Wisconsin. 110-15 t-tP~L. C~pT t~Z
N"ox" L-)T,
PARCEL IDENTIFICATION NUMBER
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