HomeMy WebLinkAbout040-1236-50-000
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STC - 104 p
AS BUILT SANITARY SYSTEM REPORT n RECEIVED a
JUN 0 5 1997
OWNER - EiE > ST CROIX
COUNTY
ADDRESS ZONR4G O FICE
SUBDIVISION / CSM# LOT #
SECTION ~T~gN-R_L~_W, Town of ~~vJ
ST. CROIX COUNTY, WISCONSIN
LAN VIEW
SHOW EVERYTHIN WITHIN 100 FEET OF SYSTEM
wall
r~
v
C
2
7y'
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
Y .
BENCHMARK: z2'ev ep
ALTERNATE BM:,,,
SEPTIC TANK PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Liquid Capacity:
Setback from: Well 9_5-_ House Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: J~ Length 7y' Number of trenches
Distance & Direction to nearest prop. line: )1 /per 4
Setback from: well: e.5- Housed Other
ELEVATIONS
Building Sewer ST Inlet: o- ST outlet:
r.
PC inlet PC bottom Pump Off
Header/Manifold L / Bottom of system
Existing Grade 94.E Final grade
DATE OF INSTALLATION: S
PLUMBER ON JOB: zaA' L
LICENSE NUMBER: INSPECTOR:
3/93:jt
Wisconsin,Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT CROII
Safety and Buildings Division,,
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 2.44265
Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.:
HOMMES JEFFREY J TROY
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
040-1236-5,--000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing
Aeration Bldg. Sewer
Holding St/O Inlet
TANK SETBACK INFORMATION St/peoutlet ~-7
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Y? x4-
Septic NA Dt Bottom
Dosing NA Header / Man. op, 23
Aeration NA Dist. Pipe P.3s~
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
oss Head
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Di Liquid Depth
DIMENSION DIMENSIONS
LEACHING Manufacturer.
SETBACK SYSTEM TO P/ L BLDG WELL LAKE /STREAM
INFORMATION Type O CHAMBER Mode 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.).~4s~^~'~ Kea!-~
LOCATION: TROY. 3. 28.19, SE, SW 536 LBERT ROAD
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
1
I
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
i
E
.e.~.
Safety and Buildings Division
v~~i~i;'■~ 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. I le__
• See reverse side for instructions for completing this application State sanitary Permit Numb
.,2- S'y"024?-S,
The information you provide may be used by other government agency programs ❑ Check if revision to previous application
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Prope y Owner Name Property Location ,~9
1/4 1/4,S T , N, R (ori
Property Owner' ailin dd e s Lot Number Block Number
City ate Zip Code Phone Number Subdivision ame o CSM Num er S f
( )
II. TYPE F BUILDING: (check one) ❑ State Owned ❑ its t]Neamst Ro
❑ VII age
Public 1 or 2 Family Dwelling - No. of bedrooms Town OF
111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash
5 ❑ Hotel /Motel 9 ❑ Office/Factory 13 ❑ Other: specify
IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable)
A) 1. ig New 2. ❑ Replacement 3. Q Replacement of 4_ Q Reconnection of 5. ❑ Repair of an
System System Tank Only Existing System ExistingSystem
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 JM 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./i ch) Elevation
Feet Feet
VII. TANK Capactt
inallos Total # of Prefab. Site Fiber- Exper.
INFORMATION g Gallons Tanks Manufacturers Name Concrete Con Steel glass Plastic App
New Existing structed
Tanks Tanks
-am I - El 1:1 1:1 1:1
Septic Tank or Holding Tank
Lift Pump Tank /Siphon Chamber ❑ ~ ~ El ❑ E]
VIII. RESPONSIBILITY STATEMENT
1, th undersigned, assume responsibility for i allation of nsite sewage system shown on the attached plans.
Plu ~be Nam . (P K~l Plumb is nat e: mps) MP/MPRSW No.: Business Phone Number:
` - f
PI mber's A dress (Street, Ci y, State, ode):
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved San tary Permit Fee (Includes Groundwater ate Issue Issuing A nt Signatu aNoSt
11 Approved ❑ Owner Given Initial /p~
Adverse Determination l/v `3/~J
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Ruildings Division, Owner, Plumber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
i
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 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.
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STEEL'S SOIL SERVICE
Gary L. Steel Richard Stout 1554 200th Ave.
CSTM2298 SE4SW1j S3-T28N-R19W New Richmond, WI 54017
MPRSW 3254 town of Troy (715) 246-6200
lot #54-Country Wood
1"=40'
BM.= top of steel pipe C el. 100'
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209'_ 5o
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Gary L. Steel
4-23-96
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• Wisconsip Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3
=Human 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, b~.rf S#r` Ci'wix
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or CEL I D #
dimensioned, north arrow, and location and distance to nearest road. pendirig` - `
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION BY DATE
PROPERTY OWNER: PROPERTY L CATION
Richard Stout GOVT. LOT S) 1/4 SW, 1/4,S: 3 T 28 ,R 19 xk(or) W
PROPERTY OWNERS MAILING ADDRESS LOT # BLO t#- •SUB~ NAME CSR rISM , u
1353 Awatukee Trl. 54 na = `fount rf 1~.
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGEQ t ST ROAD
Hudson, (715 549-6731 Troy I~ ower Rd.
New Construction Use k J 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) 93.39 ft (as referred to site plan benchmark)
Additional design / site considerations na
Parent material pitted outwash plain Flood plain elevation, if applicable na It
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable fors stem ® S ❑ U ~7 S ❑ U ® S ❑ U ®S ❑ U ®S ❑ U ❑ S MU
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Bourclaty Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trends
1 0-11 10 r2/2 none 1 2msbk mfr Cfw if .5 .6
1
2 11-24 10 r4 4 none sil lfsbk mfr if .2 .3
Ground 3 24-80 7.5 r4 6 none s os ml na na .7 .8
elev.
96.39ft.
Depth to
limiting
factor
+80"
Remarks:
Boring #
1 10-16 10 r2 2 none 1 2msbk mfr
:>w>:
2 2 16-24 10yr4/4 none sl 2m r mfr Cfw if .5 .6
Ground 3 24-80 7.5 r4 4 none s os
elev.
96.67ft.
Depth to
limiting
fa+$r0
Remarks:
CST Name:-Please Print Phone:
Gary L. Steel 715-246-6200
Address:
1554 200th Ave., New Richmond, WI. 54017 m02298
Signature: Date: CST Number:
4-23-96
PROPERTY OWNER Richard Stout SOIL DESCRIPTION REPORT Page--2-of 3.
PARCEL I.D. # pending Lot#54
Depth Dominant Color Mottles Structure GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench
1 0-13 10 r2/2 none 1 2msbk mfr cfw if .5 .6
ff 3
2 13-20 10 r4 4 none sil lfsbk mfr C1w if .2 .3
Ground 3 20-28 10 r4 4 none sl lcsbk mfr CM na -4 .5
elev.
97.1 ft. 4 28-84 7.5yr4/6 none s os mvfr na na .7 €.8
Depth to
limiting
factor
+84"
Remarks:
Boring #
1 0-12 10 r2 2 none 1 2c 1 mfr if .5 .6
4M 2 12-31 10yr4/4 none sil 2msbk mfr gw if .2 .3
Ground 3 31-40 7.5 r4 4 none sl 2m r mfr C1w na .5 .6
elev. 4 40-84 7.5 r4 6 none s os ml na na .7 .8
97.69 ft.
Depth to
limiting
factor --T
+84"
Remarks:
Boring #
1 0-12 10yr2/2 none 1 2msbk mfr gw if .5 .6
2 12-28 10yr4/4 none sil 2msbk mfr gw if .5 .6
'\•ti:::~: iti~hvii:
}}:~::•i:??ti:i} is
3 28-38 10yr4/4 none is osg mvfr gw na .7 .8
Ground
elev. 4 38-84 7.5yr4/6 none s osg ml na na .7 .8
95.9 ft.
Depth to
limiting
factor
+84" F-F
Remarks:
Boring #
.
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
S T C - 100
This application form is to be completed in full and signed by the
owner(s) of the property being developed. Any inadequacies will
only result in delays of the permit issuance. Should this
development be intended for resale by owner/contractor, (spec
house), then a second form should be retained and completed when
the property is sold and submitted to this office with the
appropriate deed recording.
Owner of property. ~1 b►uwao5 f-1X2A-b~ VA~ 4vmw►ps
Location of property ] 1/4 aK--1 1/4, Section T 2T N-R11 -W
Township -reoy Mailing address 25$~ R>a% jx ( d2 l'
u.~ wt~v ~51ZS
Address of sit S
Subdivision name Cnuu~wN w-->vocQ Lot no.
Other homes on property? Yes X_No
Previous owner of property
Total size of property zeoo
Total size of parcel 7,15 Atw-t5
Date parcel was created
Are all corners and lot lines identifiable? X Yes No
Is this prQerty being developed (spec house)? Yes ___X _No
Volume 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 ,.pf the County Register of
Deeds as Document No.'s and that I (we) presently
own the proposed site for the sewage disposal system or I (we)
obtained an easement, to run the above described property, for the
construction of said system, and the same has been duly recorded in
the office of the County Register of Deeds as Document No.
Si e of Applicant Co-Apt licant
Date of ignature Date o Si nature
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
M St. Croix County
OWNER/BUYER J. -4omwtvS 1 i za 6,e4+ Pomw~a 5
MAEU NG ADDRESS ~1Z1 bLu NK N 61 Z 5-
3 (p y /rte ✓lp
PROPERTY ADDRESS
(location of septic syst m) Please obtain from the Planning Dept.
CITY/STATE _rkV t t..):r-
PROPERTY LOCATION 5E 1/4, 5 LO 1/4, Section •3 T Zg N-R 9 W
TOWN OF ILO ST. CROIX COUNTY, WI
SUBDIVISION U n 2t wo CA LOT NUMBER 5 t- _
CERTIFIED SURVEY MAP _,VOLUME , PAGE , LOT NUMBER L
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: 'k I
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
/ L,
5356228 STATE BAR OF WISCONSIN FORM 1 - 1982
J WARRANTY DEED
DOCUMENT NO. r
_ REG1STER'S OFFICE
_ ST, CAOIx cN, wi
This Deed, madebetween Richard O Stout MWdb FW=d
MAR 3 1991
Grantor, 1:40 P.m
and Jeffrey J Hommes and Elizabeth A. Hommes. at
husband and wife as joint tenants. -yol-L. `K OAA.
r,,° ~ie~lstsr of Deeds I,
Grantee,
Witnesseth, That the said Grantor, for a valuable consideration
conveys to Grantee the following described real estate in Sty Croix THIS SPACE RESERVED FOR RECORDING DATA
County State of Wisconsin: NAME AND RETURN ADDRESS J~
Lot 54, Country Wood First Addition in the ozir ~iiUA)n , &W(
Town of Troy, St. Croix County, Wisconsin. / "
This deed is given in full and final satis-
faction of that land contract between
Richard O. Stout and Jeffrey J. Hommes and
Elizabeth A. Hommes dated October 1, 1996,
and recorded in the Office of the St. Croix PARCEL IDENTIFICATION NUMBER
County Register of Deeds on October 3, 1996,
in Vol . 1201, page616, as Document No. 550406.
This is not homestead property.
(is) (is not)
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And Richard O Stout
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
easements, restrictions, reservations, rights-of-way and covenants
of record, (no outbuildings are allowed on this lot)
and will warrant and defend the same.
Dated this 27th day of February 19 C) 7
e .~i11 A~ t (SEAL) (SEAL)
i Richard 0. Stout •
(SEAL) (SEAL)
i i
AUTHENTICATION ACKNOWLEDGMENT
State of Wisconsin,
Signature(s) ss:
St. Croix
County.
authenticated this day of 19 Personally came before me this 27 1day of